Inspection·July 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 observations, interviews, and record reviews, 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 4 resident (Residents #9) reviewed for infection control.RN A failed to put on a gown prior to administering medications through a jejunostomy tube (also called aJ-Tube, enteral tube, or feeding tube).This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections.Findings include: A record review of a face sheet dated 07/08/2025 indicated Resident #9 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included feeding difficulties, artificial opening of gastrointestinal tract status (a jejunostomy which is a tube inserted through the abdomen into the small intestine to provide nutrition and medications), oropharyngeal dysphagia (difficulty in swallowing), and cerebral infarction (a stroke). A record review of Resident #9's admission MDS assessment dated [DATE] noted Resident #9 had a BIMS of 3 which indicated her cognition was severely impaired. The MDS assessment indicated Resident #9 had a feeding tube. A record review of the physician's orders dated 07/08/2025 indicated Resident #9 had a J-Tube for administration of medications and nutrition. A record review of Resident #9's care plan dated 05/21/2025 indicated EBP were to be used when providing care involving the J-Tube.During an observation on 07/08/2025 at 09:08 AM, RN A prepared Resident #9's morning medications for administration through her feeding tube. RN A put on gloves and entered Resident #9's room. Resident #9 had a sign on the doorway entrance into her room which indicated Enhanced Barrier Precautions were required. The sign also said that all providers and staff must wear gloves and a gown for high-contact activities which included feeding tube care or use. There was a 3-drawer plastic container outside the doorway which contained PPE that included gloves and gowns. RN A did not put on a gown. RN A told Resident #9 that she had her medications. RN A checked tube placement and administered the medications through the feeding tube. After completion of the task, RN A removed her gloves, disposed of them, and washed her hands. RN A then returned to her cart and said she was finished. During an interview on 07/08/2025 at 09:12 AM, RN A said she should have put on a gown prior to administering Resident #9's medications because Resident #9 had a feeding tube which required EBP. RN A said EBP was important for preventing the spread of infection. RN A said she forgot to put on a gown because she was nervous. During an interview with the DON on 07/08/2025 at 10:45 AM, she said she expected the nurses to adhere to Enhanced Barrier Precautions when providing direct care to residents with feeding tubes. She said EBP required the wearing of gloves and gowns when providing direct care to residents with indwelling medical devices. She said the purpose was to reduce the risk of spreading infections and diseases. During an interview with the MDS Coordinator on 07/08/2025 at 03:12 PM, she said she was a registered nurse and the Infection Preventionist for the facility. She said nurses were required to wear gloves and a gown when Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675981 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675981 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mineola Gardens Wellness & Rehabilitation 716 Mimosa Street Mineola, TX 75773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)