Health inspection·November 6, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few top of the nightstand was white sand like debris. There was a purple top container of disinfectant sani-wipes sitting on the nightstand. Resident nightstand drawer was ajar with a used suctioning catheter size 14 French (unit measurement used to describe the outer diameter of the catheter) that was not enclosed but laying in drawer. Further observation was made of Resident #1's floors not clean with debris on the floor and underneath the bed. Bed B by the window was not made. The bed had a fitted sheet on the mattress with red brownish spots on the sheet and a used alcohol swab on the bed. Interview on 11/05/25 at 11:25AM with CNA G, she said she had been working at the facility for 2 months and worked the morning shift. CNA G said Resident #1 did not have a roommate. CNA G said resident room did not appear clean and organized and there was stuff all over resident room. CNA G said resident floor was dirty. CNA G said she did not know who placed the disinfectant sani-wipes in resident room and did not notice that earlier in resident room. CNA G said she had been off work for several days and worked another hall and therefore could not say when the last time resident room had been cleaned. Interview on 11/05/25 at 11:30AM with RN B, she said she worked at the facility on the morning shift from 6a-6p full time. RN B said Resident #1's room was not clean, the floor in resident room was dirty, and B bed was not clean or made. RN B said resident nightstand was cluttered and did not appear to be cleaned. RN B said she did not know who placed the disinfectant sani-wipes in resident room on the nightstand. RN B said she could not explain why there was a used suction catheter laying inside of resident nightstand drawer. RN B said she did not handle the respiratory supplies, but the respiratory therapist did. Further interview with RN B said she was the nurse that admitted Resident #1 back to the facility on [DATE]. RN B said she was not aware that Resident #1 was being admitted back to the facility on [DATE]. RN B said had she known that Resident #1 was returning to the facility on [DATE], she would have called housekeeping to come and clean resident room. RN B said she just saw resident being wheeled down the hallway on a stretcher. RN B said resident room had not been cleaned when resident returned from the hospital on [DATE]. RN B said resident did not have any sheets on his bed and that she was trying to clean the room as best as she could by disinfecting resident bed. RN B said she had to remove linens from the other bed in the room (bed B) and placed them on Resident #1's bed (Bed A). RN B said she would remove the sani-wipes from resident room and place them in the trash because the sani-wipes should not be in the resident's room. RN B said Resident #1 had been discharged from the facility for several days and did not answer why resident room was not cleaned. RN B said whenever a resident was discharged from the facility to the hospital, it was the Nursing department that stripped the sheets off the bed, disinfected all residents' care equipment such as feeding pumps, IV poles, etc. and bagged all residents' care equipment placing them in the storage room. RN B said this was done to prevent cross contamination and for infection control. Interview on 11/05/25 at 11:40AM with Respiratory Therapist, she said she worked at the facility from 7a-7p three times a week and every other weekend. She said she had not checked Resident #1's drawer where respiratory equipment was stored. After checking resident drawer, she said the used suction tubing should have been trashed. Interview on 1:03PM 11/05/25 with Housekeeping Director said the housekeeper assigned to Resident #1's room was Housekeeper E. She said she ensured that the housekeepers were cleaning the residents' rooms daily, and that the residents' rooms were clean and presentable by performing random rounds on residents' rooms but not all the rooms. She said when a resident was admitted or readmitted to the facility, the room had to be cleaned prior to the resident being placed in the room. She said when a resident was discharged from the facility, the room had to be deep cleaned and disinfected. She said it was the DON, ADON, Social Worker, and sometimes the Nursing staff that communicated with Housekeeping that a residents' room needed to be cleaned prior to any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675078 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 675078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodway Nursing & Rehab 2808 Stoneybrook Drive Houston, TX 77063 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete admissions. Interview on 11/05/25 at 1:14PM with Housekeeper E said she was assigned to Resident #1's room. She said the last time Resident #1's room was cleaned was on 11/04/25. She said it was herself and another housekeeper that was cleaning and that she did not know if the other housekeeper had cleaned resident room thoroughly. She said it was important for