Health inspection·May 20, 2025

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 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 one (CNA A) of two staff observed for infection control. Residents Affected - Few CNA A failed to change their soiled gloves and wash hands during incontinent care to Resident #1. This failure could place residents at risk for spread of infection through cross-contamination. Findings included: Observation of incontinence care on 05/19/2025 at 11:24 a.m. revealed CNA A used hand gel in the hallway and donned (placed on gloves & gown) clean gloves and gown. CNA A entered the room, Resident #1 was lying on his back. CNA A unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarding the wipe in the trash bag. CNA A wiped the genitals, discarding the wipe in the trash bag. CNA A wiped the shaft of the penis and discarding the wipe in the trash bag, and then cleaned the head of the penis and discarding the wipe in the trash bag. CNA A positioned Resident #1 on his right side with the help of another staff member. CNA A wiped the rectal area that was soiled with bowel movement and discarded the wipe, using another wipe CNA A completed cleaning the rectal area of bowel movement, discarding the wipe. CNA A wiped the right buttocks, which was soiled with urine, discarding the wipe. Repositioning Resident #1with her soiled gloves to his left side, CNA A cleaned the left buttocks, which was soiled with urine, discarding the wipe. CNA A assisted, with her soiled gloves, the other staff member to reposition Resident #1 on his back. CNA A pulled the clean brief up underneath him with the soiled gloves and fastened the brief, removing the soiled brief placing it in the trash. CNA A then pulled the clean sheet up on the resident. CNA A removed her dirty gloves did not wash her hands or use hand sanitizer, placed on new gloves, and continued to assist the other staff member to straighten Resident #1 clothing and his linens and blanket on the bed. CNA A removed her gloves and gown in the room and then washed her hands. In an interview on 05/20/2025 at 1:00 p.m., CNA A said she was to perform hand hygiene before and after the procedure and between changes of gloves. The glove changes should occur at the beginning and at the end of the incontinent care. She said she did not do it this time because she was nervous and talking. She stated the risk would be spread of infection. In an interview on 05/20/2025 at 2:45 p.m., the DON stated the expectation was to perform hand hygiene and glove changes before and after any care, and any time after removing dirty gloves. If hands are visibly soiled clean with soap and water, otherwise can use hand sanitizer. The DON stated the risk is not performing hand hygiene, would be cross contamination. The DON stated she would be doing (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: 745056 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 745056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern Oaks Therapy and Living Center 3350 Bonnie View Rd Dallas, TX 75216 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)