Health inspection·January 14, 2026

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with a diagnosis of mental illness were provided an accurate Preadmission Screening and Resident Review (PASARR) Level 1 Screening for 1 of 3 residents reviewed for PASARR (Resident #8). The facility failed to ensure that Resident #8 had an accurate PASARR Level 1 Screening indicating a diagnosis of mental illness after newly evident diagnosis dated 05/31/2019. This failure could place residents at risk of not receiving needed assessments (PASARR Evaluation), individualized care, and specialized services to meet their needs. The findings included: Record review of undated face sheet, obtained 01/14/2026, indicated Resident #8 was a [AGE] year-old female admitted to the facility on [DATE] and had a diagnosis of Major Depressive Disorder, Recurrent and Moderate (a psychiatric diagnosis characterized by persistent sadness, anxiety, apathy, irritability, or emotional numbness). Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #8 had a BIMS score of 0 indicating severe cognitive impairment. The MDS section for active diagnosis indicated that Resident #8 had the psychiatric/mood disorders of depression. Section B0100 indicated that Resident #8 had unclear speech, was sometimes understood, and sometimes understood others. Record review of Resident #8's admitting PASARR Level 1 Screening completed 03/01/2019 indicated in section C0100 this resident did not have evidence of a mental illness. Record review of psychoactive medication consent dated 03/16/2019 for Resident #8 included a signed consent for Lexapro (an antidepressant that primarily treats depression and anxiety by increasing serotonin levels in the brain) to treat the diagnosis of depression. Record review of physician's progress note dated 05/31/2019 indicated that Resident #8 had obtained the diagnosis of Major Depressive Disorder, Recurrent and Moderate. Record review of the Quarterly MDS dated [DATE] first indicated Resident #8 had a diagnosis of depression. During an interview on 01/14/2026 at 10:15 AM, the MDS Nurse stated she was responsible for ensuring residents had an accurate PASARR Level 1 Screening. The MDS Nurse stated that residents were only able to be evaluated for services if the PASARR Level 1 Screening was accurate. The MDS Nurse stated that Resident #8 should have had an updated PASARR Level 1 Screening at the time of the diagnosis of Major Depressive Disorder, Recurrent and Moderate. During an interview on 01/14/2026 at 10:26 AM, the ADM stated he was not aware of the procedure for PASARR Level 1 Screening for a resident with a newly evident diagnosis of mental illness. During a joint interview on 01/14/2026 at 11:10 AM, the ADON and DON stated they were not aware of the procedure for PASARR Level 1 Screening for a resident with a newly evident diagnosis of mental illness. A review of an undated facility policy titled Preadmission Screening and Resident Review indicated the following: It is the policy of this facility to ensure the all residents are screen and appropriately addressed via the PASRR process as outlines by regulations. The results of this process will be used to develop, review, and revise the residents care plan. Event ID: Facility ID: 455856 If continuation sheet Page 2 of 8 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 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement comprehensive care plans with measurable objectives and timeframes to address resident's medical, nursing, and required enhanced barrier precautions needs for 2 of 4 residents reviewed. The facility failed to ensure that Resident #7's and Resident #32's care plans reflected focus instructions on Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device. The facility fails to ensure that Resident #7's care plans reflected focused interventions for indwelling catheter care in accordance with facility policy and physician orders. This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs. Finding included: A review of a face sheet dated 01/13/2026 indicated Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included aortic (value) stenosis (the aortic valve narrow or stiffens and restricts blood flow), benign prostatic hyperplasia ( non-cancerous enlargement of the prostate gland), orthostatic hypotension(decrease in systolic blood, and diastolic blood pressure ), gastro-esophageal reflux disease (GERD), hyperlipidemia ( increase in lipids in your bloodstream), hypertension, syncope (fainting), and urinary tract infection. A review of an admission MDS dated [DATE] reflected Resident's #7 had a BIMS score of 11 indicating his cognition was moderately impaired. A review of Resident's #7's physician orders form dated 1/14/2026 reflected: Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device, Gloves and gowns prior to high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift related to Benign prostatic hyperplasia with lower urinary tract symptoms. Order/start date 12/29/2025. A review of Resident's #7 physician orders form dated 1/14/2026 reflected: May insert 16 French 5 cc foley catheter as needed related to Benign Prostatic Hyperplasia without lower urinary tract symptoms. Order /start date 12/24/2025. A review of Resident's #7 Care Plans last reviewed and completed dated 12/30/2025 reflected: Resident's #7 and family had elected Hospice Care: Focus, placement of indwelling catheter date initiated 12/30/2025. Resident #7's care plans did not reflect focused interventions for indwelling catheter care in accordance with facility policy and physician orders. A review of Resident's #7 Care Plans last reviewed and completed dated 12/30/2025 did not reflect implementation of Enhanced Barrier Precautions for