the residents' rooms to remain clean prior to admission and discharge to prevent the spread of bacteria. Interview on 11/06/25 at 8:50AM with the Administrator, she said the NF had started an in-service on Infection Control with the staff on 11/05/25 due to Resident #1's room not being cleaned. The Administrator said the residents' rooms should be cleaned every day. The Administrator said if a resident is discharged from the facility the resident's room should be deep cleaned, and everything should be removed from the room and placed in the storage room. The Administrator said before a resident is admitted to a room, the room had to be cleaned to prevent infections. The Administrator said there was a gap in communication with the housekeeping department regarding the cleaning of Resident #1's room. The Administrator was asked to provide the facility policy on Physical Environment. The Administrator was asked to provide the facility policy on Physical Environment on 11/06/25 at 4:30PM. Record review of the NF policy on Resident Rights revised June 10, 2025, reflected in part: .The resident has a right to a safe, clean, comfortable environment and homelike environment including but not limited to receiving treatment and supports for daily living safely. Event ID: Facility ID: 675078 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 675078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodway Nursing & Rehab 2808 Stoneybrook Drive Houston, TX 77063 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 0760 Ensure that residents are free from significant medication errors. 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 ensure that its residents are free of any significant medication errors for 1 (Resident #1) of 4 residents reviewed for medication administration. RN B failed to call the hospital, ADON, and Administrator on 11/04/25 when she did not receive report from the hospital when Resident #1 returned to the facility from the hospital on [DATE]. The facility failed to administer Resident #1's IV Vancomycin 1gm evening dose on 11/04/25 and morning dose on 11/5/25. The facility failed to administer Resident #1's IV Meropenem 500mg every 4 hours when he returned to the NF on 11/04/25 from the hospital. The facility did not initiate the medication until 11/05/25 at 8:00PM. Resident #1 missed a total of 4 doses. This failure could place residents at risk of prescribed antibiotics not working effectively to treat residents' infections. Findings: Record review of Resident #1's face sheet dated 11/05/25 revealed a [AGE] year-old-male admitted to the NF initially on 05/07/25 and again on 11/04/25. Resident #1's diagnoses included the following: respiratory failure with hypoxia (low oxygen levels in the body), cerebral infarction (blood flow to a part of the brain is blocked), sepsis (bacterial infection in the body that could lead to organ failure and death), type 2 diabetes mellitus (when blood sugar in the body is too high), pneumonia (infection of the lungs), muscle wasting and atrophy (shrinking and weaking of muscle tissue when not being used enough), traumatic subarachnoid hemorrhage (bleeding in the space around the brain due to an injury), hypertension (elevated blood pressure), heart disease, neuromuscular dysfunction of the bladder (when the nerves and muscles that control the bladder is not working properly causing the bladder to not empty adequately), altered mental status, restlessness and agitation, tracheostomy (surgical opening made in the front of the neck directly into the windpipe and a small tube is inserted to help one breathe), and gastrostomy (surgical opening made directly into the stomach to allow for feeding through a tube). Record review of Resident #1's quarterly MDS dated [DATE] reflected that resident had a BIMS score of 3 indicating that Resident #1's cognition was severely impaired. Further review section H (Bladder and Bowel) revealed that Resident #1 had an indwelling catheter and feeding tube. Section O (Special Treatments) revealed that Resident #1 was receiving oxygen therapy, suctioning, and tracheostomy care, but was not on isolation or quarantined for active infections. Record review of Resident #1's Comprehensive Care Plan dated 10/24/25 reflected that Resident #1 was being care planned for being at risk for frequent infection with an intervention that included administering medication as order by the physician. Record review of Resident #1's hospital records dated 10/28/25 revealed that Resident #1 was receiving IV antibiotic vancomycin and Meropenem. The hospital physician electronically signed on 11/03/25 for Resident #1 to continue IV meropenem for pneumonia bacteremia and IV vancomycin for MRSA, final duration of antibiotic through 11/07/25. Record review of Resident #1's NF active Physician orders for the month of November 2025 included the following orders: Dated 11/05/25 Vancomycin 1gm IV every 12 hours for pneumonia and bacteremia.Dated 11/05/25 Meropenem 500mg IV 4 (four) times a day for MDRO Dated 11/05/25 Isolation for MDRO Record review of Resident #1's MAR for November 2025 