Inspection·August 8, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 3 residents (Resident #23) reviewed for infection control, in that: Residents Affected - Few CNA B failed to wash or sanitize her hands or change her gloves after touching the remote of Resident #23's bed before starting incontinent care. After cleaning Resident #23's genitals, CNA B let the soiled briefs get in contact with the resident's genitals. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #23's face sheet, dated 08/07/2024, revealed an admission date of 11/14/2022 and, a readmission date of 06/15/2023, with diagnoses which included: Dementia (General decline in cognitive abilities), Neutropenia (low concentration of neutrophils (white blood cell) in the blood making it harder to fight infection), Hyperlipidemia (high concentration of lipids(fats) in the blood) and, squamous cell carcinoma (skin cancer). Record review of Resident #23's Annual MDS assessment, dated 06/17/2024, revealed the resident had no BIMS score, he had memory problems and was severely cognitively impaired. Resident #23 was always incontinent of bladder and frequently incontinent of bowel and, required limited to extensive assistance with his ADLs. Record review of Resident #23's care plan, dated 11/14/2022, revealed a problem of The resident has bladder incontinence, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 08/07/24 at 1:36 p.m. revealed while providing incontinent care for Resident #23, CNA B after putting gloves on, touched the bed remote that was on Resident #23's bed and then without changing her gloves or sanitizing her hands, started to provide care to the resident. CNA B rolled Resident #23's soiled brief between his legs. After cleaning the resident's genitals, CNA B let the soiled brief get in contact with the resident's genitals. During an interview on 08/07/2024 at 1:50 p.m. with CNA B, she confirmed the environment around the resident was considered dirty and she should have changed her gloves and sanitized her hands prior to providing care. She confirmed the soiled briefs should not have come in contact the resident's (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 676030 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676030 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shady Oak Nursing and Rehabilitation 101 S Lancaster Moulton, TX 77975 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)