high-contact care related to a history of MDRO and an indwelling catheter. Observation and interview of Resident #7 on 1/12/2026 at 1046 AM revealed Resident #7 was in bed, awake and watching TV; alert and oriented. Resident was clean, dry, and well-groomed. Resident #7 reported staff assisted with transfers and ADLs. Foley catheter noted to gravity with covered bag and urine was clear. Resident #7 denied UTI symptoms and reported history of bladder issues. A review of a face sheet dated 1/14, 2026, indicated Resident #32 was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses which included cerebral ischemic attack( OR stroke: when a blood clot blocks blood flow to the brain), type 2 diabetes mellitus, polymyositis with myopathy (chronic inflammation, pain and weakness in skeletal muscles), syncope (fainting), dysphagia ( difficulty swallowing), vascular dementia, neuromuscular dysfunction of bladder, depression, muscle wasting and atrophy, hypothyroidism, sarcopenia (loss of skeletal muscle mass, strength and function), presence of cardiac pacemaker, poly-osteoarthritis, atrioventricular block, dementia, hypertension, and esophagitis ( inflammation of the esophagus). A review of an admission MDS dated [DATE] reflected Resident #32 had a BIMS score of 14 indicating his cognition was cognitively intact. A review of Resident's #32 physician orders form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455856 If continuation sheet Page 3 of 8 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 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete dated 1/14/2026 reflected: Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device, Gloves and gowns prior to high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift. Order/start date 09/17/2025. A review of Resident's #32 physician orders form dated 1/14/2026 reflected: If the resident develop retention replace 16 French foley catheter and phone urology with volume from catheter placement. Order dated 07/11/2025. May re-insert 16 French 5 cc foley catheter as needed related to retention. Order date 07/21/2025. A review of Resident's #32 Care Plans last reviewed and completed dated 12/10/2025 reflected: The resident had an indwelling catheter. At risk for UTI, complications Neurogenic bladder. Dated initiated 08/06/2025. Intervention: Catheter care per facility policy and physician orders as needed. Assess reports of abnormal urinesediment, odor, color, amount. Report to MD as needed. A review of Resident's #32 Care Plans last reviewed and completed dated 12/10/2025 did not reflect implementation of Enhanced Barrier Precautions for high-contact care related to a history of MDRO and an indwelling catheter. Observation and interview on 1/12/2026 at 11:37 AM revealed Resident #32 were in bed, awake, alert, and watching TV. The resident was clean, dry and well-groomed. The foley catheter observed draining to gravity below bladder with privacy cover in place; urine was clear/amber in color. Resident #32 stated he was doing fine, denied current UTI symptoms, and reported a UTI a few months ago. Resident #32 stated staff provided catheter care per orders. During an interview on 1/14/2026 at 1:52 PM., the MDS nurse said she was an LVN, and she was responsible for updating and keeping the MDS indicators updated. She further stated the initiation of the comprehensive care plan was the responsibility of the DON who was an RN. During an interview on 1/14/2026 at 2:00 PM., the ADON said she was an LVN, and the care plans were the responsibility of the MDS Nurse and the DON who was an RN. During an interview on 1/14/2026 at 2:15 PM. the DON said she was the RN, and she was responsible for initiating and updating the comprehensive care plans. The DON stated she had been updating care plans as incidents happen and tried to cover incidents in daily staff meetings. However, she said she planned on changing her method of updating the care plans. A Review of the facility's policy (section 18 - Minimum Data Set (MDS) titled Comprehensive Care Plans The comprehensive, person-centered care plans reflect currently recognized standards of practice for problem areas and conditions. Event ID: Facility ID: 455856 If continuation sheet Page 4 of 8 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 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 2 medication carts ((Cart A/B halls and Cart C/D halls) reviewed for pharmacy services. The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented the performance of change of shift narcotic counts on multiple shifts and days for Medication Cart A/B halls and Cart C/D halls. This failure could place residents at risk for loss of medications and possible drug diversion.Findings included: A review of the 01/01-13/2026 narcotic count signature sheets for the Medication Aide cart for Halls A and B on 01/13/2026 at 02:30 PM reflected 21 missing signatures indicating change of shift narcotic counts had not been routinely performed by on-coming and off-going medication aides. Further review indicated change of shift narcotic counts had not been done for 21 of 37 change of shifts dated 01/01-13/2026. A review of the 01/01-13/2026 narcotic count signature sheets for the Medication Aide cart for Halls C and D on 01/13/2026 at 02:30 PM reflected 26 missing signatures indicating change of shift narcotic counts had not been routinely performed by on-coming and off-going medication aides. Further review indicated change of shift narcotic counts had not been done for 26 of 37 change of shifts dated 01/01-13/2026. A review of the December 2025 narcotic count signature sheets for the Medication Aide cart for Halls A and B reflected 24 missing signatures indicating change of shift counts had not been routinely