reflected that Resident #1 did not receive his 1st dose of Vancomycin 1gm IV until 7pm on 11/05/25 at 7pm. The medication times on the MAR for the medication Vancomycin were 7:00AM and 7PM. The times for the meropenem was 10:00AM, 3:00PM, 8:00PM, and 2:00AM. Interview on 11/04/25 at 4:33PM with the RP of Resident #1 said Resident #1 was at the hospital and still receiving IV antibiotics to treat his infection. The RP said the hospital would be discharging Resident #1 back to the NF on 11/04/25. The RP said the hospital doctor wanted resident to continue on the IV antibiotics for several more days. Observation on 11/05/25 at 10:45AM revealed Resident #1 was resting in bed with his eyes closed to Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675078 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 675078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodway Nursing & Rehab 2808 Stoneybrook Drive Houston, TX 77063 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his left side with a pillow wedge to his back. Resident had a tracheostomy that was connected to continuous oxygen. There was no IV antibiotics being administered. Interview on 11/05/25 at 11:30AM with RN B, she said she worked at the facility on the morning shift from 6AM to 6PM. RN B said she was the nurse that admitted Resident #1 when he returned from the hospital on [DATE]. Interview on 11/05/25 at 3:18PM with RN B, she said when Resident #1 returned to the facility on [DATE] she did not know who took report on resident. RN B said she did not administer any antibiotics to Resident #1 due to no antibiotics being listed on Resident #1's medication list when he returned to the NF. RN B said she had informed the ADON about this around 2:00PM on 11/05/25. RN B said she learned on 11/05/25 that resident was supposed to be on the antibiotic Meropenem (antibiotic used to treat a variety of severe bacterial infections, particularly those caused by multidrug-resistant bacteria) 4 times a day. RN B said she needed to clarify the orders with the NP . Interview on 11/05/25 at 4:11PM with LVN C via phone. LVN C said he worked at the facility full time on the night shift from 6PM-6AM. LVN C said he had been working at the facility for 4 to 5 months. LVN C said he worked on 11/04/25 and received report from nurse RN B who did not tell him much about Resident #1's return from the hospital to the NF. Interview on 11/05/25 at 4:26PM with the ADON, she said the NF did not have a DON but that the facility's new DON would be starting on 11/17/25. The ADON said the NF was waiting for an update from the hospital when Resident #1 would be returning to the NF. ADON said when resident returned to the NF on 11/04/25, the hospital did not call to give a report on resident. The ADON said when resident returned via EMS the staff did not receive a full medication list with the initial paperwork. The ADON said she did not review the 2nd clinical records regarding resident antibiotics for Resident #1 until 11/05/25. The ADON said she received the 2nd clinical record via e-mail. The ADON said the hospital sent over the 1st set of clinical records via email on 11/04/25 and did not send the 2nd set of clinical records until later on 11/04/25. The ADON said she was doing the best she could and that it must have been an oversight on her part. Interview on 11/06/25 at 8:50AM with the Administrator, she said there was a gap in communication regarding Resident #1's return from the hospital to the facility. The Administrator said EMS just showed up at the facility on 11/04/25 toward the end of the day shift. The Administrator said the nursing staff was in-serviced on 11/05/25 on the importance of getting a report from the hospital when a resident is discharging back to the NF. The Administrator said nurse RN B could have called the ADON to tell her what had taken place, and they could have come up with a solution on how to handle the situation. The Administrator said she could not say what system the NF had in place if the nurse did not receive report on a resident because that had never happened before. The Administrator said the NF did not have a Clinical Marketer. The Administrator said the last Clinical Marketer would communicate with the hospital and let the NF know when a resident was due to return to the facility. The Administrator said this was done to ensure the NF had all necessary orders at the time of discharge. The Administrator said the NF had morning meetings discussing admissions and the resident clinicals. The Administrator said on 11/05/25 the NF only had a brief morning meeting due to State surveyor being at the facility as well as the Rapid Response being at the facility. The Administrator said the RRT had been coming to the facility on a weekly basis for several weeks reviewing the NF systems that were in place and communicating with the NF areas that needed to be corrected. The Administrator said the staff that normally participated in the morning meetings included herself, DON, ADON, MDS Coordinator, Clinical Marketer, and Rehab Department. The Administrator said she would have to ask