Health inspection·November 21, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based observation, interview, and record review, the facility failed to 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 four of four clean linen closets (100, 200, 300, 400 Halls) reviewed for infection control. Residents Affected - Some The facility failed to ensure clean linen closets were kept sanitary. This failure could place residents at risk of cross-contamination resulting in infections. Findings included: Observation and interview on 11/21/2023 between 12:30 PM and 12:45 PM with the Housekeeping / Laundry Supervisor revealed the clean linen closet on 200 Hall had a fitted sheet and a box containing gowns stored on the floor. The gowns in the box were overflowing and touching the floor. Used rubber gloves, a container of zinc oxide, and trash were on the floor. An observation in the clean linen closet on 100 hall revealed gowns, used gloves, wipes, and candy wrappers on the floor. Cobwebs were observed around the baseboards. A laundry basket containing lift slings were also on the floor. The slings were hanging off the side of the basket and touched the floor. An observation in the clean linen closet on 400 hall revealed pillows, blankets, trash, and an empty toilet paper roll on the floor. Also, gait belts, tissues, personal care items, an insert for a bed-side commode, and unopened medical supplies were on the top shelf on top of the clean linen. Observations in the clean linen closet on the 300 Hall revealed a gown on the floor and pillows piled on the floor between the wall and shelves that contained clean linen. The Housekeeping / Laundry Supervisor said laundry staff were responsible for keeping the clean linen closets clean but could not control what the nursing staff placed in the closets. She said only clean linen should be in the closets to prevent contamination of the clean linens. She stated laundry staff stock the closets 2 -3 times a day and checked the closets each time. She said none of the clean linen closets appeared to be cleaned recently. In an interview on 11/21/2023 at 12:45 PM, on the 400 Hall clean linen closet, CNA D stated she did not know why pillows, blankets, trash, and an empty toilet paper roll were on the floor. She said gait belts, tissues, personal care items, an insert for a bed-side commode, and unopened Foley catheter kit should not be stored on clean linen or in the clean linen closet. She said she did not know who was responsible for keeping the closets clean, but they should only have clean linen in them to prevent any cross-contamination. In a follow up interview on 11/21/2023 at 2:15 PM, the Housekeeping / Laundry Supervisor said she spoke to the facility's District Manager who confirmed Housekeeping / Laundry staff were responsible for keeping the clean linen closets sanitary. She said she did not know why the rooms were not (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: 676388 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 676388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Pavilion at Creekwood 2100 Cannon Dr Mansfield, TX 76063 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)