performed by on-coming and off-going medication aides. Further review indicated change of shift narcotic counts had not been done for 24 of 93 change of shifts dated 12/01-31/2025. During an interview with MA-E on 01/13/2026 at 02:56 PM, she said narcotic counts were to be done at every change of shift. She said the Medication Aide at the end of his/her shift was supposed to count the narcotics in the cart with the Medication Aide at the start of the next shift. She said the purpose of counting the narcotics in the carts was to ensure the number of narcotics in the cart was accurately reflected by the count. MA-E said both Medication Aides involved in the change of shift were to sign the narcotic count sheet to indicate the count had been done. She said the missing signatures looked like the narcotic counts had not been done. MA-E said the narcotic counts were done but sometimes the medication aides forgot to sign the sheets. During an interview with MA-D on 01/14/2026 at 09:25 AM, she said she had been told about the concern for the narcotic counts. She said she always counted the narcotics at the beginning and end of her shifts but sometimes forgot to sign the sheets. She said if she did not sign the narcotic count sheet after performing a narcotic count, then she had no proof that she had counted the narcotics at the beginning nor at the end of her shift. MA-D said narcotic medications could come up missing or lost and she could be suspect for the missing drugs. MA-D said narcotic counts and signing the narcotic count sheets were crucial for showing accountability for the safekeeping of narcotics. During an interview with the DON on 01/14/2026 at 10:40 AM, she said the Medication Aides were responsible for maintaining the security of the narcotics in their carts. She said narcotic counts were to be performed on each cart at change of shift and was to be completed by the on-coming and off-going Medication Aides. She said they were to sign the narcotic count sheets after completing the narcotic counts to indicate the narcotic counts were done and the count was accurate. She said failure to sign the narcotic count sheets could lead to missing drugs that could not be accounted for. The DON said she and the ADON were responsible for ensuring the change of shift narcotic counts were being completed and signed for. During an interview with the ADON on 01/14/2026 at 10:45 AM, she said she and the DON shared duties and both were responsible for ensuring narcotic counts were being (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455856 If continuation sheet Page 5 of 8 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 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete completed at change of shift. A review of the facility's undated policy titled Shift Change and Medication Cart Responsibility indicated the following: It is the policy of this facility to ensure the transition from one shift to the next is appropriate, ensure proper handling of all medications and minimize risk.Procedure:1.At the end of each shift, the outgoing shift is to count all narcotics with the oncoming shift (per policy)2.Whoever accepts the keys and verifies the narcotic counts are accurate is assuming responsibility for the medication cart until the above point )#1) occurs again. Event ID: Facility ID: 455856 If continuation sheet Page 6 of 8 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 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 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)

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 observations, interviews, and record review, the facility failed to establish and 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 2 of 4 residents (Residents #7 and #32) reviewed who required Enhanced Barrier Precautions. The facility failed to ensure Enhanced Barrier Precautions signage was posted on the entry doors for Resident's #7 and Resident #32. This failure had the potential to expose residents, staff, and visitors to the transmission of infectious organisms.Finding included: A review of a face sheet dated January 13, 2026 indicated Resident #7 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included aortic (value) stenosis (the aortic valve narrow or stiffens and restricts blood flow), benign prostatic hyperplasia ( non-cancerous enlargement of the prostate gland), orthostatic hypotension(decrease in systolic blood, and diastolic blood pressure), gastro-esophageal reflux disease (GERD), hyperlipidemia ( increase in lipids in your bloodstream), hypertension, syncope (fainting), and urinary tract infection. A review of an admission MDS dated [DATE] reflected Resident's #7 had a BIMS score of 11 indicating his cognition was moderately impaired. A review of Resident #7‘s physician orders form dated 1/14/2026 reflected: Enhanced Barrier precautions for high contact care related to history of multidrug-resistant organism (MDRO) and an indwelling device, Gloves and gowns prior to high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift related to Benign prostatic hyperplasia with lower urinary tract symptoms. Order/start date 12/29/2025.A review of Resident #7's physician orders form dated 1/14/2026 reflected: May insert 16 French 5 cc foley catheter as needed related to Benign Prostatic Hyperplasia without lower urinary tract symptoms. Order /start date 12/24/2025. A review of Resident #7's Care Plans last reviewed and completed dated 12/30/2025 reflected: Resident's #7 and family had elected Hospice Care: Focus, placement of indwelling catheter date initiated 12/30/2025. A review of Resident #7's Care Plans last reviewed and completed dated 12/30/2025 reflected: No implementation of Enhanced Barrier Precautions for high contact