Health inspection·February 18, 2026

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 2 of 5 staff (CNA A and CNA B) reviewed for competent nursing care.The facility failed to ensure CNA A and CNA B were able to demonstrate competency in the skill of hand hygiene when they failed to perform hand hygiene and change their gloves during incontinent care provided to Resident #8 on 2/18/2026.These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.The findings included:Record review of an admission Record for Resident #8 dated 2/18/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart's inability to pump effectively), anemia (decreased red blood cell production), and osteoporosis (brittle bones).Record review of a Significant Change MDS assessment dated [DATE] indicated Resident #8 had moderate impairment in thinking with a BIMS score of 10. She required partial/moderate assistance with toileting hygiene and was always incontinent of urine/bowel.Record review of a care plan for Resident #8 revised on 2/16/2026 indicated she had a UTI with interventions to check at least every 2 hours for incontinence.During an observation on 2/18/2026 at 9:20 am, CNA A and CNA B entered the room of Resident #8 and did not wash or sanitize their hands and donned (put on) gloves. CNA A and CNA B provided incontinent care and wore the same gloves during the entire procedure that included changing the resident's brief that was soiled with urine, cleaning the perineal and rectal area, applying barrier ointment to the resident's perineal, applied a clean brief, touched the resident and her clothing.During an interview on 2/18/2026 at 9:32 am, CNA B said she had been employed at the facility since August 2025. She said she had a skills check off on hire. When asked about the incontinent care that was provided to Resident #8, she said she should have changed her gloves when she changed from touching dirty items and then clean items. She said she thought she could wear the same pair of gloves during the care if they were not visibly dirty with feces and if they were she would change them. She said she had been observed by nursing staff and never changed her gloves during care that was provided. She said there could be a risk for cross contamination if they did not change gloves.Record review of a CNA competency skill checklist for CNA B dated 8/15/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 9:36 am, CNA A said she had been employed at the facility since March 2025. She said she should have changed her gloves during care after handling dirty items. She said she thought she could wear the same gloves if they were not visibly soiled with feces and she thought they were clean. She said she had a skills check off on hire. She said there was a risk for cross contamination and spreading infections to residents if staff did not change gloves during care.Record review of a CNA competency skill Page 1 of 5 676124 676124 02/18/2026 Pinecrest Retirement Community 1302 Tom Temple Dr Lufkin, TX 75904

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few checklist for CNA A dated 9/5/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 11:26 am, the ADON said she had been employed at the facility since August 2025 and was in her current position since December 2025. She said she was the IP for the facility and responsible for training staff on infection control and risk management. She said staff were trained monthly on infection control that included basic hand hygiene, and perineal care. She said hand hygiene should be performed before, during, and after care was provided. She said gloves should be changed before changing tasks from dirty to clean. Staff should wash their hands between glove changes. She said at no point should staff wear the same gloves from beginning to the end of care nor should they touch clean items with dirty gloves. She said the facility started in-services with the two staff (CNA A and CNA B) on proper hand hygiene and perineal care. She said there was a risk for staff to receive infections or spread infections to other residents. She said the staff were trained per policy with performing hand hygiene and changing gloves.During an interview on 2/18/2026 at 12:00 pm, the DON said she was made aware of the care that was provided to Resident #8 and CNA A, and CNA B were provided 1:1 education on proper care and procedure. She said they conducted monthly random audits on perineal care and hand hygiene. She said hand hygiene should be performed before going in the room, between glove changes, after touching dirty items and when care was completed. She said at no point should staff wear the same gloves and touch clean items with dirty gloves when care was provided. She said new hires were placed with a lead trainer and they completed a skills check off and if there was any remediation the lead trainer would let the ADON or her know and if they needed more training they would get a nurse, ADON/DON to provide training. She said there was a risk of spreading infections to other residents. She said if staff were not trained in the proper steps, it could cause an infection to other residents.During an interview on 2/18/2026 at 1:15 pm, the Administrator said the IP was the ADON and she along with the DON were responsible for training staff on policies and procedures with infection control. She said staff should not wear the same gloves during care provided to residents. She said staff were trained on hire and monthly during random audits observed performing skills. She said there was a risk for infections if staff did not follow policy with infection control and glove changes.Record review of a facility policy titled Staffing, Sufficient and Competent Nursing revised August 2022 indicated, .Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: o. Infection control. 676124 Page 2 of 5 676124 02/18/2026 Pinecrest Retirement Community 1302 Tom Temple Dr Lufkin, TX 75904

