Health inspection·December 9, 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 disease and infection for 1 of 2 residents (Residents #1) reviewed for infection control:The facility failed to ensure CNA A utilized hand hygiene between glove changes during peri-care on Resident #1. This failure could place residents at-risk for infection due to lack of hand hygiene and could result in infection or illness.The findings included:Record review of Resident #1's face sheet dated 10/30/25 revealed a [AGE] year-old female admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included encephalopathy (general term used to describe any disease or disorder that affects the structure or function of the brain), memory deficit, Parkinson's disease (progressive neurological disorder that affects movement), muscle wasting and atrophy (wasting away or decrease in size of a body part, tissue, or organ), lack of coordination, and retention of urine.Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills, required substantial/maximal assistance with mobility, and was frequently incontinent of bladder, and always incontinent of bowel.Record review of Resident #1's comprehensive care plan with revision date 10/15/25 revealed the resident had bowel/bladder incontinence and used incontinence briefs with interventions that included changing every 2 hours and as needed for incontinence.During an observation on 10/31/25 at 9:01 a.m. of incontinent/peri care to Resident #1 revealed CNA A washed her hands with soap and water, returned to Resident #1's bedside, took the bed remote and raised the resident's bed and lowered the head of the bed. CNA A then took a pair of gloves and put them on without utilizing hand hygiene. CNA A then used several wipes and provided incontinent/peri care to Resident #1's vaginal area. CNA A then completed incontinent/peri care to Resident #1's rectal area and buttocks with the same gloves used to provide incontinent/peri care to the resident's vaginal area. During an interview on 10/31/25 at 9:15 a.m., CNA A stated she should have changed her gloves when providing incontinent/peri care and when moving from Resident #1's vaginal area to the rectal/buttock area. CNA A stated she should have utilized hand hygiene before putting on a pair of gloves after using Resident #1's bed remote because it was considered a break in infection control and was cross contamination. CNA A stated she had done computer training on hand hygiene and infection control practices approximately a month ago. CNA A stated she was nervous.During an interview on 10/31/25 at 10:40 a.m., the DON stated that it was her expectation when CNA A completed incontinent/peri care to Resident #1's vaginal area, CNA A should have utilized hand hygiene and changed her gloves when moving to the resident's rectal and buttock area for infection control purposes and it was considered cross contamination which could potentially give Resident #1 an infection. Record review of the facility CNA/CMA Competency Checklist for CNA A, dated 8/5/25 revealed CNA A had satisfied the requirements for utilizing proper hand Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676312 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 676312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - West S 222 Bertetti Dr San Antonio, TX 78227 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)