Health inspection·February 18, 2026

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) reviewed for wound care.- LVN A failed to utilize proper hand hygiene and glove practices during wound care for Resident #1. This failure could place residents at risk for cross contamination and infection.Findings included:Record review of Resident #1's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #1 had a medical history of acute respiratory failure (when the lungs cannot properly oxygenate the blood or remove carbon dioxide), dependence on respirator ventilator status, pressure ulcer of the sacral region (triangular bone at the base of the lumbar vertebrae and between the hip bone) and quadriplegia (paralysis affecting all four limbs and the torso).Record review of Resident #1's quarterly MDS , dated 11/12/2025, Section C- Cognitive Pattern, revealed a BIMS score of seven which indicated Resident #1 had severe cognitive impairment.Record review of Resident #1's care plan, dated 04/01/2025, revealed, [Resident #1] has a pressure ulcer or potential for pressure ulcer development: . Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD . Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN,. The care plan revealed an intervention for Enhanced Barrier Precaution , dated 4/01/2025, with the following, Gloves and gown should be donned (put on) if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care (delivers liquid nutrients directly into the stomach or small intestine), catheter care, trach ( a surgically created opening (stoma) in the neck leading directly to the trachea (windpipe) to facilitate breathing care, bathing, or other high-contact activity.Record review of Resident #1's physician orders, dated 02/06/2026, revealed, TX to stage 4 Pressure wound (a severe, full-thickness wound extending deep into muscle) of the left buttock cleanse with vashe (solution designed for cleaning, irrigating, and moistening acute and chronic wounds) wound cleanser.iodosorb gel (antimicrobial wound dressing designed to treat chronic wounds).collagen (wound care dressing to accelerate healing) then calcium alginate (a natural, highly absorbent wound dressing ).cover with gauze island (a sterile, multi-layer, self-adhesive bandage used for wound care).daily and prn. Physician orders further revealed, TX of the sacrum (a triangular bone in the lower back): cleanse with vashe wound cleanser.iodosorb gel (antimicrobial wound dressing designed to treat chronic wounds).collagen then calcium alginate.cover with gauze island.daily and prn.During a wound care observation on 2/17/2026 at 3:40 p.m. for Resident #1 , LVN A put on a pair of gloves and a gown that had thumb holes. The thumb holes went over the first pair of gloves. LVN A proceeded to put a second pair of gloves over the first pair of gloves. LVN A removed Residents Affected - Few Page 1 of 3 676028 676028 02/18/2026 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1's wound dressings from the sacrum and left buttock. LVN A removed the top pair of gloves from both her hands and placed a new glove, over the first glove, to the right hand only. LVN A did not utilize hand hygiene and maintained the first pair of gloves on to both hands. LVN A used the right hand to clean the sacrum wound, removed the right top glove with the left gloved hand and donned a new glove over the first glove, to the right hand only. LVN A applied the treatment and dressing to the sacrum and removed the glove from the right hand. LVN A again utilized the left gloved hand to remove the dirty top glove from the right hand. LVN A did not put on a new glove to either hand. LVN A utilized the first pair of base gloves to clean the left buttock wound. LVN A removed gloves from both hands, used ABHS and donned new gloves. LVN A applied treatment to Resident #1's left buttock wound and removed the glove from the right hand, using her left hand. LVN A used the left gloved hand again to put on a new glove to the right hand and dressed the wound.During an interview with LVN A on 2/17/2026 at 4:00 p.m., she stated she was not trained on wound care upon hire in January of 2026. She stated she had been a nurse for approximately 30 years in Ohio. She stated she did not have any form of competency check-off and all she knew was from her previous training courses in her career. She stated she was aware Resident #1 had a history of MDRO and required contact precautions to prevent the spread of infection. She stated she double gloved (placed two pairs of gloves over each other) during the wound care because she had done so when she worked in home care. She stated she was concerned about the gloves breaking and getting something on her, as that had happened to her in her previous job and was trying to keep herself and the resident safe. She stated she was not sure why she double gloved this time as she had not been doing that in the past and it was her first time doing so with Resident #1. She stated she did not change the glove to her left hand with each glove change because she had not used it during the wound care, so it was not dirty. She stated she removed the right-hand glove carefully and felt the left-hand glove was not contaminated. She stated hand hygiene was used between glove changes because there could be a potential for contamination during the care or when removing gloves. She stated a potential negative outcome of double gloving could be potentially contaminating the second pair of gloves and spreading infection. LVN A stated, I don't know why we need to change both gloves if we are just using one hand. I guess I was thinking of sterile technique, but I guess the clean glove could technically become soiled and contaminate the new glove since it is not being changed out.During an interview on 2/17/2026 at 4:52 p.m., the Regional Compliance Nurse (RCN) stated she was responsible for training the nursing staff, and trained LVN A, upon hire. She stated she did one on one wound care observations and training with LVN A prior to LVN A assuming her duties. She stated she had conducted the training for LVN A from 1/26/2026 to 1/29/2026. She stated LVN A was not trained to double glove and had not observed LVN A do that during the wound care observations. She stated she would be providing additional training to LVN A prior to resuming as the wound care nurse. RCN stated double gloving and not changing both gloves during wound care could have the potential for spreading infection.During an interview on 2/18/2026 at 11:44 a.m., the ADM stated the RCN had been conducting the training for the new nursing staff as they did not have a DON at that time. He stated they had a new DON that was hired approximately three weeks ago and two new ADONs that would assume the training responsibilities. He stated infection control training was done yearly and as needed and they would be doing an in-service training regarding proper glove usage. He stated it was never appropriate to utilize double gloving during any resident care for any staff member. He stated the potential risk of not using proper glove technique and hand hygiene could be potentially spreading infection. He stated LVN A should have removed both gloves and utilized ABHS in between glove changes while she provided wound care.Record review of facility policy 676028 Page 2 of 3 676028 02/18/2026 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few titled, Fundamentals of Infection Control Precautions undated revealed, You may use alcohol-based hand cleaner or soap/water for the following: .Before and after changing a dressing.after removing gloves or aprons.after handling soiled or used linens, dressings, bedpans, catheters and urinals. In addition, gloves or the use of baby wipes are not a substitute for hand hygiene.Gloving. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.Failure to change gloves between resident contacts is an infection control hazard.Record review of facility email dated 2/9/2026 at 8:49AM from RCN to ADM revealed; Entrance: 1/26-1/29.Specifics: Wound care nurse training. Training completed on [EMR] Weekly skin assessments to be completed by the wound care nurse. Shower schedule must be done by wound care nurse, update list and task in [EMR] Wound care must be completed by wound care nurse, do not delegate wounds to floor nurses. Step by step education provided on ulcer assessments/ non pressure ulcer assessments and care plans. All new admission and readmission skin assessments must be completed by the wound care nurse, on weekends and after hrs [hours] admissions/readmissions please do a second skin assessments. Per [facility] expectations, wound care nurses do not have an office. Wound care nurses must be in the on-call schedule. Education provided on EBP, how to put orders on special instructions, task and care plan updates. 676028 Page 3 of 3