**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity for one (Resident #107) of three residents reviewed for rights, in that: The facility failed to ensure Resident #107's ostomy drainage bag was placed in a privacy bag while performing physical therapy in the facility's hallway area. Ostomy (an opening (stoma) from an area inside the body to the outside). This failure could place residents with catheters at risk for embarrassment and reduced self-esteem. The findings included: Review of Resident #107's electronic record on 9/5/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of incarcerated hernia. (An incarcerated hernia is a type of hernia in which a part of the small bowel protrudes into the groin area and cannot be pushed back in). Record review of Resident #107's care plan dated 09/01/24 indicated in part: Patient would like to be able to use regular colostomy after recovery. Will be free from trauma to site and infection. Patient to have less leakage from ostomy. Record review of Resident #107's MDS dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Bladder and bowel: Ostomy checked yes. During an observation on 09/04/24 at 10:42 AM, Resident #107 was being assisted by PTA A with ambulating in the hallway with the use of the resident's walker. The resident's ostomy drainage bag was seen hanging on the walker and not covered with a privacy bag exposing the bowel movements in the drainage bag. There were other resident's seen in the hallway as well as several visitors. During an interview on 09/05/24 at 3:02 PM, Resident #107 said she was aware of her ostomy bag not being covered while out in the hallway. The resident said she did not mind it being uncovered. The resident said it did not make any difference to her if it was covered or not and that the facility staff had not asked her if they could cover it. During an interview on 09/05/24 at 3:07 PM, RN B said whenever a resident that used for example a urinary catheter bag they would make sure it was kept below the resident's waist to prevent back flow of the urine when being transferred out of bed. RN B said if the resident came out of their room they would also place a linen bag over the catheter bag for privacy. RN B was made aware of Resident #107 observed in the hall with her drainage bag uncovered. RN B said as far as she knew Resident #107 had not asked for a privacy bag nor had she asked the resident if she would like one. RN B said she did not think it was a privacy issues if Resident #107's drainage bag was uncovered while out in the hallway even if other residents and visitors were there unless Resident #107 said so. During an interview on 09/05/24 at 3:25 PM, PTA A said Resident #107 did not use a cover on her drainage bag. PTA A said Are we supposed to use a cover on the drainage bag ?. PTA A said the resident had never requested one be used and as far as he knew Resident #107 was fine with the bag not covered when walking in the hallway. During an interview on 09/05/24 at 3:32 PM, the DON was made aware of the observation of Resident #107 ambulating in the hallway with her ostomy drainage bag uncovered. The DON said the drainage bags were usually not covered as it was a skilled facility. The DON said Resident #107 had not voiced that she wanted her drainage bag covered. The DON said if the resident complained about the bag not being covered then they would offer to cover it. Record review of the facility's document titled Patient rights and responsibilities and dated 12/5/2023 indicated in part: Patients are entitled to dignified and respectful care regardless of age, race, color, national origin, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 (Resident #59) of 3 residents reviewed for infection control. The facility failed to ensure: PTA B cleaned the counter prior to setting up a barrier for setting up wound care supplies for Resident #59. PTA B used a non-permeable barrier when setting up wound care supplies for Resident #59. PT A cleaned scissors between dirty procedure and clean procedure during wound care for Resident #59. PT A used the same scissors after cutting off Resident #59's dirty [NAME]-boot dressing (plaster dressing used to squeeze fluid out of a closed wound) to cut his clean [NAME]-boot dressing. These failures could place resident's at risk for cross contamination and the spread of infection. The findings included: Review of Resident #59's electronic record on 9/5/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including debility and septic discitis of the thoracic region (spine infection). Resident #59 