Health inspection·December 10, 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 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, and to help prevent the development and transmission of communicable diseases and infections, for two residents (Resident #1 and Resident #2) of twelve residents observed for infection control practices. The facility failed to ensure a sanitary environment for Resident #1 and Resident #2. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included: Review of Resident #1's face sheet dated 12/10/2025 revealed Resident #1 was a [AGE] year-old female who was readmitted to the facility on [DATE]. She has diagnoses of right hip fracture, protein-calorie malnutrition, anxiety disorder, insomnia, chronic kidney disease, high blood pressure, past heart attack, dementia, high cholesterol, coronary artery disease with angina pectoris (cholesterol or fat narrows the heart arteries causing chest pain), obstructive and reflux uropathy (a blockage in the urinary tract with urine flowing backward), magnesium deficiency, vitamin D deficiency, iron deficiency and presence of a cardiac pacemaker (a device that regulates her heart beats). Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of a zero which indicated that her cognition was severely impaired. Review of Resident #1's Comprehensive Care Plan dated 12/1/2025 revealed the resident had a urinary catheter and was at risk for a urinary infection. An intervention with an initiation date of 11/10/2025 reflected that the staff should monitor, record and report to the physician any signs of a urinary tract infection including pain, burning, blood-tinged urine, foul-smelling urine, fever, chills, urinary frequency, altered mental status and changes in behavior. Resident #1 had the need for Enhanced Barrier Precautions (due to surgical incisions and foley) and was at increased risk for infection. An intervention with an initiation date of 11/13/2025 reflected that staff must assess the resident for risk factors or current injuries or treatments that could put the patient at risk for infection (wounds, central lines, drains, catheters and tracheostomy). Review of Resident #1's physician orders with a start date of 11/13/2025 reflected an order for Enhanced Barrier Precaution: Use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices). An order with a revision date of 11/24/2025 reflected please exchange the foley catheter under sterile technique. Obtain Sample for UA with reflex for culture from new foley. Then cleanse with Theraworx foam around foley. An order with a start date of 11/24/2025 reflected WOUND CARE DTI to left heel Cleanse with NS/WC. Pat dry with gauze. Apply skin prep and LOTA. An order for wound care with a start date of 12/1/2025 reflected Unstageable pressure wound to left gluteus Cleanse with Dakin's 1/4 strength. Pat dry with gauze. Apply calcium alginate to wound bed and cover with a dry dressing.Review of Resident #2's face sheet dated 12/10/2025 revealed Resident #2 was an [AGE] year-old male who was admitted to the Residents Affected - Some Page 1 of 3 676222 676222 12/10/2025 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] and readmitted on [DATE] with the following diagnoses: Hyperlipidemia, Protein-calorie malnutrition, Type II Diabetes Mellitus, Dementia, Anemia, Thrombocytopenia (deficiency of platelets in the blood), Insomnia, Gastro-esophageal reflux disease, Malignant Neoplasm (tumor) of Colon, Essential Hypertension, Ischemic Cardiomyopathy (a serious heart condition where poor blood flow from Coronary Artery Disease weakens the heart muscle, reducing its ability to pump blood), Chronic Systolic Congestive Heart Failure (when the heart's main pumping chamber weakens and can't contract forcefully enough to pump blood out, leading to fluid backup in the lungs and body), fracture of right hip and fracture of right pubis (pair of bones forming the two sides of the pelvis). Review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 7 which indicated that his cognition was severely impaired. Review of Resident #2's Comprehensive Care Plan initiated on 11/3/2025 revealed that the resident is at risk for neuropathy, vision impairment, DKA, kidney disease, foot damage, skin damage/breakdown, hearing impairment, digestive impairment, problems with teeth and gums r/t to dx of Diabetes Mellitus with an intervention to monitor/document/report PRN any s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Another intervention for Resident #2 was if infection is present, consult doctor regarding any changes in diabetic medications. Another problem on the care plan revised on 11/24/2024 revealed that the resident has impaired cognitive function/impaired thought processes AEB Difficulty making decisions, Impaired decision-making secondary to Dementia. Is at risk for infection, falls, impaired verbal communication, loss of ability to do ADL's, inability to interact with others, reduced lifespan, personality changes, difficulty reading/writing, poor judgment, delusions, agitation, difficulty swallowing, incontinence, withdrawing from social contact, and change in sleep patterns with an intervention to communicate with the resident/family/caregivers regarding residents capabilities and needs. An observation on 12/10/2025 at 11:23 AM reflected that MA A entered the room for Resident #1 and removed the blood pressure cuff from her wrist. She left Resident #1's room. She did not perform hand hygiene or wash her hands after leaving Resident #1's room. She entered Resident #2's room. She removed the blood pressure cuff from Resident #2's upper arm. She did not perform hand hygiene or wash her hands before touching Resident #2 or after leaving Resident #2's room. In an interview on 12/10/2025 at 11:25 AM, MA A stated that she did not perform hand hygiene between going from Resident #1's and Resident #2's rooms. MA A stated that she did not perform hand hygiene before or after touching the residents. She stated that she should have performed hand hygiene before and after providing care to residents and before and after entering their rooms. She stated that the impact to the residents was that she could potentially spread infections if she did not wash her hands or perform hand hygiene after resident care or between going from room to room. In an interview on 12/10/2025 at 1:35 PM, the ADMIN stated that he expected staff to wash their hands between caring for residents and between entering and leaving resident rooms. He stated that he would start an in-service on hand hygiene and initiate a write up for the staff involved. The ADMIN stated that he knew who did not perform hand hygiene or wash their hands. He stated she did know better. He stated that if staff do not perform hand hygiene according to the facility policy, they could potentially get a resident sick.In an interview on 12/10/2025 at 5:24 PM, the DON stated that staff should perform hand hygiene or wash their hands before and after touching a resident or providing care. She stated they should wash their hands for 20 seconds when they are soiled. She stated that they should perform hand hygiene or wash their hands before and after putting on and taking off gloves. She stated that she conducted an in-service for the staff that day regarding her expectations on hand hygiene. She stated that she will start performing random observations to ensure that the staff are washing their hands. She stated that 676222 Page 2 of 3 676222 12/10/2025 Bastrop Lost Pines Nursing and Rehabilitation Cent 430 Old Austin Hwy Bastrop, TX 78602

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the staff could potentially spread infections or cross-contaminate the environment by not performing hand hygiene according to the facility's hand hygiene policy.Review of the facility hand hygiene policy dated 10/24/2022 reflected that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is defined as a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.Review of the facility infection prevention and control program policy dated 5/13/2023 reflected the facility has established and maintains 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 as per accepted national standards and guidelines. The policy defines staff as all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. Under the Standard Precautions paragraph, the policy reflected that all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. It also reflected that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. 676222 Page 3 of 3