Health 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 Page 1 of 2 676418 676418 01/13/2026 The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for performing wound care for Resident #1. LVN G stated Resident #1 was on EBP for a wound to the coccyx and stated residents on EBP were identified by a sign on their door indicating the need for EBP precautions. LVN G stated all facility staff were responsible for ensuring the proper signage was in place and stated, for residents with wounds, LVN G tried to make sure the signs were in place. LVN G stated residents on EBP would have a physician's order for EBP and stated it was important for a resident on EBP to have a physician order, to follow the orders for the benefit of the resident and prevent the spread of cross contamination. LVN G stated it was important for a resident on EBP to have a sign on their door, so anyone that goes in that room is following protocol including family members and staff. LVN G stated she had received training on EBP.During an interview with the Administrator, on 01/13/2026 at 12:00 p.m., the Administrator stated residents on EBP had a sign outside their room door that indicated the resident was on EBP precautions and had a physician order for EBP. The Administrator stated staff had received training on the placement of EBP signs and physician orders and stated a resident on EBP had care plans for EBP and EBP was reflected in a resident's Kardex(instructions) that revealed information from a resident's physician orders and care plan. The Administrator stated it was important for a resident on EBP to have a physician order, so it's in the chart and important for the EBP signs to be posted at a resident room doorway, so the staff know who is on EBP.Observation, on 01/12/2026 at3:12 p.m., of the enhanced barrier precaution sign posted outside of Resident #1's room revealed 2 large stop signs in the top corners and revealed, providers and staff must also: wear gloves and gown for the following High Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing.Record review of a facility policy titled, Infection Prevention and Control, date implemented 03/13/19 and date revised April 2024, revealed, Compliance Guidelines: The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Section II: Categories: Types of Isolation Precautions revealed, In addition to isolation practices, Enhanced Barrier Precautions (EBP) maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when Contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but is not necessary in other situations. Residents/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI or complicated/non-healing surgical incisions or wounds, and/or open wounds requiring a dressing; excluding simple skin breaks or tears that are covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. 676418 Page 2 of 2