Health inspection·December 28, 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 establish and 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 (Resident #1) reviewed for infection control. The facility failed to identify on the exterior of Resident #1's room that contact precautions were required before entering and did not provide the appropriate PPE at or near the door for Resident #1. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Findings Included: A record review of Resident #1's MDS, dated [DATE], reflected that she was a [AGE] year-old female that admitted to the facility on [DATE] and she had a BIMS score of 14, which indicated intact cognitive function. She was incontinent of bowel and bladder, and she required a wheelchair for mobility. A record review of Resident #1's face sheet, dated 12/28/2025, revealed her primary diagnosis was enterocolitis due to clostridium difficile (severe inflammation of the intestines, usually the colon, triggered by C. diff bacteria overgrowth after antibiotics disrupt gut flora, causing watery diarrhea, cramping, fever, and potentially life-threatening complications like sepsis or toxic megacolon). A record review of Resident #1's physician orders revealed an order for an infectious disease consult dated 12/19/2025. An observation of the exterior of Resident #1's door on 12/28/2025 at 10:05am revealed there were not any signs posted on the exterior of the room indicating the resident was on enhanced barrier precautions and/or contact precautions. Additionally, there was not any PPE outside the room in a cart nor hanging on the exterior of the door. No staff were observed to enter the room between 10:10am and 10:30am. During an interview with Resident #1 on 12/28/2025 at 10:10am, she stated she still had diarrhea sometimes and her stomach was not the best. Resident #1 stated she received antibiotics twice a day. Resident #1 stated she cannot leave the room because she was in isolation for her infection, but she wants to go back to her room and be able to go to the dining room. During an interview with the DON on 12/28/2025 at 11:30am, she stated there was one resident in the facility that was on contact precautions due to a C. diff infection. She further stated that resident was previously on enhanced barrier precautions due to a wound on her bottom that she had taken antibiotics for. The DON further stated that resident returned from the hospital about a week ago where she was not in isolation because her hospital lab tests came back negative for C. diff, but the facility tests resulted in a negative and then positive result, so they have implemented contact precautions and placed the resident on isolation, in accordance with their policy. The DON stated a referral has been requested for infectious disease to evaluate Resident #1 to determine if she still needs to be in isolation or not. When told that there was not any indication on the door that contact precautions were required and there was not any PPE outside the room, she stated there should be a sign on the door and she did not know why it was not. The DON further stated the PPE cart had been taken by the staff to the supply closet to be refilled and was Residents Affected - Few Page 1 of 2 455494 455494 12/28/2025 Glenview Wellness & Rehabilitation 7625 Glenview Dr North Richland Hills, TX 76180

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few placed back by the door. The DON stated that staff knew they needed to wear the appropriate PPE (gowns and gloves) to provide care to Resident #1 and all residents identified to require enhanced barrier precautions. The DON stated the risk of not identifying contact precautions were in place is that the infection could spread. A record review of the facility's Infection Prevention and Control Program, dated 10/24/2022, did not directly address the need to have signs posted on the door for infection control, but reflected the following: The facility must establish an Infection Prevention and Control Program under which it: Infection Control Committee:iii. Develop isolation precaution protocols when control of an infectious or communicable disease or disease risk is required in accordance with current Centers of Disease Control (CDC) guidelines and recommendations including but not limited to: The type and duration of the isolation depending on the infectious agent organism involved, and a requirement that the isolation should be the least restrictive possible for the resident under the circumstances. iv. Identify situations that may result in the employee's exposure to blood, body fluids, or other potentially infectious materials. Duties and Responsibilities: iv. Review food handling practices, laundry practices, waste disposal, pest control, traffic control, visiting rules for high-risk areas, and sources of airborne infection. xv. Reviews isolation precaution techniques and procedures and helps ensure that Facility staff, residents and visitors follow established procedures/precautions. xxi. Help assure that an adequate amount of protective supplies (i.e., gowns, gloves, masks, etc.) are on hand and readily accessible for handling infectious wastes, blood and/or body fluids. 455494 Page 2 of 2