Health inspection·August 2, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care tasks. ADON M confirmed the name of the three staff shown in the video. ADON M identified LVN A as the staff who implemented the dressing application and then administered an injection. After viewing the video, ADON M confirmed LVN A did not perform hand hygiene between the wound care dressing application and injection administration. She stated according to facility policy and CDC guidelines, staff must perform hand hygiene, before and after wound dressing application, incontinence care, and before performing another clean or invasive task like an injection to prevent cross-contamination.Interview with the Administrator on 08/01/2025 at 4:30 PM, the Administrator stated that the facility's Director of Nursing (DON), who also served as the Infection Preventionist, was out of the facility on vacation. The Administrator indicated that she was the designated backup Infection Preventionist while the DON was out. The Administrator stated the facility had not received information regarding LVN A not wearing gloves during the wound care dressing change for Resident #1. She stated if the information had been emailed, it was possible that it had been overlooked due to the large number of emails from the family, despite being advised about the importance of following the grievance process to ensure concerns related to Resident #1 were thoroughly investigated and appropriate interventions were implemented to ensure the safety and well-being of each resident. The Administrator affirmed that all staff were expected to adhere to the facility's infection control policy. She stated standard precautions such as hand hygiene should always be implemented before and after staff tasks such as administering an injection or applying wound dressing. She stated the shortcoming of LVN A not wearing gloves was a breakdown in staff adherence to infection control training and could have placed both staff and residents at an increased risk for cross-transmission and infection. The Administrator stated the facility had provided ongoing infection control training to all staff to prevent such action. She stated the most recent training was conducted in 07/2025. She stated the DON, Administrator, and ADON was responsible for ensuring staff implemented infection prevention measure. She stated compliance is assessed during facility environmental and safety rounds. Interview with the CNA A on 08/01/2025 at 6:30 PM, she stated the facility had provided infection control training, including prior hand hygiene. CNA A recalled the occurrence depicted in the video but could not recall the specific date, time, and details of the occurrence. CNA A confirmed she was one of the two CNAs observed in the video. She stated LVN A did not wear gloves, did not perform hand hygiene between the dressing application and injection administration and did not wash hands prior to exiting Resident #1's room. CNA A verbalized knowledge of when to implement hand hygiene and gloves. She stated gloves should be worn by LVN A when there was direct contact with a resident's buttocks and genital area of the body. She stated she did not recall LVN A not wearing gloves, but if she had witnessed staff not wearing gloves, she would have encouraged them to do so. She stated LVN A not wearing gloves and not performing hand hygiene placed residents at risk for infection.Observation of Resident #1 on 08/01/2025 around 8:45pm, Resident #1 observed lying in bed, eyes closed, with no notable sign of pain or distress.Interview with LVN A on 08/02/2025 at 4:34 PM, was conducted via telephone. LVN A stated she had been a Licensed Vocational Nurse for twenty-four years and had worked at the facility for four years. LVN A stated she always washed her hands before providing care but could not recall specific details from her shift on 09/24/2024. She acknowledged being aware of Resident #1 and the presence of video surveillance in Resident #1's room. LVN A confirmed that she had provided care to Resident #1 but could not recall whether she had performed wound care or administered an injection to the resident on 09/24/2024. She stated it was likely she had provided both wound care and administered an injection without wearing gloves and a gown, explained that she may had attempted to quickly implement care because Resident #1 demonstrated aggressive behaviors toward staff at the time. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676396 If continuation sheet Page 2 of 3 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 676396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE S.P.J.S.T. Rest Home 3 248 Wisteria Lane El Campo, TX 77437 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete confirmed that the facility had provided infection control and wound care training upon hire, as well as ongoing training throughout her four years of employment. She explained the appropriate steps for providing wound care to a resident, stated that proper hand hygiene should be performed before and after the procedure. She stated gloves should have been implemented with any care provided to the resident buttocks. She stated when applying a dressing application as a prevention measure it was considered a wound care intervention. She further stated an aseptic or clean technique should be used depending on the wound type, and that appropriate dressings should be applied using proper technique to prevent contamination. LVN A did not view video footage. LVN A acknowledged that if she had failed to wear gloves dressing application to a resident's buttocks, and did not wash or sanitize her hands before administering an injection, it could have caused contamination and exposed both Resident #1 and herself to infection. She did not provide any additional explanation as to why she had not performed hand hygiene between providing dressing application and administering the injection.Interview with the CNA B on 08/08/2025 at 6:30 PM, CNA B confirmed she was the second CNA observed in the video. She stated the facility had provided infection control training, including prior hand hygiene. CNA B verbalized LVN A should have worn gloves when care was provided to a resident's buttock area to protect residents and staff. She stated she did not notice LVN A had not worn gloves at the time of the occurrence. She stated she would have reminded LVN A to wear gloves. CNA B stated that failure to do so could place residents at risk for infection.Record review of LVN A employee file revealed the facility provided infection control and wound care training upon hire on 08/09/2021 and most recent 07/2025.Review of the facility's infection control policy, revised 12/2023, stated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. There was no specific language, for Hand Hygiene and, Wound care technique referenced in the infection control policy provided by the facility.Review of CDC's Summary of Infection Prevention Practices retrieved from CDC website on 08/01/2025.According to the CDC's Summary of Recommendations for Application of Standard Precautions, healthcare personnel must wear gloves when it is reasonably anticipated that contact will occur with blood, other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) (CDC, 2023). The sacral/buttocks area is a high-contamination zone due to its proximity to the perineal region. Therefore, contact with any dressing, even over intact skin, may involve exposure to potentially contaminated materials.Gloves must be changed during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face). Aseptic technique must be used to avoid contamination of sterile injection equipment (CDC, 2023). Additionally, perform hand hygiene: After contact with blood, body fluids, excretions, mucous membranes, nonintact skin, or wound dressings. If hands will be moving from a contaminated-body site to a clean-body site during patient care (CDC, 2023). Event ID: Facility ID: 676396 If continuation sheet Page 3 of 3