Inspection·January 13, 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 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 #1) reviewed for infection control in that: Resident #1 had an open wound and did not have an EBP sign on Resident #1's room door and did not have a physician order for EBP.This failure could affect residents on enhanced barrier precautions and place them at risk for infection.The findings were:Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (when the body does not make or use insulin well) and chronic kidney disease (a reduction in kidney function).Record review of Resident #1's quarterly MDS assessment, dated 11/24/2025, revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment. Section GG- Functional Abilities revealed Resident #1 was dependent on staff for ADL care, bed mobility, and transfers.Record review of Resident #1's January 2026 physician orders revealed an order, wound to coccyx cleanse with wound cleanser or NS, pat dry, apply Cal alginate and cover with dry dressing QD and PRN till healed, start date 12/18/2025. Resident #1 did not have a physician order for enhanced barrier precautions related to Resident #1's wound to her coccyx.Record review of Resident #1's comprehensive care plan revealed a care plan that revealed, I am at risk for significant infections and/or recurrent infections r/t compromised medical condition. Actual, date initiated 05/15/2024. An intervention revealed, enhanced barrier precautions practices as clinically indicated, date initiated 06/25/2025.During an observation, on 01/12/2026 at 11:39 a.m., Resident #1's room door was observed with a PPE supply cart outside of the room and no EBP sign on the door or doorway entrance to Resident #1's room.During an observation, on 01/12/2026 at 3:12 p.m., Resident #1's room door had 2 signs on the wall that indicated Resident #1 was on EBP and required specific PPE to be worn during care.During an interview with Resident #1, on 01/12/2026 at 11:40 a.m., Resident #1 stated she had a wound on her buttocks that was being treated by the nurses. Resident #1 stated nurses put cream and a dressing on the wound daily. Resident #1 stated staff wear a gown and gloves when performing wound care.During an interview with LVN A, on 01/12/2026 at 11:54 a.m., LVN A stated residents with wounds were on EBP and were identified by a sign outside of the resident door that indicated the resident was on EBP. LVN A stated staff were required to wear a gown and gloves when a resident was on EBP precautions. LVN A stated she had received training on EBP and stated everyone was responsible for ensuring a resident on EBP had a sign outside of their door to notify visitors and staff that the resident was on EBP. LVN A stated Resident #1 was on EBP and should have had a sign on Resident #1's door. LVN A stated it was important for residents on EBP to have signs posted on their door, for the safety of the residents and the staff to prevent further infection.During an interview with LVN G, on 01/13/2026 at 9:25 a.m., LVN G stated she was the wound treatment nurse and was 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: 676418 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 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)