Health inspection·November 20, 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 1 residents reviewed for infection control practices (Resident # 7). 1.The facility failed to ensure CNA A and CNA B wore personal protective equipment while providing incontinent care for Resident #7 who was on EBP with a Foley catheter (a thin, flexible tube inserted through the urethra into the blader to facilitate urine drainage), Gastrostomy tube (is a feeding tube that delivers nutrition to your stomach) and a wound on 11/1/2025. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included:Record review of the face sheet dated 11/7/2025 indicated Resident #7 was a [AGE] year old male who was re-admitted on [DATE] with diagnoses which included end stage renal disease (a gradual loss of kidney function), osteomyelitis (an infection in a bone that can affect one or more parts of the body into the bone), acute on chronic systolic heart failure (a condition in which the left ventricle of heart is weak), neuromuscular dysfunction of bladder (occurs when nerve damage impairs bladder control), gastrostomy (a medical procedure that involves creating an artificial opening through the skin into the stomach), atherosclerotic heart disease of native coronary artery without angina pectoris (a progressive disease where plaque, composed of fat, cholesterol, calcium and other substances, accumulates in the walls of the arteries), peripheral vascular disease (refers to any disorder that affects the blood vessels outside of the heart and brain), acquired absence of right below the knee (refers to the loss of the lower portion of the right leg) and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). Record review of the physician's orders dated 11/7/2025 indicated Resident #7 was on enhanced barrier precautions related to Foley catheter, Gastrostomy tube and wound care. Record review of Resident #7's MDS assessment, dated 8/28/2025, indicated the resident was sometimes understood and sometimes understood others. The MDS also indicated Resident #7 was unable to complete BIMS. The MDS indicated Resident #7 required substantial, maximum assistance with showering/bathing, and dressing lower body. He was dependent on toileting and putting on/taking off footwear and was dependent on mobility. Record review of the undated care plan indicated Resident #7 was on enhanced barrier precautions due to foley catheter, gastrostomy status and chronic wounds. Interventions included educating the resident and the family on the reason and procedure of EBP, ensure signage is posted, ensure PPE is available for use on the resident and notify the physician of any signs and symptoms of infection. During review of photo evidence submitted by RP on 11/7/2025 at 12:56 PM, a photo dated 11/1/2025 at 10:13 AM from video recorder in Resident #7's room revealed 2 staff members providing incontinent care to Resident #7 without proper PPE on. Record review of daily staffing dated 11/1/2025 indicated CNA A and CNA B were scheduled to work 6 AM to 2 PM. Record review of a certification titled Enhanced Barrier Residents Affected - Few Page 1 of 3 675602 675602 11/20/2025 Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Precautions dated 8/26/2025 indicated CNA A completed her training. Record review of a certificate titled Enhanced Barrier Precautions dated 8/4/2025 indicated CNA B completed her training. During a phone interview on 11/8/2025 at 9:36 AM, CNA A said she assisted on the floor and had come to the facility for a few hours. She said she was at the facility from approximately 9 am- 12:30 pm. CNA A said she recalled she assisted CNA B with changing Resident #7. She said she could not recall if she wore PPE while providing incontinent care to Resident #7. CNA A said she has not always worn PPE while providing care. She said she believed she wore PPE on 11/1/2025. CNA A said a resident on EBP precautions would have a plan of care in the computer and the supplies would be in the room with an orange sticker on the door. CNA A said if proper PPE were not worn, it could cause infection if my clothes were contaminated. She said it would be an infection control issue. CNA A said the facility had plenty of PPE. CNA A said the nurses, charge nurses, ADON and DON were responsible for ensuring the staff was wearing proper PPE and the aides were following proper precautions. CNA A said she had been in-serviced on PPE and EBP through townhalls and through the facility's online in-services. During a phone interview on 11/8/2025 at 9:47 AM, CNA B said she worked at the facility PRN, and she did not think she worked that day. CNA B said she did recall providing care to Resident #7. CNA B said she was not familiar with EBP. She said she wore a gown if a resident had an open wound. She said you never wear gowns while performing incontinent care with residents with a catheter and she said she was not required to wear a gown with a resident with a