Williamsburg Village Healthcare Campus

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Interview on 10/01/25 at 3:24 PM, the DON revealed discharge summary should be completed by nursing team when the resident discharges. She stated she was not aware Resident #1 did not have discharge summary. The DON stated the nursing team should all be following up to ensure the discharge summary was completed. She stated prior to the new system the discharge summary should be completed within 10 days. She stated there was no potential risk to the resident for not having a discharge summary. Interview

on 10/01/25 at 4:37 PM, the Administrator revealed when a resident discharges from the facility the resident should have a discharge summary and a physician discharge summary. He stated the discharge summary should be completed by the nursing team. He stated the expectation was for discharge summary to be developed and completed. Record review of the facility's Discharge / Transfer policy, dated 04/24/24, reflected the following: The resident will be discharged /transferred (home/another entity) by order of his/her attending physician in accordance with standard practice guidelines.2. Notify resident, their legal representative, if any, or an interested family member and document the discharge. 3. Provide written discharge instructions/education to the resident and family when discharged to a lower of care, in a language they can understand and document in a medical record. EHR>Discharge>Instructions if discharged to an equal or lower level of care setting to transfer if discharged to a higher level of care such as an acute hospital.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsburg Village Healthcare Campus

941 Scotland Dr Desoto, TX 75115

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

bed. She stated her brief was changed, but she could not tell when. The resident's bed linen was soaked with urine. Observation and interview on 09/30/25 at 11:44 AM revealed Resident #6 in her room on her bed. She stated her brief was last changed last night. She stated she was wet. Observation on 09/30/25 at 12:00 PM revealed CNA D providing Resident #5 with incontinence care. He went to the room and explained the procedure to Resident #5. CNA D put supplies together and went to the bedside. He performed hand hygiene before contact with Resident #5. He put on gloves and unfastened the resident's brief. Resident #5 was heavily soaked in urine. He did not cleanse the resident's perineal area (labia majora). He only cleansed the resident's abdominal folds. He then positioned the resident on her side and cleansed her buttocks. Observation on 09/30/25 at 12:15 PM revealed CNA D providing Resident #6 with incontinence care. He went to the room and explained the procedure to Resident #6. CNA D put supplies together and went to the bedside. He performed hand hygiene before contact with Resident #6. He put on gloves and unfastened the resident's brief. Resident #6 was heavily soaked in urine. The brief, draw sheet, and the mattress cover were soaked with urine. He did not cleanse the resident's perineal area. He was observed cleansing the resident's abdominal folds. He then positioned the resident on her side and cleansed her buttocks. The resident had had a bowel movement. He cleaned the resident, but he did not change his gloves or wash his hands. Interview on 09/30/25 at 12:24 PM with CNA D revealed he was the one assigned to Residents #5 and #6. He stated he last did his round when he took over from night shift.

He stated he had changed Resident #6 at around 7:15 AM before she ate breakfast, but he had not changed Resident #5. He stated he was aware he was supposed to do rounds every two hours and as needed, but he was busy with other residents. He stated failure to round and change resident every two hours could lead to skin breakdown. CNA D stated they had been given training on rounding every two hours and incontinence care, but he could not recall when. Interview with on 09/30/25 at 12:39 PM with LVN C, who was the day shift nurse, revealed staff were supposed to perform the incontinent rounds every 2 hours and as needed. She stated she was supposed to monitor the CNA to ensure they completed the rounds, and she could not tell when she last did her rounds. She stated the risk of leaving residents wet for

a long time was that they would be predisposed to skin irritation and urinary tract infections. Interview on 09/30/25 at 1:25 PM, the ADON revealed she expected staff to perform rounds every two hours and as needed. She stated the nurses were responsible for monitoring the CNAs during their shifts. She stated the risk of not performing every two hours rounds and could lead to skin issues and infections. Interview on 09/30/25 at 2:02 PM, the DON revealed she expected staff to perform rounds every two hours and as needed. She stated the nurses were responsible for monitoring the CNAs during their shifts by performing rounds behind the CNAs. She stated the risk of not performing every two hours rounds could lead to skin issues and infections. The DON stated she had done training with staff on providing incontinence care every two hours. The DON was not asked if it was the facility policy that they do rounds every 2 hours.

