Park Village Healthcare: Infection Control Failures - TX
The resident, identified in the report only as Resident 2, had two pinpoint openings in the sacral area, a wound site that demands careful infection control. Two certified nursing assistants, identified as CNA C and CNA D, performed the care together. CNA C cleaned the sacral wounds, removed her gloves, and washed her hands. CNA D then cleaned the other side of the resident's buttocks, then the penis and scrotum, and then applied cream to the perineal area and fastened the brief. She did none of it with clean gloves. She never performed hand hygiene between steps.
When inspectors interviewed CNA D that afternoon, she said she knew she was supposed to change gloves and perform hand hygiene. She said she didn't because "there was a lot going on."
CNA C was more direct about what she had done wrong. She told inspectors she did not perform hand hygiene when she should have, that she should have gone back to the sink, and that the risk to the resident was a possible transfer of infection. CNA D said the same thing about her own lapse: infection control.
Both aides had signed an infection prevention in-service on hand washing and hand sanitizer use on August 10, ten days before the inspection. Both had also signed a training on proper use of personal protective equipment. The training covered exactly the situation they were in.
The facility's assistant director of nursing, identified as ADON E, served as the infection preventionist. She told inspectors that Resident 2 was supposed to be on Enhanced Barrier Precautions, a protocol that requires staff to wear a gown, gloves, and face shield during high-contact care. It exists specifically to stop the spread of multidrug-resistant organisms, which can move from a resident's skin to a caregiver's hands and clothing and then to the next person they touch.
Resident 2 did not have a precautions sign posted on the door.
ADON E said the sign was missing because another resident in the facility kept taking the signs down. She said everyone on staff was responsible for making sure signs stayed posted. She said she did not know why no sign was up on August 20. She acknowledged that if staff didn't know a resident was on Enhanced Barrier Precautions, the risk of transmitting infection to others went up.
There was one more gap. LVN A, a licensed vocational nurse, had not signed either the August 10 hand hygiene training or the PPE training. The records showed the aides had signed them. The nurse had not.
When inspectors observed CNA C during the care, she changed gloves but skipped hand sanitizer between glove changes. She told inspectors afterward that she was supposed to use hand sanitizer between each glove change but didn't have it available. "I'm supposed to use it between each glove change," she said, "but I don't have it."
ADON E, when asked about the failures, was precise about the consequences. Failure to wear appropriate PPE, change gloves, and perform hand hygiene placed residents at risk for infection, she said. If staff weren't aware a resident was on Enhanced Barrier Precautions, there was a risk of transmission. She said it plainly, in the same interview where she couldn't explain why the warning sign wasn't on the door.
Inspectors cited the facility for failing to maintain proper infection control practices. The violation was classified as causing minimal harm or the potential for actual harm, affecting some residents.
Resident 2 had open wounds. The aides who cared for him knew what hand hygiene was for. One said she didn't do it because things were busy. The sign that would have reminded everyone what precautions were required had been taken down, and no one had put it back up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Village Healthcare and Rehabilitation from 2025-08-20 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Park Village Healthcare and Rehabilitation in Desoto, TX was cited for violations during a health inspection on August 20, 2025.
The resident, identified in the report only as Resident 2, had two pinpoint openings in the sacral area, a wound site that demands careful infection control.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.