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Complaint Investigation

Park Village Healthcare And Rehabilitation

Inspection Date: August 20, 2025
Total Violations 1
Facility ID 455727
Location Desoto, TX
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Inspection Findings

F-Tag F0880

Infection Control Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

CNA C and CNA D put on gloves and gowns to provide incontinence care before entering the room. CNA C said the resident was on EBP. CNA C said the sign was posted, but another resident in the facility would walk around and take down the signs. CNA C assisted the resident to turn to his left side. His brief was soiled with bowel movement. CNA C began cleaning the bowel movement. CNA C changed gloves and said I'm supposed to use hand sanitizer, but I don't have it. I'm supposed to use it between each glove change.

CNA C changed gloves, but did not perform hand hygiene. The sacral area had two pinpoint openings areas. CNA C cleaned the area thoroughly, removed her gloves, and washed her hands. CNA C put down a clean brief and the resident was turned to his right side. CNA D cleaned the resident's other side of buttocks, and the resident was turned to his back. CNA D cleaned the resident's penis and scrotum. CNA D did not change gloves or perform hand hygiene. CNA D used the soiled gloves to apply cream to the resident's peri-area and fastened the brief. CNA D removed her gloves and washed her hands. An interview

on 08/20/25 at 10:55 AM with CNA C revealed she said she did not perform hand hygiene. She said she should have gone in and washed her hands. She said the risk to Resident #2 was a possible transfer of infection. An interview on 08/20/25 at 12:55 PM with CNA D revealed she knew to change gloves and perform hand hygiene during incontinence care. She said she did not because, there was a lot going on.

CNA D said the risk to Resident #2 was infection control. An interview on 08/20/25 at 1:10 PM with ADON E revealed she was the infection preventionist. She said EBP were used for residents with wounds, indwelling devices, and tracheostomies. ADON E said EBP were important to reduce risk of spread of infection. ADON E said with EBP, staff were supposed to wear a gown, gloves, and face shield (if spills were possible). She said the staff were trained on EBP in August 2025. ADON E said a resident on EBP was supposed to have a sign on the door and PPE in close proximity. She said Resident #2 did not have a sign posted because another resident in the facility would take the signs down. She said everyone was responsible for ensuring signs were kept posted, and she did not know why the resident did not have a sign posted on 08/20/25. ADON E said staff were supposed to wear appropriate PPE for EBP. ADON E said staff were supposed to change gloves and perform hand hygiene during wound care after cleaning the wound. ADON E said failure to wear appropriate PPE, change gloves, and perform hand hygiene placed

the residents at risk for infection. ADON E said if staff were not aware of a resident being on EBP, there was

a risk of transmission of infection. Record review of the facility in-service, PPE Donning and Doffing and EBP, dated 08/10/25, reflected:LVN A did not sign the in-service.MA B, CNA C, and CNA D signed the in-service. Record review of the facility in-service, Infection Prevention - Hand Washing/Hand Sanitizer, dated 08/10/25, reflected:LVN A did not sign the in-service.CNA C and CNA D signed the in-service.

Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: .3. Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.

Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: When and How to Clean Hands.Before or after caring for someone who is sick.

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📋 Inspection Summary

Park Village Healthcare and Rehabilitation in Desoto, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Desoto, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Park Village Healthcare and Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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