Record review of training on perineal care/incontinent care dated 08/29/25 revealed CNA B was in attendance. The in-service covered the procedure and guidelines on perineal care /incontinent care but did not address incontinent care every 2 hours.Record review of the facility's Perineal Care policy, revised April 2024, reflected the following: . Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Williamsburg Village Healthcare Campus

941 Scotland Dr Desoto, TX 75115

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

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

room and explained the procedure to Resident #5. CNA D put supplies together and went to the bedside.

He performed hand hygiene before contact with Resident #5; he put on gloves and unfastened the resident's brief. Resident #5 was heavily soaked in urine. He did not cleanse the peri area. He was only observed cleansing the abdominal folds and positioned the resident on her side and cleansed the buttocks.

He did not change gloves or wash hands after handling soiled linen. He used the same gloves to put a clean brief. Observation on 09/30/25 at 12:15 PM, revealed CNA D providing Resident #6 with incontinence care. He went to the room and explained the procedure to Resident #6. CNA D put supplies together and went to the bedside. He performed hand hygiene before contact with Resident #6; he put on gloves and unfastened the resident's brief. Resident #6 was heavily soaked in urine. The brief, draw sheet and the mattress cover were soaked with urine. He did not cleanse the peri area for Resident#6, he only cleaned

the abdominal folds; he positioned the resident on her side and cleansed the buttocks. She was observed to have bowel movement. He cleaned the resident, and he did not change gloves or wash hands. He was observed using the same gloves on clean linens and brief. He removed gloves and left the room. Interview

on 09/30/25 at 12:24 PM with CNA D revealed he forgot to perform hand hygiene during perineal care. CNA D said he was aware he was supposed to wash hands between the care if gloves were contaminated, but

he forgot. CNA D stated he was supposed to cleanse the peri area before he turned Resident #5 and Resident#6 and after he changed the soiled brief, pad, and linen but he forgot it escaped his mind. He stated failure to wash hands between care and when gloves were contaminated could lead to cross contamination. C N A D said failure to perform peri care on Residents #5 and #6 could predispose them to infection. Interview on 09/30/25 at 12:39 PM with LVN C, who was in the room during incontinent care for Resident # 6 revealed CNA D failed to change gloves and wash hands after they were soiled. She also stated CNA D failed to cleanse the peri area before turning Resident#6. She stated the risk of not cleaning

the peri area and changing gloves and perform hand hygiene could lead to skin irritation and urinary tract infections. Interview on 09/30/25 at 1:25 PM, the ADON revealed her expectation during incontinent care was staff to complete hand hygiene before contact with residents, during care, and after care and also to perform peri care before applying a clean brief. The ADON stated CNA D was supposed to complete hand hygiene and change gloves while performing incontinence care on Resident #5 and #6 to prevent cross contamination and infection. The ADON stated the nursing staff had been offered the in-service on hand hygiene/infection control. Interview on 09/30/25 at 2:02 PM, the DON revealed her expectation during incontinence care was for staff to complete hand hygiene before, during and after care. The DON also stated in between care CNA D was supposed to complete hand hygiene and change gloves because the hands were considered dirty after cleaning the resident. The DON stated CNA D was to complete peri care

before applying a clean brief on Resident #5 and before putting clean linen and brief on Resident#6. She stated staff was expected to perform hand hygiene to prevent the spread of infection. The DON stated the nursing staff had been offered the in-service on hand hygiene/infection. Record review of the facility training records was requested on 09/30/25 and records revealed training on hand washing dated 08/29/25. Record

review of the facility's Hand Hygiene for Staff and Residents policy, dated July 2024, reflected, .The purpose of this procedure is to reduce the spread of infection with proper hand hygiene ' 1.Hand hygiene is done: Before A.resident contact After: A.contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. Resident contact. D. Toileting or assisting others with toileting, or after personal grooming.

Event ID:

Facility ID:

If continuation sheet