feeding tube. CNA B said she felt the facility had plenty of PPE. She said she had been in-serviced on EBP through clinics, and she said she still had training to complete. CNA B said no one was responsible for ensuring staff wore proper PPE. She said it was chaotic sometimes and it would be an infection control issue for both staff and residents. During an interview on 11/8/2025 at 10:00 AM, LVN D said she had been at the facility for approximately 3 years. She said residents who have a wound, tube feeding, catheter or immune-compromised would be on EBP. LVN D said there would be a hanging organizer on the door with PPE. She said that was how the staff know to use PPE. LVN D said there was not a sign on the outside of the door but thought there was a sign on the inside of the resident room on the organizer. LVN D said EBP was important to prevent germs from getting to the residents and was an extra precaution. She said the Infection Control nurse was ADON and she was responsible for ensuring staff were wearing PPE. LVN D said it was everyone's job to ensure they were wearing it properly. LVN D said it could cause cross-contamination and make residents sick if not worn. LVN D said she had been in-serviced on EBP. During an interview on 11/8/2025 at 10:07 AM, the ADON said residents who had catheter, gastrostomy tube, wounds, and PICC (peripherally inserted central catheter) lines were required to be on EBP. The ADON said the residents on EBP have little orange stickers on the outside of their door and then have a sign on the inside of the door with an organizer with PPE. The ADON said she had in-serviced the staff repeatedly and said they were having a hard time getting it and using EBP. The ADON said the staff continue to not follow despite her education. The ADON said EBP prevents the spread of MDRO's (Multidrug-resistant organisms). She said the staff could be spreading infection from one resident to another. She said the facility had plenty of PPE. The ADON said a resident could be affected if EBP was not followed causing a resident could develop a MDRO, an infection or make them sick with something else. The ADON said she was ultimately responsible, but the nurses were responsible in her absence. During an interview on 11/8/2025 at 10:15 AM, CNA C said he has changed Resident #7 in the past. He said EBP was to prevent infections with residents with catheters, wounds, or tube feedings. CNA C said he always wore PPE. CNA C said there were signs on the wall in the room and the organizer with PPE. He said the facility had plenty of PPE available to staff. He said a resident could get an 675602 Page 2 of 3 675602 11/20/2025 Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infection and were at high risk if PPE was not worn. CNA C said he had not observed any staff members not wearing proper PPE. He said he would tell the staff member if he noticed they were not wearing proper PPE. CNA C said the charge nurse or DON were responsible for ensuring the staff were wearing proper PPE. During an interview on 11/8/2025 at 10:42 AM, the DON said she had been at the facility for 2 years and in her role as DON for 11 months. The DON said EBP were used when a resident had an insertion device such as a catheter, feeding tube, or a wound. The DON said she expected the staff to wear proper PPE when providing care to residents who were on EBP. The DON said the facility had in-services with staff on which residents were on EBP. She said the facility had a Kardex and it was also on the care plan. The DON said the facility had signage on the door with what the precautions were. She said there was an organizer on the door with PPE available to staff. The DON said the facility had plenty of PPE. During an interview on 11/8/2025 at 10:50 AM, the ADM said EBP was used when a resident had an open wound, feeding tube or a catheter. She said she expected the staff to be following proper precautions. The ADM said a resident would have an orange sticker on the door and an organizer in the room with supplies available to them. The ADM said the Infection Preventionist was primarily responsible, but all staff should make sure they were following the precautions. She said a resident could be at risk for infection if proper PPE was not followed. The ADM had identified the 2 CNA's as CNA A and CNA B.Record review of a facility's Standard and Enhanced Precautions policy dated 4/1/2024 indicated.Enhanced Barrier Precautions (EBP) are a CDC guidance to reduce the transmission of multi-drug-resistant organisms (MDRO) in healthcare settings, including nursing homes.Procedure.1. Determine residents MDRO status on admission to community.2. Determine if a resident has wounds.3. Place signage on residents' closet door, maintain PPE in residents' room, and assure all team members are aware of resident status. 4. High contact resident care activities.Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. 675602 Page 3 of 3