the ADON when she reviewed Resident #1's clinical records. Interview with ADON on 11/06/25 10:05AM, she said it was nurse RN B that transcribed Resident #1's Physician Orders on 11/05/25. The ADON said Resident #1 was on the antibiotic Vancomycin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675078 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 675078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodway Nursing & Rehab 2808 Stoneybrook Drive Houston, TX 77063 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some IV and had missed two doses. The ADON said resident was also on the antibiotic Meropenem IV and had missed 3 doses. The ADON said RN B did not call her about the hospital not giving a report on Resident #1 on 11/04/25. The ADON said normally the Clinical Marketer communicated with the hospital Case Manager regarding resident care and the anticipated date of discharge. The ADON said the facility no longer had a Clinical Marketer. The ADON said prior to Resident #1 being readmitted to the facility, it was the NF Business Office Manager that was communicating with the hospital and sending a group email to herself, Corporate MDS Coordinator, Administrator, Social Worker, Wound Care Nurse, and Rehab Director regarding a resident's plan of care. The ADON said the Case Manager at the hospital had informed her that the hospital called to give report on Resident #1 on 11/04/25 and no one at the facility answered the phone. The ADON said when an admission comes to the NF, the admitting nurse did the initial assessment, contacted the doctor or NP to do a medication reconciliation with the doctor or NP. The ADON said it was discovered on 11/05/25 around 4:30PM by herself that Resident #1 was supposed to be on IV antibiotic therapy and the antibiotics had not been initiated. The ADON said when resident medications were transcribed by RN B on 11/04/25 there were no antibiotics included on resident MAR. The ADON said she did not see the 2nd list of resident medications that was sent on 11/04/25 until 4:30PM on 11/05/25. The ADON said although the NF was utilizing the Corporate Regional Nurse who was easily available by phone and email, it was still a challenge due to the facility not having a Clinical Marketer. The ADON said she was being pulled in so many different directions and therefore it made it a challenge to try and keep up with everything. The ADON said the Business Office Manager was doing the best that she could while learning the process. The ADON said the Business Office Manager was emailing her Resident #1's clinical records while resident was still at the hospital and emailed her the updated email on 11/04/25 around 4:10PM. The ADON said ultimately, she missed the email. The ADON said RN B did not inform her on 11/04/25 that she did not get report from the hospital on Resident #1's return to the NF. The ADON said she in-serviced the staff that if they do not get a report on a resident being admitted to the facility from the hospital to call the hospital to get a thorough report even if they have to speak to hospital supervisor to confirm the residents' medication list was correct and that the facility had received all of residents' clinical hospital records. The ADON said after the nurse did this, he or she would call the NF doctor to do a medication reconciliation. The ADON said it was the MDS Nurse that reviewed the residents' records to ensure that they met the medical necessity prior to admission and that it was herself and the DON that was responsible in reviewing clinical records on all admissions to ensure everything was correct. Interview on 11/06/25 at 11:06AM via phone with Business Office Manager, she said she had been working at the facility since July 7th 2025. The Business Office Manager said she had been communicating with the hospital regarding the care of Resident #1 the computer referral portal. The Business Office Manager said when a resident was getting close to being discharged from the hospital, the hospital started sending clinical records to the NF. The Business Office Manager said she started receiving clinical records on Resident #1 on 10/31/25 from the hospital case manager. The Business Office Manager said she received records again on 11/03/25 that resident was expected to be discharged back to the NF in 1 - 2 days and the hospital case manager sent over resident clinical records. The Business Office Manager said on 11/04/25 resident was clear to be discharged from the hospital to the NF and that Resident #1 needed antibiotics through 11/07/25. She said she gave the hospital case manager the mode of transportation and what room resident would be admitted to. She said she also gave the hospital case manager the ADON's phone number because she knew the hospital would be calling to give report and the nurses could be away from the nurse station on the halls providing care for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675078 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 675078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodway Nursing & Rehab 2808 Stoneybrook