was still in his MDS Assessment period. Review of Resident #59's care plan dated 8/23/24 revealed: Problem/ Need Problems: hospitalization abscess to leg Resident will exhibit: Be free from infection during hospital stay; verbalize how to prevent disease. Interventions: Teach patient about handwashing; assess every shift for signs and symptoms of infection; monitor vital signs and lab values; administer medication/ antibiotics as ordered; notify physician of any abnormal values; reinforce hygiene behavior; teach patient signs and symptoms of infection. Wound #1 Right Antero-lateral leg/Venous Ulcer WDL (closed or open, chronic wound that occurs when the veins don't return blood to the heart properly. Resident #59's wounds were closed and seeped fluid) within defined limits, except ulceration, venous, no drainage, dressing in place Review of Resident #59's Order Summary documented Rehab Services: wound care treatment orders: Order date 8/26/24 active. Observation on 9/4/24 at 10:07 a.m., PT A entered Resident #59's room to do wound care. PT A sanitized his hands with alcohol based hand rub (ABHR) and donned gloves. Then after surveyor entered the room, PTA B entered the room and moved Resident #59's belongings to the side and placed a folded towel on the counter without sanitizing the counter and set up the wound care supplies. PT A cut off Resident #59's [NAME]-boot dressing (plaster soaked dressing that compresses as it dries) with a pair of clean scissors. PT A took off the gloves, sanitized hands with ABHR and donned a new pair of gloves. He took measurements of Resident #59's wounds. PT A then applied lotion to Resident #59's leg, then he applied a new [NAME]-boot dressing. When PT A got to the top of Resident #59's calf, PT A used the same, uncleaned scissors to cut the remainder of the [NAME]-boot dressing off. PT A put gauze over the [NAME]-boot dressing, the kerlix (self-adhesive gauze), and put a tube covering over it and left with no hand hygiene. Interview on 9/5/24 at 1:01 p.m., PT A stated he knocked on Resident #59's door, asked about any issues, asked about pain, a student came in to set up supplies and they started the treatment. PT A said Resident #59 had the [NAME]-boot to treat edema. PT A said PTA B was the tech and she moved Resident #59's clothes and put down a clean towel. PT A stated the procedure was clean not sterile so as far as they knew a clean towel was enough. PT A said no one had talked to the PT department about using a non-permeable barrier when setting up wound care. PT A stated after the scissors were used they were considered dirty but they were used for the same resident. PT A said the facility policy was they could use the same instruments. Surveyor requested the policy. PT A stated he did not think it was a formal policy just a facility practice. Interview on 9/5/24 at 1:30 p.m., the ICP stated the expectation for wound care was staff wear the proper PPE which would be gown and gloves. The ICP said she thought a chuck (absorbent pad with plastic on one side to prevent leaks) which was disposable would be acceptable for wound care. The ICP stated she was not sure what the policy stated. The ICP stated once the dressing was cut off the scissors were considered dirty, and the facility did have a spray the PT could have used to clean them. The ICP said hand hygiene was expected before donning PPE, in between glove changes, after touching patient surroundings, and when exiting the room. In an interview on 9/5/24 at 2:21 p.m., the DON stated clean technique could be completed with a towel because the resident was the only person in the room. At this time PT A brought the mandatory in-services by the facility and infection control was completed 2/6/24. In an interview on 09/05/24 at 3:33 p.m., the DON said they did not have a specific policy for wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan with necessary information within 48 hours of the resident ' s admission for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for baseline care plans. The facility failed to include physician orders for medications and diets in Resident #101, Resident #51, and Resident #103 ' s baseline care plan. This failure placed residents at risk of not receiving continuity of care and communication among nursing staff and residents as well as increased risk of resident safety and safeguard against adverse events that are most likely to occur after admission. Findings included: Resident #101 Review of Resident #101 ' s patient profile revealed Resident #101 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of