Health inspection·December 23, 2025

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 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 1 of 3 residents (Resident #3) reviewed for infection control in that: LVN A did not wash his hands between removing soiled gloves and putting on clean gloves when providing direct care to Resident #3 who had a skin tear and was on enhanced barrier precautions (EBP). The DON did not wash her hands after touching a window blind, bed controls, and bed linens prior to providing direct care to Resident #3 who had a skin tear and was on EBP. This deficient practice could affect residents who are receiving wound care or were on enhanced barrier precautions placing them at risk for infection.The findings were: Record review of Resident #3's admission record printed on 12/23/2025 revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinsonism (slow movements, stiffness, tremor and problems with walking and balance) and a stage IV pressure ulcer (full-thickness skin and tissue loss exposing bone, tendon, or muscle) of the sacral region (triangular bone at the base of the spine). The admission record indicated that Resident #3 was seen by the MD Wound Care who provided orders for daily treatment. Record review of Resident #3's comprehensive care plan printed on 12/23/2025 revealed a care plan that revealed, Resident #3 had a skin tear on the right arm and left thigh requiring treatment for the injury, date initiated 12/4/2025 and required enhanced barrier precautions, date initiated 11/10/2025. Resident #3 had a stage IV pressure ulcer (PU) to her sacrum (present on admission) requiring treatment, date initiated 11/10/2025. Record review of Resident #3's orders printed on 12/23/2025 revealed that she was to receive wound care treatment once a day for non-pressure wounds of the right arm, left thigh, and a stage IV PU, sacrum. During a wound care treatment observation on 12/23/2025 at 2:25 PM, Resident # 3 was observed lying in bed with her eyes closed. She did not give a response when LVN A or the DON communicated with her prior to or during the procedure. She had received morphine sulfate prior to the treatment for pain as ordered. LVN A and the DON prepared to perform wound care on Resident #3's right arm skin tear. Resident #3 had a sign on her door that reflected Enhanced Barrier Precautions. Prior to starting the procedure, LVN A and the DON washed their hands and donned (put on) gowns and gloves.In preparation for the procedure, the DON lowered and closed the blinds, adjusted the bed using the attached remote, and moved the sheets exposing Resident #3's right arm. She then held Resident #3's arm up for treatment, touching both sides of the arm an inch from the wound cover without washing her hands or changing gloves.LVN A was observed cleaning the wound with wound cleanser. He needed more gloves, so he removed his soiled gloves, walked to the treatment cart, obtained more gloves, and donned a clean set of gloves without washing his hands. He completed dressing the wound. During an interview with LVN A on 12/23/2025 at 4:15 PM, he stated that the Wound Care MD saw the resident weekly and LVN A made rounds with the MD. He agreed Residents Affected - Few Page 1 of 2 455444 455444 12/23/2025 Mesa Vista Inn Health Center 5756 N Knoll Dr San Antonio, TX 78240

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that he had missed the hand washing step during an interview at the conclusion of the wound care treatment procedure. LVN A stated that hands should be washed before starting a wound care procedure, anytime you change a task during wound care, and after finishing wound care. He stated that the impact of not washing his hands during wound care at the appropriate times can open (the resident) for infection and [NAME] down. During an interview with the DON on 12/23/2025 at 3:43 PM, the DON agreed that she had not changed her gloves during the procedure after touching non-sterile surfaces and prior to direct contact with Resident #3. She stated that hands should be washed during wound care at the beginning of wound care, anytime your hands are soiled, when going from touching something dirty, you wash them in between. The DON stated that the impact to the resident of not washing their hands at the appropriate times was it is open for infection, the possibility of spreading infection and bacteria. Record review of LVN A's and the DON's orientation and training competencies revealed that both were trained in infection control and handwashing in 2024 and held a current nursing license. Record review of the facility's undated policy Hand Hygiene revealed, You may use alcohol-based hand cleaner or soap/water for the following:Before and after performing any invasive procedure (e.g., fingerstick blood sampling);Before and after changing a dressingUpon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident)After contact with a resident's mucous membranes and body fluids or excretionsAfter handling soiled or used linens, dressings, bedpans, catheters and urinalsAfter handling soiled equipment or utensilsAfter removing gloves or aprons 455444 Page 2 of 2