Inspection·February 28, 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 residents (Resident #1) reviewed for infection control. Residents Affected - Few The DON and RN A failed to follow EBP procedures by not wearing a gown while providing Resident #1 wound care. This failure could place residents at risk for cross contamination and infection. The findings include: Record review of Resident #1 's admission record revealed Resident #1 was an [AGE] year-old male with an admission date to the facility of 08/01/2015. admission record revealed Resident #1 had diagnoses list that included acute osteomyelitis (Inflammatory condition of bone secondary to infection) left ankle and foot, type II diabetes, muscle weakness, mild protein calorie malnutrition, peripheral vascular disease (narrowing/blocking of the blood vessels), hypertension, and cerebral infarction (stroke). Record review of Resident #1 's quarterly MDS dated [DATE] revealed the resident had a BIMS of 15 indicating the resident was cognitively intact. Record review of Resident #1 's order summary revealed an order dated 02/03/2025 of Cleanse venous stasis ulcer to left distal great toe with wound cleanser. Pat dry, cover with therahoney, then cover dressing, every Monday, Wednesday Friday, util healed one time a day every Mon, Wed, Fri for wound care. Record review of Resident #1 's Care plan dated 12/30/2024 revealed a focus of Resident is on Enhanced Barrier Precautions. Observation on 02/26/2025 at 2:48 pm the DON nor RN A put on a gown prior to or during wound care for Resident #1. During an interview on 02/27/2025 at 4:30 pm with the DON, whom was also the infection preventionist, stated that Resident #1 is on EBP (Enhanced Barrier Precautions) and she and RN A should have been wearing a gown during wound care. The DON stated that she did not think about it and they had been so busy. The DON stated that this failure is a potential for cross contamination. (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: 676068 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 676068 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901 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)