right hip fracture. Review of Resident #101 ' s admission assessment dated [DATE] revealed BIMS of 15, indicating resident was cognitively intact. Review of Resident #101 ' s physician orders dated 07/19/2023 revealed resident was prescribed Aspirin 325mg two times per day with breakfast and supper, atorvastatin 40mg at bedtime, levothyroxine 137mg before breakfast, multivitamin 1 tablet daily, Prednisolone ophthalmic drops four times per day to right eye, paroxetine 20mg daily, MiraLAX 1 packet daily, as needed sliding scale insulin for blood glucose above 200, 1800 ADA Carbohydrate Control diet, and Glucerna Vanilla shakes twice a day. Review of Resident #101 ' s baseline care plan dated 07/20/2023 revealed no evidence of focus, objectives or interventions for Aspirin 325mg two times per day with breakfast and supper, atorvastatin 40mg at bedtime, levothyroxine 137mg before breakfast, multivitamin 1 tablet daily, Prednisolone ophthalmic drops four times per day to right eye, paroxetine 20mg daily, MiraLAX 1 packet daily, as needed sliding scale insulin for blood glucose above 200, 1800 ADA Carbohydrate Control diet, and Glucerna Vanilla shakes twice a day. During an interview on 07/25/2023 at 10:05 am, Resident #101 stated she did not remember participating in care plan meetings. Resident #51 Review of Resident #51 ' s patient profile revealed Resident #51 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of [NAME] fracture of proximal end of left tibia (fracture left lower leg). Review of Resident #51 ' s admission assessment dated [DATE] revealed BIMS of 13, indicating resident was cognitively intact. Review of Resident #51 ' s physician orders dated 07/18/2023 revealed resident was prescribed ascorbic acid 200mg daily, Aspirin 81mg 2 times per day with meals, furosemide 40mg daily, losartan 25mg daily, Multivitamin Vitamin B Complex with C and Folic Acid daily, MiraLAX 1 packet daily, heel protectors, and Ensure Enlive Shakes two times per day. Review of Resident #51 ' s baseline care plan dated 07/19/2023 revealed no evidence of focus, objectives or interventions for ascorbic acid 200mg daily, Aspirin 81mg 2 times per day with meals, furosemide 40mg daily, losartan 25mg daily, Multivitamin Vitamin B Complex with C and Folic Acid daily, MiraLAX 1 packet daily, heel protectors, and Ensure Enlive Shakes two times per day. During an interview on 07/25/2023 at 10:14 am, Resident #51 stated not knowing anything about care plans. Resident #103 Review of Resident #103 ' s patient profile revealed Resident #103 was [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of fracture of left ulna (fracture of left upper arm). Review of Resident #103 ' s admission assessment dated [DATE] revealed BIMS of 14, indicating resident was cognitively intact. Review of Resident #103 ' s physician orders dated 07/21/2023 revealed resident was prescribed amiodarone 100mg daily, apixaban 2.5mg two times per day, celecoxib 200mg two times per day, losartan 100mg daily, metoprolol succinate XL 50mg daily, probenecid 500mg two times per day, rosuvastatin 20mg at bedtime, regular diet, and Ensure Enlive shakes two times a day. Review of Resident #103 ' s baseline care plan dated 07/22/2023 revealed no evidence of focus, objectives or interventions for amiodarone 100mg daily, apixaban 2.5mg two times per day, celecoxib 200mg two times per day, losartan 100mg daily, metoprolol succinate XL 50mg daily, probenecid 500mg two times per day, rosuvastatin 20mg at bedtime, regular diet, and Ensure Enlive shakes two times a day. During an interview on 07/25/2023 at 1:29 pm, Resident #103 stated she had not been informed of care plans. During an interview on 07/26/2023 3:44 pm, the DON stated the facility had no policy or procedures on baseline care plans. She stated that the facility follows Texas Administrative Code for baseline care plans. DON stated that each discipline creates their portion of the baseline care plan upon the resident ' s admission. Review of Texas Administrative Code 554.802(a) https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=26&pt=1&ch=554&rl=802 accessed 07/28/2023 revealed: (a) Baseline care plans. (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must: (A) be developed within 48 hours of a resident's admission; (B) include the minimum healthcare information necessary to properly care for a resident, including: (i) initial goals based on admission orders; (ii) physician orders; (iii) dietary orders; (iv) therapy services; (v) social services; and (vi) PASRR recommendation, if applicable.