care related to history of multidrug-resistant organism (MDRO) and an indwelling catheter device. Observation and interview on 1/12/2026 at 10:46 AM revealed Resident #7 in bed, awake and watching TV; alert and oriented. The resident was clean, dry, and well-groomed. Resident #7 reported staff assisted with transfers and ADLs. The foley catheter was observed draining to gravity below bladder with privacy cover in place; urine was clear/yellow in color. Observation revealed the resident did not have EBP signage posted at the point of entry, and no instructions for required personal protective equipment were observed.A review of a face sheet dated January 14, 2026, indicated Resident #32 was a [AGE] year-old-male who admitted to the facility on [DATE] with diagnoses which included cerebral ischemic attack( OR stroke: when a blood clot blocks blood flow to the brain), type 2 diabetes mellitus, polymyositis with myopathy (chronic inflammation, pain and weakness in skeletal muscles), syncope (fainting), dysphagia ( difficulty swallowing), vascular dementia, neuromuscular dysfunction of bladder, depression, muscle wasting and atrophy, hypothyroidism, sarcopenia (loss of skeletal muscle mass, strength and function), presence of cardiac pacemaker, poly-osteoarthritis, atrioventricular block, dementia, hypertension, and esophagitis ( inflammation of the esophagus).A review of an admission MDS dated [DATE] reflected Resident #32 had a BIMS score of 14 indicating his cognition was cognitively intact. A review of Resident #32's physician orders form dated 1/14/2026 reflected: Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device, Gloves and gowns prior to Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455856 If continuation sheet Page 7 of 8 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 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete high contact care which includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting toileting. PPE may be discarded in regular trash every shift. Order/start date 09/17/2025. A review of Resident #32's physician orders form dated 1/14/2026 reflected: If the resident develop retention replace 16 French foley catheter and phone urology with volume from catheter placement. Order dated 07/11/2025. May re-insert 16 French 5 cc foley catheter as needed related to retention. Order date 07/21/2025. A review of Resident #32's Care Plans last reviewed and completed dated 12/10/2025 reflected: The resident had an indwelling catheter. At risk for UTI, complications Neurogenic bladder. Dated initiated 08/06/2025. Intervention: Catheter care per facility policy and physician orders as needed. Assess reports of abnormal urine- sediment, odor, color, amount. Report to MD as needed. A review of Resident #32's Care Plans last reviewed and completed dated 12/10/2025 reflected: No implementation of Enhanced Barrier Precautions for high contact care related to history of MDRO and an indwelling catheter device. Observation and interview on 1/12/2026 at 11:37 AM revealed Resident #32 in bed, awake, alert, and watching TV. The resident was clean, dry and well-groomed. The foley catheter was observed draining to gravity below bladder with privacy cover in place; urine was clear/amber in color. Resident #32 stated he was doing fine, denied current UTI symptoms, and reported a UTI a few months ago. Resident #32 stated staff provided catheter care per orders. Observation revealed the resident did not have EBP signage posted at the point of entry, and no instructions for required personal protective equipment were observed. During an interview on 1/13/2026 at 11:00 AM., CNA A said she had worked for the facility for 2 years and had been educated on EBP. She accurately described EBP protocols for high contact residents with indwelling catheters and located the PPE supplies. The CNA stated she was unaware why Resident #32 did not have an EBP signage posted on the door, but acknowledged the resident had a foley catheter and stated she would put on the PPE located in the room during ADL's and Foley care. During an interview on 1/13/2026 at 11:15 AM., CNA B stated she had worked for the facility for 8 years and had received education EBP. She stated that she was also unaware of why the EBP signage was not posted on Resident #7's and #32's doors. But it was acknowledged the residents had a foley catheter and stated she would [NAME] (to put on) the PPE located in the room during ADL's care and Foley care. During an interview on 1/13/2026 at 11:30AM, LVN C said she was the charge nurse on the units and trained staff putting on PPE supplies. She accurately described EBP protocols for high contact care involving residents with indwelling catheters, including donning (to put on) PPE during dressing, bathing/showering, transferring, hygiene care, linens changes, briefs changes, and toileting assistance. During an interview with LVN C, observations of Resident #7, and Resident #32 rooms, who required Enhanced Barrier Precautions (EBP), revealed the EBP signage was not posted at the point of entry, and no instructions for required personal protective equipment were observed. LVN C stated she was unaware why EBP signage was not posted and stated she would immediately place the EBP's signage on both residents' doors. A review of facility's ( Section 12-infection Control ) Standard Precautions Policy, (Section 12- infection Control) Policy: Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MSROs to staff hands and clothing. A review of facility's (Section 12- Handwashing) Policy: Handwashing hand washing is regarded by this facility as the single most important means of preventing the spread of infections. Event ID: Facility ID: 455856 If continuation sheet Page 8 of 8