Health inspection·December 9, 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 5 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure LVN-A donned gloves and performed proper hand hygiene when dealing with secretions and body fluids. These failures could place residents at risk for cross contamination and infection. Findings included:Record review of Resident #1's face sheet, dated 10/01/25, revealed a [AGE] year-old-female with an admission date of 09/04/25. Diagnoses included Cerebral Infarction Unspecified (a stroke, when blood supply to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients), Expressive Language Disorder (a communication challenge which affects a person's ability to express thoughts, ideas, or feelings), and Seizures. Record review of Resident #1's admission MDS assessment dated [DATE], revealed a BIMS score of 12, moderately impaired cognition. Record review of Resident #1's progress note dated 09/30/25 revealed Resident #1was noted to be lethargic, had slurred speech, and was coughing up phlegm. The physician was notified, and new orders were received for labs. In an observation on 09/30/25 at 11:00 AM, Resident #1 was observed gagging and coughing up copious amounts of thick phlegm (a type of mucus) into a paper towel. She continued to gag and cough up phlegm the entire time the nurse was in the room with her. The phlegm was thick and stringy from Resident #1's mouth to the paper towel in her hand. Then, LVN-A was observed grabbing the paper towel with phlegm dripping off it without gloves, walking out of Resident #1's room to her medication cart in the hallway to throw the paper towel away and grabbed Resident #1 a cup to spit the phlegm into. After LVN-A came back into the room and handed the resident a cup to spit in, LVN-A walked into the bathroom and washed her hands. In an interview on 09/30/2025 at 11:07 AM, LVN-A stated she did not want to put gloves on because she felt like it was a dignity issue for Resident #1 and did not want to offend the resident. When asked if it was an infection control issue, she stated she guessed so, but stated Resident #1 did not have anything contagious and was not on any precautions. She stated Resident #1 had not had Covid and had not been exposed to it as far as she knew. LVN-A did not recall the most recent infection control in-service but stated she had been in-serviced on infection control in the past. In an interview on 10/01/2025 at 8:41 AM, the ADON, who was also the infection control nurse, stated LVN-A should have put gloves on prior to grabbing the paper towel from Resident #1's hand, dropped the paper towel into the trash, then washed or sanitized her hands. The infection control nurse stated improper techniques such as that could have caused cross-contamination and could have placed other residents' health and safety at risk. She stated she had already educated LVN-A regarding the incident, as well as started an infection control in-service. The infection control nurse also stated there were no active cases of Covid in the facility, and Resident #1 had not been exposed to Covid as far as she Residents Affected - Few Page 1 of 2 675309 675309 12/09/2025 Windsor Nursing and Rehabilitation Center of Alice 606 Coyote Tr Alice, TX 78332

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few knew. In an interview on 10/01/2025 at 1:25 PM, the DON stated LVN-A should have put on gloves before grabbing and throwing away the paper towel which Resident #1 was spitting into. Then LVN-A should have removed the dirty gloves and washed or sanitized her hands after throwing the tissue away. The DON stated they had already educated LVN-A regarding that, as well as started a staff in-service regarding infection control and cross contamination. The DON stated there were no active cases of Covid in the facility, and Resident #1 had not been exposed to Covid as far as she knew. Record review of the facility's Infection Prevention and Control Policy, implemented 05/13/23, revealed This facility has established and maintains 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 as per accepted national standards and guidelines. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of 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 governing the use of PPE. 675309 Page 2 of 2