Health inspection·November 29, 2023

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 observations, interviews, and record reviews, 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 for 1 (Resident #1) of 2 residents reviewed for infection control practice. Residents Affected - Few CNA A and CNA B failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 11/29/23, revealed the resident was an 80- year- old female admitted to the facility on [DATE] with diagnoses of urinary tract infection, muscle weakness and dementia. Review of Resident #1's MDS assessment, dated 11/02/21, revealed she required total assistance with most activities of daily living (ADLs) and one-person assist. Resident #1 was frequently incontinent of bladder and bowel. Review of Resident #1's care plan, undated, revealed the Resident #1 did not have a specific plan for being incontinent of bladder and bowel. Observation of incontinent care for Resident #1 on 11/29/23 at 3:39 p.m. revealed CNA A and CNA B did not wash their hands before the start of care. Both CNAs donned gloves. CNA A and CNA B removed the resident's brief which was completely soiled with urine and fecal matter. CNA A wiped the resident from front to back. CNA A made 5 strokes of clean with the same soiled wipe. CNA A did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #1's clean brief. She placed the clean brief on the resident and fastened it. Meanwhile, CNA B was assisting CNA A to provide care to Resident #1. CNA B wore the same gloves for repositioning including touching the perineal area and fastened the clean brief to the resident. CNA A and CNA B doffed their gloves. Both washed their hands before exiting Resident #1's room. In an interview on 11/29/23 at 3:50p.m with CNA A, she said she had been employed in the facility for 2 years and received infection control training last month. CNA A stated cross contamination meant mixing clean with dirty. CNA A acknowledged she should have washed hands and changed gloves before retrieving the clean brief and placing on Resident #1. (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 2 Event ID: 676499 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 676499 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springtown Park Rehabilitation and Care Center 201 Williams Ward Rd. Springtown, TX 76082 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)