Health inspection·December 8, 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 disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 09/18/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including methicillin susceptible staphylococcus aureus infection (bacterial infection), methicillin resistant staphylococcus aureus (bacterial infection), constipation, bacteremia (presence of live bacteria in the bloodstream) and personal history of malignant neoplasm of breast (breast cancer). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 required dependent assistance with most activities of daily living (ADLs). Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Care Plan revised 07/30/25 revealed he had bowel and bladder incontinence. The goal stated Resident #1 will be clean and odor free through the next review date. Observation of incontinence care for Resident #1 on 09/17/25 at 11:14 a.m., revealed CNA A washed her hands prior to putting on gloves. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. She did not change gloves but continued to clean the resident. Her gloves were visibly soiled with urine. CNA A did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A retrieved the old, soiled brief and placed on a trash can. CNA A removed her gloves and picked up the trash. She washed her hands before leaving Resident #1's room. In an interview on 09/17/25 at 11:14 a.m. with CNA A, she stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for 2 years and received infection control training during orientation. She said cross contamination was going from clean to dirty. CNA A noted the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. CNA A stated she did not change her gloves because she was put on the spot and was nervous. During the interview on 09/18/25 at 1:30 p.m., the DON acknowledged being aware of some of the concerns raised about infection control practice. She stated ADON B was responsible for infection control in the facility. The DON stated employees receive training in infection control monthly. She explained that the facility conducts spot checks and training with return demonstrations, and monitors staff with return demonstration periodically. The DON stated the aides were expected to follow standard precautions including washing hands and changing gloves while providing care. Review of the facility's infection control policy revised 04/12/23 reflected:Policy:This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and Residents Affected - Few Page 1 of 2 455957 455957 12/08/2025 Santa Fe Health & Rehabilitation Center 1205 Santa Fe Dr 1205 Santa Fe Dr, TX 76086

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines.Standard Precautions:a) All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted while providing resident care services.b) Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.c) All staff shall use personal protective equipment (PPE) according to established facility policy.d) Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility practices.e) Environmental cleaning and disinfection are performed routinely with high touch cleaning proceduresf) All staff have responsibilities related to reporting cleanliness issues in the facility to the Administrator/designee and housekeeping 455957 Page 2 of 2