Health inspection·September 19, 2024

F 0695 the concentrator in his room with the nose prongs on floor . Level of Harm - Minimal harm or potential for actual harm In an Interview on 09/18/2024 at 4:45 PM the DON stated oxygen tubing was changed weekly based on the resident's orders, or as needed if the tubing become contaminated or occluded. The DON said oxygen tubing and the humidifier bottle should be changed per doctor's orders and the nasal cannula should have been stored in a plastic bag when not in use to prevent cross contamination and infection. He said the charge nurses were responsible for seeing that it was done. Residents Affected - Few In an Interview on 09/18/2024 at 5:00 PM the Administrator stated the resident care was handled by the nursing department and nasal cannulas should be put in a plastic bag when not in use. The facility was unable to provide a policy for Respiratory Therapy -Prevention of Infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676091 If continuation sheet Page 2 of 4 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 676091 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagecrest Alzheimers Care Center 438 Houston-Harte San Angelo, TX 76903 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)

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 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 one (Resident #11) of two residents reviewed for infection control practices. Residents Affected - Few CNA A failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #1 This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #11's face sheet, dated 9/19/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of urinary tract infection, essential hypertension (high blood pressure), chronic kidney disease (loss of kidney function). Review of Resident #11's Minimum Data Set (MDS) assessment dated on 09/3/24, revealed Resident #11, BIMS score of 15 (cognitively intact), required partial/moderate dependence with most activities of daily living (ADL's) with two-person assistance. She was frequently incontinent of bowel and bladder. Observation on 9/18/24 at 5:56 PM of incontinence care for Resident #11 revealed CNA A assisted the resident to bed. CNA A put on gloves, removed the brief that was soiled with urine and feces from Resident #11. CNA A wiped the resident from front to back with wipes, cleaning both urine and feces. CNA A gloves were soiled with urine and feces, but she continued to use. CNA A did not change gloves or perform hand hygiene but proceeded to retrieve Resident #11's clean brief. CNA A placed the clean brief on the resident, fastened the brief, then pulled up pajama pants into position on the resident . In an interview on 9/18/24 at 6:06 PM CNA A stated that after performing pericare including cleaning urine and fecal material from the resident, her hands/gloves were dirty. CNA A further stated that when going from dirty to clean they should always perform proper hand hygiene and lack of doing so could cause infections . Interview on 9/18/24 at 6:16 PM with the DON revealed his expectation was for clinical staff to follow infection control policy and use proper hand hygiene. The DON further stated that not following proper hand hygiene could lead to cross contamination and infection. The DON also stated that the clinical staff was responsible for following infection control policy and that he was ultimately responsible infection control. Interview on 9/19/24 at 11:55 AM the Administrator revealed her expectation was for staff to follow infection control policy and to use proper hand washing including washing between dirty and clean. The ADM further stated that lack of doing so could cause infection. ADM also stated that everyone in facility is responsible for infection control and proper hand hygiene. Review of Hand Hygiene policy from BRS Operations and Service Standards Manual revised on July 16, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676091 If continuation sheet Page 3 of 4 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 676091 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagecrest Alzheimers Care Center 438 Houston-Harte San Angelo, TX 76903 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)

F 0880 2024 indicated the following [in-part]: Level of Harm - Minimal harm or potential for actual harm Service Standard: Handwashing is the most important procedure to follow to prevent the spread of infection. Residents Affected - Few Associates are expected to follow the CDC guidelines related to hand hygiene. Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: After touching contaminated items Review of Clinical Safety: Hand Hygiene for Healthcare Workers from the Centers for Disease Control and Prevention (https://www.cdc.gov/handhygiene/providers/index.html ) accessed on 9/19/24 indicated the following: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. When to change gloves and clean hands If gloves become damaged. If gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. If moving from care on one patient to another patient. If they look dirty or have blood or body fluids on them after completing a task. Before exiting a patient room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676091 If continuation sheet Page 4 of 4