Health inspection·November 14, 2024

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with CNA A on 11/13/24 at 4:40 pm CNA A said she didn't recall doing anything incorrect when performing incontinence care with Resident #115. She said she must sanitize her hands every time she changed her gloves. She said she knew when the state was here, they need to be very strict with hand hygiene. She then said, she always performed hand hygiene per protocols. She said she did not remember the last time the facility assessed her skills for incontinent care or foley care. She said she knew every time she changed her gloves, she must sanitize her hands, but she just got confused. CNA A said at every in-service or training for infection control, they train them on when to wash their hands and when to gown up. She did not remember when the last infection control in-service was done, but they go over infection control daily. In an interview with CNA B on 11/24/25 at 1:22 pm she said the last infection control in-service she received was about 2 weeks ago. She said hand hygiene must be performed before entering a resident's room, between glove changes and as needed. She said they must remove gloves, sanitize hands, and apply clean gloves. She said when providing incontinent care to a resident, they must use one wipe per swipe when cleaning both the front and back areas. She said they must change gloves and sanitize hands after cleaning the front area and before continuing with the rest of the incontinent care. In an interview with CNA C on 11/14/24 at 1:42 pm she said she did not remember when the last infection control in-service was. She said they go over hand hygiene and PPE. She said hand hygiene must be done every time they provide care to a resident. She said they perform hand hygiene before entering a resident's room and when leaving a resident's room. She said they must sanitize hands between glove changes. She said when performing incontinent care on a resident, they must use one wipe per swipe. She said they must change gloves and sanitize hands when moving from front to back. She said they completed an incontinent care check off at hire and periodically by one of the ADONs. In an interview with LVN D on 11/14/24 at 1:53 pm he said the last infection control training he completed was also about one month ago. He said they go over hand hygiene, PPE, and contact precautions. He said they performed hygiene before and after care with a resident. He said they must complete hand hygiene between glove changes. He said when performing incontinent care, they must use one wipe per swipe. He said he tried to ensure the CNAs were performing correctly. In an interview LVN E on 11/14/24 at 2:25 pm she said she was one of the ADONs who conducted in-services for staff. She said for infection control in-services they go over new policy on enhanced barrier precautions (EBP), hand hygiene and incontinent care. She said the staff were told perform hand hygiene before performing resident care, when going in and out of resident's rooms and between glove changes. She said staff were instructed to use one wipe per swipe, not to fold or roll, when incontinent care was provided to residents. In an interview with the DON on 11/14/24 at 5:05 pm, she said one of the ADONs does the monthly hand hygiene and PPE in-services as well as skills checklist for incontinent care and foley care. The DON said all staff must perform hand hygiene between glove changes. She said when performing incontinence care on a resident, staff must use one wipe per swipe. The DON also said staff must change gloves and perform hand hygiene when peri care was completed and before touching a resident. She said if they did not, it would cause cross contamination. Review of the facility's Infection Control Policy implemented 5/13/23 revealed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 2 of 4 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 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 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)

F 0880 Policy: Level of Harm - Minimal harm or potential for actual harm This facility has established and maintains 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 as per accepted national standards and guidelines. Residents Affected - Few Policy Explanation and Compliance Guidelines: . 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of the facility's Hand Hygiene policy implemented 10/24/22 revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Policy for Incontinent Care requested on 11/13/2024 at 5:30 pm and the Administrator provided a copy of pages from Lippincott Nursing Procedures, 11th Edition. The Administrator said they follow Lippincott Nursing Procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 3 of 4 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 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 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)

F 0880 Review of documents revealed, Level of Harm - Minimal harm or potential for actual harm When caring for a patient with an indwelling urinary catheter, follow infection-prevention practices, such as performing hand hygiene, . Residents Affected - Few Implementation: Gather the equipment and supplies at the patient's bedside. .Advise the patient to remind staff members to perform hand hygiene before and after handling the catheter if they fail to do so. Perform hand hygiene. Put on gloves and other personal protective equipment, as needed, to comply with standard precautions. Reviewed Incontinent Care Proficiency Checklist provided by Administrator for CNA A dated 8/30/24. The checklist revealed the following: .Put on gloves. Use more than one washcloth, if needed . Wash hands before performing peri care. Use hand gel between glove changes. If heavily soiled, wash hands with soap and water. Wash hands after cleaning the resident and before touching clean linens. Wash hands after peri care is completed and before leaving the room. Wash hands any time you are unsure if you touched something dirty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 4 of 4