Health inspection·November 21, 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 to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control in that:CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1.These deficient practices could place residents at risk for infection due to improper care practices.Findings included: Review of Resident #1's face sheet dated 10/30/25, revealed a 73- year- old female admitted to the facility on [DATE] with diagnoses including urinary tract infection (infection in any part of the urinary system), bacteremia (presence of bacteria in the blood), abdominal pain, malignant neoplasm of pancreas (pancreatic cancer), and muscle weakness. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required moderate assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was always incontinent with bowel and bladder. Review of Resident #1's Care Plan dated 10/14/25 revealed he had bowel and bladder incontinence. Its goal stated Resident #1 will have less episodes of incontinence through the review date. Observation of incontinence care for Resident #1 on 10/30/25 at 10:46 a.m. revealed CNA A did not wash her hands prior to donning gloves. She put on gloves in the hallway before entering Resident #1's room. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. CNA A wiped the resident from front to back. CNA A did not change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. She removed her gloves and picked up the trash. CNA A again, did not wash her hands before exiting Resident #1's room. In an interview on 10/30/25 at 10:58 a.m. with CNA A, she stated she should have washed her hands before starting care and changed her gloves during care. CNA A also said she should have changed her gloves before retrieving a clean brief and placing them underneath Resident #1. CNA A stated she has been in the facility for 4 years and received infection control training about 6 months ago. She said she was not paying attention, that was the reason for not changing her gloves. CNA A added the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. During an interview with the DON on 10/30/25 at 3:30 p.m., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the staff to follow the facility protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. She explained the employees receive infection control training annually and periodically monitor staff with return demonstrations in providing care. The DON stated she was responsible for the infection control prevention for the facility. Review of the facility's Handwashing and Hand hygiene policy revised March 14, 2024, reflected the following:PURPOSE:Perineal care, 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: 745005 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 745005 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Center at Zaragoza, LLC 12660 Pebble Hills Blvd. El Paso, TX 79938 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)