Cedar Manor Nursing: Infection Control Failures - TX
The violation, cited under the infection control tag F0880, covered what inspectors described as enhanced barrier precautions — a layer of protection that goes beyond routine handwashing and glove use. The standard applies specifically to residents who carry the highest risk of spreading or acquiring multi-drug resistant organisms: those with pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers, urinary catheters, central lines, feeding tubes, and tracheostomies.
Cedar Manor staff were not consistently putting on gowns and gloves before providing high-contact care to those residents.
The logic behind the precaution is straightforward. A staff member who touches a wound or handles a catheter without a gown can carry organisms on their clothing from one resident's room to the next. The resident doesn't have to be known to carry a drug-resistant infection for the precaution to apply. The requirement exists precisely because colonization is often invisible — a resident can harbor organisms without showing any symptoms, and staff moving between rooms without proper barriers become the transfer mechanism.
Inspectors noted the facility's own corrective plan acknowledged the gap. Cedar Manor's response described posting signs outside resident rooms and flagging affected residents in its electronic documentation system so staff would know when enhanced precautions were required. The facility also committed to ensuring that personal protective equipment and alcohol-based hand rub were physically accessible near the rooms where they were needed.
That corrective language, written after the fact, described a system that should have been functioning before inspectors arrived.
The residents affected were not a small or unusual subset of the nursing home population. Chronic wounds and indwelling medical devices are among the most common conditions in long-term care. Pressure ulcers develop when residents who cannot reposition themselves remain in one place too long. Diabetic foot ulcers are a routine complication in a population where diabetes is widespread. Urinary catheters are used routinely for residents who cannot manage bladder function independently. Feeding tubes and tracheostomies appear in residents with advanced neurological or respiratory conditions. In a skilled nursing facility, these are not edge cases.
The inspection was triggered by a complaint, meaning someone — a resident, a family member, or a staff member — contacted regulators before inspectors showed up. The report does not identify who filed the complaint or what specific incident prompted it.
Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted the deficiency affected some residents. That language, drawn from the federal rating scale, sits below the threshold of actual harm but above a purely technical finding. It reflects a judgment that the missing precautions created real exposure, even if inspectors did not document a specific infection tied directly to the lapse.
Drug-resistant organisms are not an abstract threat in nursing home settings. Facilities that house medically compromised residents in close proximity, with shared staff moving between rooms throughout a shift, are environments where transmission can move quickly once it starts. The organisms that enhanced barrier precautions are designed to contain include bacteria that have become resistant to multiple antibiotics, making infections significantly harder to treat and more dangerous for residents whose immune systems are already compromised by age, chronic illness, or both.
Cedar Manor's corrective plan placed the solution partly in signage and electronic alerts. Whether staff now routinely check those alerts before entering a room, and whether gowns and gloves are stocked close enough to the point of care to make compliance practical rather than inconvenient, are questions the inspection report leaves open.
The residents with wounds that weren't healing, the ones with catheters and feeding tubes, were there before the complaint was filed and before inspectors walked in. They were there during whatever period the precautions were being skipped.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Manor Nursing and Rehabilitation Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 29, 2026 · Our methodology
Cedar Manor Nursing and Rehabilitation Center in San Angelo, TX was cited for violations during a health inspection on August 28, 2025.
Cedar Manor staff were not consistently putting on gowns and gloves before providing high-contact care to those residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.