Health inspection·February 19, 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 and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) and of 1 of 2 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes and that she changed gloves when going from dirty area to clean area on 2/19/26 during perineal care for Resident #5. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings include: Record review of a facility face sheet dated 2/19/26 for Resident #5 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently re-admitted on [DATE] with diagnosis of encephalopathy (brain disease, damage, or malfunction that causes an altered mental state). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated she had a BIMS score of 7, which indicated she had severely impaired cognition. She was dependent on staff for toileting hygiene and was always incontinent to bowel and bladder. Record review of a comprehensive care plan dated 1/30/26 for Resident #5 indicated she had an ADL self-care performance deficit and had an intervention that read: .toileting: requires extensive assist X1 staff participation. During an observation on 2/19/26 at 2:35 pm CNA A was observed providing incontinent care to Resident #5. She was observed to wash her hands upon entrance to room. She was then observed to put on gloves before unfastening the resident's brief and proceeding to clean peri-area. After cleaning peri-area, she then rolled resident over and removed soiled brief. Without removing dirty gloves, she disposed of soiled brief in trash bag, then removed her gloves and applied new gloves without performing hand hygiene. She proceeded to clean resident's rectal area, and without removing dirty gloves, she was observed to retrieve a clean draw sheet. She was observed putting the clean draw sheet underneath the resident, along with the clean brief, still wearing gloves that she wore during cleaning rectal area. She then rolled the resident back over, fastened the brief, straightened the draw sheet and repositioned the resident. CNA A then removed her gloves, tied trash bag and washed her hands before exiting room. During an interview on 2/19/26 at 2:50 pm CNA A said she did not perform hand hygiene when she changed her gloves. She said she did not know if she changed her gloves after cleaning resident's rectal area and before applying new brief and clean draw sheet. She said she knew she was supposed to use sanitizer when she changed her gloves. She said residents could be at risk for infections if proper hand hygiene was not performed. She said she must have just forgotten because she was nervous. During an interview on 2/19/26 at 3:10 pm the ADON said she expected her staff to wash their hands and use sanitizer between glove changes. She said it put residents at risk for UTI's, infections, or possibly skin breakdown. She said going forward, she would provide further education for staff members. During an interview on 2/19/26 at 3:20 pm Administrator (interim) said he expected the staff to follow policies and Residents Affected - Few Page 1 of 2 676147 676147 02/19/2026 Stallings Court Nursing and Rehabilitation 4616 NE Stallings Dr Nacogdoches, TX 75965

F 0880 Level of Harm - Minimal harm or potential for actual harm procedures regarding infection control. He said going forward, they would provide more skills checkoffs and in-services. Record review of a facility policy titled Handwashing/Hand Hygiene dated August 2015 read: .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care; and .after removing gloves. Residents Affected - Few 676147 Page 2 of 2