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 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 8 residents (Resident #8) reviewed for infection control.The facility failed to ensure CNA A and CNA B followed contact precautions, changed their gloves, and did not touch clean items with dirty gloves when incontinent care was provided to Resident #8 on 2/18/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #8 dated 2/18/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart's inability to pump effectively), anemia (decreased red blood cell production), and osteoporosis (brittle bones).Record review of active physician orders for Resident #8 dated 2/18/2026 indicated she had an order for enhanced barrier precautions that started on 1/16/2026.Record review of a care plan for Resident #8 revised on 2/16/2026 indicated she was on contact isolation precautions related to an abnormal UA and was on antibiotics. Interventions included following facility isolation policy.Record review of a Significant Change MDS assessment dated [DATE] indicated Resident #8 had moderate impairment in thinking with a BIMS score of 10. She required partial/moderate assistance with toileting hygiene and was always incontinent of urine/bowel.During an observation on 2/18/2026 at 9:20 am, at the room of Resident #8 there was a sign on the door for contact precautions. CNA A and CNA B entered the room and did not wash or sanitize their hands and donned (put on) gloves. Neither staff donned a gown. CNA A pulled Resident #8's pants down to her ankles and opened her brief and pulled it down between her thighs. CNA A removed a wipe from the package and wiped her left inner thigh, right inner thigh and down the middle of her vagina from front to back. CNA B rolled Resident #8 onto her right side and removed a wipe from the package and wiped her rectal area from front to back and removed the brief and placed it in the trash. CNA B placed a clean brief under the resident's buttocks without changing her gloves and applied barrier ointment. The brief was secured, and the resident was repositioned in bed. Her pants were pulled back up. The room had two boxes with biohazard bags that were yellow and red in color, and it also had a container of PPE that included N95 masks, gowns, and face shields. CNA B removed her gloves and placed them in the trash and washed her hands. CNA A removed her gloves and placed them in the trash.During an interview on 2/18/2026 at 9:32 am, CNA B said she had been employed at the facility since August 2025. She said she had a skills check off on hire. When asked about the incontinent care that was provided to Resident #8, she said she should have changed her gloves when she changed from touching dirty items and then clean items. She said she did not notice the sign on the door for contact precautions and did not wear a gown when care was provided. She said she did not think about it. She said she should have washed or sanitized hands before care was started. She said she thought she could wear the same pair of gloves during the care if they were not visibly dirty with feces and if they were she would change them. She said she had been observed by nursing staff and never changed her gloves during care that was provided. She said there could be a risk of cross contamination if they did not change gloves or wear a gown when a resident was on contact precautions.Record review of a CNA competency skill checklist for CNA B dated 8/15/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 9:36 am, CNA A said she had been employed at the facility since March 2025. She said there was a sign on Resident #8's door but she did not pay any attention to it. She said she should have worn a gown when care was Residents Affected - Few 676124 Page 3 of 5 676124 02/18/2026 Pinecrest Retirement Community 1302 Tom Temple Dr Lufkin, TX 75904

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few provided. She said she should have sanitized or washed her hands before care was started. She said she should have changed her gloves during care after handling dirty items. She said she thought she could wear the same gloves if they were not visibly soiled with feces and she thought they were clean. She said she had a skills check off on hire. She said there was a risk for cross contamination and spreading infections to residents if staff did not change gloves during care.Record review of a CNA competency skill checklist for CNA A dated 9/5/2025 indicated she was observed performing perineal care and infection control.During an interview on 2/18/2026 at 11:26 am, the ADON said she had been employed at the facility since August 2025 and was in her current position since December 2025. She said she was the IP for the facility and responsible for training staff on infection control. She said staff were trained monthly on infection control that included basic hand hygiene, and perineal care. She said Resident #8 was on EBP for MDRO with a current active infection that placed her on contact precautions that were implemented on 2/13/2026 and prior to that had a different sign on the door for EBP. She said if a resident was on contact precautions then that meant the resident had a MDRO and required signage on their doors along with proper disposing bins and PPE in the rooms. She said staff should wear appropriate PPE that included a gown and gloves if a resident was on contact precautions. She said hand hygiene should be performed before, during, and after care was provided. She said gloves should be changed before changing tasks from dirty to clean. Staff should wash their hands between glove changes. She said at no point should staff wear the same gloves from beginning to the end of care nor should they touch clean items with dirty gloves. She said the facility started in-services with the two staff (CNA A and CNA B) on proper hand hygiene and perineal care. She said there was a risk for staff to receive infections or spread infections to other residents. She said the staff were trained per policy with performing hand hygiene and changing gloves.During an interview on 2/18/2026 at 12:00 pm, the DON said she was made aware of the care that was provided to Resident #8 and CNA A, and CNA B were provided 1:1 education on proper care and procedure. She said they conducted monthly random audits on perineal care and hand hygiene. She said if a resident was on contact precautions, then staff should wear a gown and gloves when care was provided. She said hand hygiene should be performed before going in the room, during care, between glove changes, after touching dirty items and when care was completed. She said if a resident was on contact isolation, then the staff needed to wash their hands with soap and water but could use sanitizer unless stool was involved. She said at no point should staff wear the same gloves and touch clean items with dirty gloves when care was provided. She said new hires were placed with a lead trainer and they completed a skills check-off and if there were any remediation the lead trainer would let the ADON or her know and if they needed more training they would get a nurse, ADON/DON, to provide training. She said there was a risk of spreading infections to other residents. She said if staff were not trained in the proper steps, it could cause an infection to other residents.During an interview on 2/18/2026 at 1:15 pm, the Administrator said the IP was the ADON and she along with the DON were responsible for training staff on policies and procedures with infection control. She said staff should not wear the same gloves during care provided to residents. She said staff were trained on hire and monthly during random audits observed performing skills. She said there was a risk of infections if staff did not follow policy with infection control and glove changes. She said if residents were on EBP staff should wash hands and wear gowns and gloves.Record review of a facility policy titled Enhanced Barrier Precautions dated August 2022 indicated, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 676124 Page 4 of 5 676124 02/18/2026 Pinecrest Retirement Community 1302 Tom Temple Dr Lufkin, TX 75904

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A. gloves and gowns are applied prior to performing the high contact resident care activity. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: f. changing briefs.Record review of a facility policy titled Isolation-Initiating Transmission-Based Precautions revised August 2019 indicated, .Transmission-Based Precautions may include Contact Precautions. D. Determines the appropriate notification on the room entrance door; e. ensures that protective equipment (i.e., gloves, gowns, masks, etc.) .Record review of a facility policy titled Handwashing/Hand Hygiene revised August 2019 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. before and after coming on duty; b. before and after direct contact with residents; i. after contact with a resident's intact skin; j. after contact with blood or bodily fluids. 676124 Page 5 of 5