Health inspection·August 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 review, the facility failed to 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 2 (Residents #1 and #2) of 5 residents reviewed for infection control.The facility failed to ensure RN A and MA B used personal protective equipment during a transfer when the residents were on enhanced barrier precautions. The facility failed to ensure RN A washed his hands correctly while completing wound care on Resident #1. These failures could place residents at risk for cross contamination and the spread of infection. Findings included:Resident #1Review of Resident #1's admission Record, dated 8/28/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a type of dementia) and chronic ulcer of the right foot with muscle involvement (Resident #4 had a sore that was deep enough to affect muscle tissue). Review of Resident #1's MDS Assessment, dated 6/16/25, revealed she had long and short-term memory impairment with severely impaired decision-making ability. She had one stage III pressure ulcer (the skin was completely gone which might expose fat, but bone or tendon were not exposed). Review of Resident #1's care plan, 4/9/24, revealed a goal of the resident had a potential for pressure ulcer development. The identified goal was the resident would have intact skin, free of redness, blisters or discoloration, by/through the review date. Identified interventions did not include anything related to wound care or enhanced barrier precautions. Review of the Order Summary, dated 8/28/25, revealed orders dated 8/26/25:Clean lateral right foot, apply skin prep (skin cleaner) around wound to prevent maceration (skin made soft by exposure to fluid(s)), apply collagen particles (a protein powder to assist in wound care), cover with bordered foam (type of bandage with foam in center and adhesive all the way around the bandage) every day shift related to other skin changes. Observation on 8/28/25 at 10:21 a.m. revealed there was no sign indicating Resident #1 was supposed to be on enhanced barrier protection and there was no personal protective equipment in the room. Continued observation showed RN A did not put on personal protective equipment prior to entering Resident #1's room. RN A washed his hands five times but did not use a paper towel to turn off the faucet when he washed his hands. Resident #1 was not interviewable. Interview on 8/28/25 at 1:05 p.m. RN A stated the proper way to hand wash was to rinse hands, get soap, lather, rinse hands, use paper towels to turn off the faucet, and then throw paper towels. RN A said to the best of his remembrance he washed his hands correctly. RN A said, I washed my hands multiple times, and can't say I washed them right every time. Interview on 8/28/25 at 1:55 p.m., the DON stated staff were expected to do hand hygiene after they touched bodily fluids or resident contact. The DON said she expected staff to wash their hands by turning on the water, put their hands in water, soap and lather for 20 seconds, rinse their hands, let hands drip-dry, grab a paper towel, pat hands dry, and turn off the water faucet with a paper towel and throw the towel away. The DON said there were annual checkoffs for hand Residents Affected - Some Page 1 of 3 676068 676068 08/28/2025 Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some washing procedures, but she did not do random checks. Interview on 8/28/25 at 2:36 p.m., RN A stated enhanced barrier precaution was used for residents with tubes and some kind of wound. RN A said he did not wear personal protective equipment when he did the wound care on Resident #1. RN A explained he did not see a sign when he went into the room and there was no tower (bin) of personal protective equipment to trigger him into thinking about it. Resident #2:Review of Resident #2's admission Record, dated 8/28/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra and lumbosacral region (infection in the bones of the lower back). Resident #2 was still in her MDS Assessment time frame. Record review of Resident #2's Care Plan, initiated 8/28/25, revealed the resident had intravenous (IV) access. The goal was the resident would not have any complication related to IV therapy through review date. Identified interventions included Administer IV medications as ordered. Review of Resident #2's Care Plan, initiated 8/28/25, revealed the resident was on enhanced barrier precautions. Identified interventions included gloves and gown should be donned (put on) if any of the following activities were to occur transfer or other high-contact activity. Posting at the resident's room entrance indicating the resident was on enhanced barrier precautions. Review of Resident #2's Care Plan, initiated 8/28/25, revealed Resident #2 was at risk for falls related to (blank). Identified goals included the resident would be free of falls through the review date. Identified interventions included staff x1 to assist with transfers. Observation on 8/28/25 at 4:32 p.m. revealed no Enhanced Barrier Sign posted outside of Resident #2's room or above the resident's bed. MA B did not put on gloves or personal protective equipment. There was a bin full of personal protective equipment inside Resident #2's room. MA B did not put on personal protective equipment prior to completing a one-person transfer with Resident #2. Interview on 8/28/25 at 1:55 p.m., the DON stated with residents on Enhanced Barrier Protections the rooms had bins had gloves, gown and gowns outside of their rooms if needed. The DON said the expectation was the staff were to put on the personal protective equipment prior to going into a resident room. The DON said the personal protective equipment was to be worn during wound care, so it did not infect the wound. Interview on 8/28/25 at 2:58 p.m., the Corporate RN stated Enhanced Barrier Protection was indicated when there was an Intravenous therapy or wounds. The Corporate RN said the staff were to wear personal protective equipment to avoid sharing organisms with the resident. Review of the facility's policy and procedure on Fundamentals of Infection Control Precautions, undated, version 03-8.0, revealed, in part: A variety of infection control measures are used for decreasing risk of transmission or microorganisms in the facility.Hand Hygiene: Hand Hygiene continues to be the primary means of prevention the transmission of infection. The following is a list of some situations that require hand hygiene: before and after isolation precaution settings; before and after changing a dressing; after handling used or soiled dressings.Consistent use by staff of proper hygiene practices and techniques is critical to preventing the spread of infections. Recommended techniques for washing hands with soap and water include: wetting hands first with clean, running warm water, applying the amount of product recommended by the manufacturer to hands, and rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers, then rinsing hands with water and drying thoroughly with a new disposable towel, and turning off the faucet on the hand sink with the disposable paper towel. Review of the facility's policy and procedure on Enhanced Barrier Precautions, effective 4/1/24, revealed: Multidrug-resistant organism transmission is common in long term care. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with [NAME]-drug resistant organisms. Enhanced Barrier precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that 676068 Page 2 of 3 676068 08/28/2025 Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some employ targeted gown and glove use during high contact resident care activities. Enhanced barrier precautions are used in conjunction with standard precautions and expand the use of personal protective equipment to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms to staff hands and clothing. Enhanced barrier precautions are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a multi-drug resistant organisms. Wounds generally include chronic wounds, not shorter-lasting wounds, such as wound breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. The facility will ensure personal protective equipment and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident's room. The facility will utilize postings outside the room and the electronic document program to communicate to staff if a resident requires enhanced barrier protections. 676068 Page 3 of 3