Health inspection·February 3, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 infections for 3 of 6 residents (Residents #1, #2 and #3) reviewed for infection control practices.1. MA A failed to disinfect the blood pressure cuff before checking Resident #1's blood pressure after she removed the cuff from her (MA A's) wrist.2. CNA B and CNA C failed to perform hand hygiene before contact, between care, and change of gloves while providing incontinence care to Resident #2 and Resident #3.These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection. Findings included: 1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was cognitively intact with a BIMS score of 14. He had diagnoses which included hypertension (abnormally high arterial blood pressure) and anemia (a condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume).Observation on 02/03/26 at 10:54 AM revealed MA A removed a blood pressure cuff from her own wrist. Without disinfecting the blood pressure cuff, she entered Resident #1's room and she checked Resident #1's blood pressure.Interview/observation with MA A on 02/03/26 at 11:39 AM revealed she was still wrapping the blood pressure cuff on her wrist. She stated she did not disinfect the blood pressure cuff before checking Resident #1's blood pressure. She stated she was supposed to use the disinfectant wipes to clean the blood pressure cuff after unwrapping it from her wrist and before applying the cuff on Resident #1 to prevent the spread of infection, but she forgot. She stated she had received training on the care and disinfection of reusable equipment, but she could not recall when.2. Record review of Resident #2's Quarterly MDS Assessment, dated 12/16/25, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] and readmitted [DATE]. The resident had severe cognitive impairment with a BIMS score of 7, and her diagnoses included hypertension and diabetes (a condition that happens when your blood sugar is too high). Record review of Resident #2's care plan, dated 07/18/25, reflected: Focus: [Resident #2] At risk for problems with eliminations bowel and bladder. Goal: [Resident #2] will have incontinent products available on daily basis over the next 90 days. Interventions: Provide peri care [the hygiene practice of cleaning and maintaining the genital and anal areas to prevent infection, discomfort, or skin breakdown] after each incontinent episode.Observation on 02/03/26 at 11:30 AM revealed CNA B went to Resident #2's room to provide the resident incontinence care. She first knocked on the resident's door and then entered the room. Without washing her hands, she put on gloves and put her supplies together. Next, CNA B used wet wipes to cleanse Resident #2's abdominal folds and perineal area (the anatomical region located between the thighs). Her technique was one wipe, one swipe. She wiped down the peri area from inner area towards the outer area. Resident #2 then turned on her right side, and CNA B wiped the Residents Affected - Some Page 1 of 3 676349 676349 02/03/2026 Accel at Willow Bend 2620 Communications Parkway Plano, TX 75093

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's buttocks and thighs from inner area towards the outer area. Resident #2 was wet. CNA B then removed the soiled brief and discarded it. Without performing hand hygiene or changing her gloves, CNA B took a clean brief and put the clean brief on Resident #2. She then positioned the resident in bed with the call light in reach. Lastly, she removed her gloves, washed her hands, and left the resident's room. Interview with CNA B on 02/03/26 at 12:00 PM revealed she knew she was supposed to perform hand hygiene before contact with Resident #2, between the care, and with each removal of gloves. She stated she forgot. She stated failure to perform hand hygiene before contact, between care, and after removal of gloves could lead to contamination and spread of infection. She stated she had done training on hand washing, but she could not remember when.3. Record review of Resident #3's Comprehensive MDS Assessment, dated 12/26/25, reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident had severe cognitive impairment with a BIMS score of 0, and his diagnoses included hypertension.Record review of Resident #3's care plan, dated 01/06/26, reflected: Focus: [Resident #3] Bowel and Bladder. Goal: [Resident #3] Improve or maintain current bladder and bowel continence. Interventions: Check and change, keep clean and dry.Observation on 02/03/26 at 3:40 PM revealed CNA C prepared incontinence care supplies and then entered Resident #3's room. Without washing his hands, CNA C put on gloves. He then positioned the resident and cleansed the resident's abdominal walls, penis, and Foley catheter starting from tip downwards. Resident #3 was observed to have had a bowel movement. CNA C then turned the resident, and he cleansed the resident's buttocks from the inner area towards the outer area. CNA C was observed changing gloves between care, but he did not perform hand hygiene. When the resident was clean, CNA C removed his gloves and put on new gloves, but he did not perform hand hygiene. CNA C then took a clean brief and put it on Resident #3. Next, CNA C applied cream on the resident. He then removed his gloves and put on new gloves without performing hand hygiene. CNA C positioned the resident in bed in a low position with his call light within reach. Lastly, CNA C removed his gloves, washed his hands, and left the resident's room. Interview with CNA C on 02/03/26 at 4:01 PM revealed he was supposed to perform hand hygiene before contact and with each change of gloves, but he forgot. He stated that failure to perform hand hygiene during incontinence care on Resident #3 could lead to cross contamination and infection. He stated he had received hand washing in-services in the facility.Interview with the DON on 02/03/26 at 5:10 PM revealed her expectation was for staff to perform hand hygiene before contact with residents, between care, and when they changed gloves. The DON stated she also expected staff to disinfect the reusable equipment before using it on a resident and after use. She stated failure to perform hand hygiene before contact, between care, and change of gloves could lead to cross contamination and spread of infection. She stated the failure to disinfect reusable equipment before contact with residents and after use could also lead to cross contamination. She stated she had been in the facility for four weeks, and she had not done training on infection control. She stated she had training on infection control that morning with staff. She stated the facility had offered training on hand washing and cleaning of equipment, and she was not sure whether the staff were in attendance. Record review of the facility's training records for the topic of Hand Washing Before and After Patient Care, dated 08/02/25, reflected CNA B and CNA C had not attended the training. Record review of the facility's training records for Focus on Infection Control-Cleansing of Designated Resident Devices, dated 08/20/25, reflected that MA A had not attended the training.Record review of the facility's current Cleaning, Disinfecting and Sterilizing Care Equipment policy, dated March 2025, reflected the following: .3. Noncritical items are those that either do not ordinarily touch the resident or touch only intact skin. Such items include.blood pressure cuffs, and other medical accessories. 676349 Page 2 of 3 676349 02/03/2026 Accel at Willow Bend 2620 Communications Parkway Plano, TX 75093

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some These items rarely transmit diseases. However, it is imperative that these items are clean. Depending on the piece of equipment or item, washing with a detergent or disinfectant detergent, rinsing and thorough drying may be sufficient.Record review of the facility's current Hand Hygiene for Staff and Residents policy, dated February 2025, reflected the following: Hand hygiene is the most important component for preventing the spread of infection.1 Hand Hygiene is done:Before A Resident contactAfter:A. Contact with soiled or contaminated articles such as articles that are contaminated with body fluids.B. Resident contact Note: Wash hands at end of procedures where glove changes are not required. For procedures in which change golfese's. clean gloves to sterile gloves, it is indicated follow the specific standard of practice. If gloves, hands become contaminated as gloves are changed hands can be washed 676349 Page 3 of 3