Health inspection·July 30, 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 to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #8) reviewed for infection control, in that: The facility failed on 07-29-2025 when CNA D failed to wear a gown while caring for Resident #8 who had a surgical chest incision and required the use of PPE., In-addition there was no EBP sign posted outside or inside the resident's room or no PPE readily available for staff or visitors use. This failure placed residents at risk of transmission of communicable diseases, a decline in health status, and hospitalization. Findings included: Record review of Resident #8's admission record dated 07/29/2025 reflected an [AGE] year-old male with an admission date of 07/24/2025. Record review of Resident #8's Medical Diagnosis tab in the EHR dated 07/29/2025, reflected diagnoses which included malignant neoplasm of retroperitoneum, chronic lymphocytic leukemia of B-Cell type, and rheumatoid arthritis. Record review of Resident #8's IDT-BIMS form, dated 07/25/2025, reflected no documented BIMS score, although all questions were answered. Further review of the document reflected Resident #8 was cognitively intact (no problems making decisions about care or activities that affected daily life). Record review of Resident #8's Initial Baseline Care Plan, dated 07/25/2025, documented a focus on skin due to the potential for pressure ulcer development, with interventions including:- Educating the resident, family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning.- Monitor nutritional status. Serve diet as ordered, monitor intake and record.- Weekly head to toe skin at risk assessment Record review of Resident #8's Order Summary Report, dated 07/29/2025, reflected doctor's orders, including the following:- Surgical Incision to abdomen: change dry dressing and monitor for s/s of infection Q MWF (Monday, Wednesday, Friday).and pm as needed, dated 07/25/2025.- Surgical incision to abdomen: change dry dressing and monitor for s/s of infection Q MWF and pm one time a day every Mon, Wed, Fri (Monday, Wednesday, Friday). During an observation on 07/29/2025 at 12:55 p.m. outside Resident #8's room, there was no EBP sign to indicate to staff that the resident required staff to wear extra PPE for high-contact care activities and no PPE readily available, Resident #8 was in the room getting assistance from CNA D to change clothes and get re-dressed, Resident #8's shirt was open and a long vertical dressing was noted to the middle of his chest. During an interview on 07/29/2025 at 12:55 p.m. Resident #8 was A & O x 4 (person, place, time, and situation) stated he had dropped cobbler all over his clothes, CNA D was present for assistance with changing the resident's clothes Resident #8 stated the staff changed the dressing to the middle of his chest about every other day, but he had not seen staff wear a gown before. During an interview on 07/29/2025 at 1:00 p.m., the MDS RN stated residents with wounds and who received high-contact care activity should be on EBP, due to Resident #8's wounds and high care activities. The MDS RN stated Residents Affected - Few Page 1 of 2 455689 455689 07/30/2025 San Pedro Manor 515 W Ashby Pl San Antonio, TX 78212

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PPE was not readily available near the Resident's door at that time, and the risks of not using PPE for a resident who needed EBP was the risk of infection, and decreased protection of the resident. During an interview and observation at the same time the ADON stated Resident #8 should have been on EBP, and that the nurse aides and other staff would know that if there was a sign posted to let them know the resident required EBP, but there was not a sign. When asked where the PPE for EBP was, the ADON stated, it was usually on the nurse aide's clean linen carts. During an observation the ADON and MDS RN checked both nurse aide clean carts and there were no disposable gowns available. Continued observation revealed gowns were in a locked linen closet on the opposite side of the hall from where Resident #8 was. During an interview and observation on 7/29/25 at 1:05 p.m. the ADON reviewed the facility's Infection Control Policy for transmission-based precautions and stated that EBP should be used for residents with wounds during high contact activities such as dressing. transferring. providing hygiene. During an interview on 07/29/2025 at 1:07 p.m. CNA D stated he assisted Resident #8 with getting dressed and positioning in bed. CNA D was able to demonstrate knowledge of EBP, but stated he did not see a sign outside or inside Resident #8's room so he did not know to put on a gown to assist Resident #8. CNA D stated he did not know if any risks to the resident if he did not wear EBP PPE. Record review of an example of the facility's Enhanced Barrier Precautions posting, with no date, revealed providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. Record review of the facility's policy titled . Standard and Transmission-Based Precautions, dated March 2024, reflected that EBP applied to . Wounds and/or indwelling medical devices. and PPE (gloves and gown) should be used during Dressing. transferring. Providing hygiene. Record review of the facility's In-service Education Record, dated 07/23/2025, reflected multiple areas of infection control were discussed with the staff, including EBP. Further review showed CNA D and MDS RN signed the in-service as attended, there was no documented evidence that the ADON attended the training. 455689 Page 2 of 2