Drive Houston, TX 77063 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete residents. She said due to the NF not having a Clinical Marketer, she was asked by the COO if she could assist with referrals. She said she was familiar with the referral process from prior experience. Attempted interview on 11/06/25 at 11:27AM via phone with the NP, no answer, left voicemail with call back number. Interview on 11/06/25 at 11:55AM with LVN F, she said she worked the morning shift from 6AM-6PM full time. LVN F said she had been working at the NF for almost a year. LVN F said if a resident was admitted to the NF without the NF receiving a report on the resident, she would immediately call the hospital to get a full report on the resident. LVN F said she would inform the doctor, Administrator and the ADON since the facility did not have a DON at present what had taken place. LVN F said whenever a resident missed a scheduled dose of their antibiotic therapy, it placed the resident at risk of the infection developing resistance to the antibiotic causing the resident to be given a stronger antibiotic to treat the infection. LVN F said it also placed other residents at risk of encountering that same bacteria. Interview on 11/06/25 at 2:03PM with Resident #1's Doctor, he said he was notified on 11/06/25 by the ADON that Resident #1 had missed several doses of his IV antibiotic therapy. Dr. said because resident was already receiving frequent scheduled doses at the hospital, he was not concerned about the missed doses and would extend the length of days for resident to receive the IV antibiotic therapy and continue to have the staff monitor resident vital signs and order labs as needed. The doctor said more than likely the infection had resolved itself, but antibiotic therapy was extended a little longer for precautionary measure due to resident having the following tubes (tracheostomy, gastrostomy, and Foley catheter). The Dr. said it was the NP that the facility would first call upon admission and then he would follow-up. The Doctor said the NP had sent him a message on 11/06/25 in the morning informing him that Resident #1 had returned to the facility and what antibiotics he was receiving for diagnosis of pneumonia and what bacteria was being treated. The Doctor said Resident #1 had a history of sepsis and going in and out of the hospital. The Doctor said Resident #1 would continue to get infections due to having tubes inside of his body which the body looks at as a foreign object and would begin to attack. The Doctor said it was an ongoing process. The Doctor said the infection would go away until another infection occurred and had to be treated. The Doctor said eventually no antibiotic would help and Resident #1 would eventually pass away. The Administrator was asked for the NF policy on Pharmacy Services on 11/06/25 at 4:30PMRecord review of the NF policy on Resident Rights revised June 06, 2025 reflected in part: .Resident has the right to receive the services and /or items included in the plan of care. Event ID: Facility ID: 675078 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 675078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodway Nursing & Rehab 2808 Stoneybrook Drive Houston, TX 77063 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 observation, interview, and record review, the facility failed to maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 4 residents (Resident # 2,) reviewed for infection control in that: CNA D failed to don (to put on) disposable gown when providing direct care for Resident #2 who was on Enhanced Barrier Precautions on 11/05/25. This failure could place residents at risk for cross-contamination and unwanted infections. Findings include: Record review of Resident #2's face sheet dated 11/06/25 revealed a [AGE] year-old-female admitted to the NF originally on 06/29/24 and again on 07/02/25. Resident #2's diagnoses consisted of the following: heart disease, type 2 diabetes mellitus (high blood sugar levels), pneumonia (infection in the lungs), dysphagia (difficulty swallowing), gastrostomy (surgical procedure to insert a feeding tube in to the stomach to allow liquid nutrition and medicine), end stage renal disease (irreversible kidney disease where the kidneys are no longer able to function on their own), renal dialysis (medical procedure to remove waste from the blood), and cerebral infarction (blockage in the brain that cuts off blood flow to the brain). Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating that Resident #2's cognition was severely impaired. Record review of Resident #2's Comprehensive Care Plan dated 06/06/25 revealed that resident was being care planned for feeding tube being in place with intervention to wear abdominal binder. Record review of Resident #2's Physician Order Summary Report for the month November 2025 reflected the following orders: -Dated 05/31/25 Enhanced Barrier Precaution every day and night shift.-Dated 08/11/25 Every shift Nepro continuous pump assist via peg at 55ml/hr x 22 hours to provide a total 1946 ml/day, may give Glucerna 1.5 pending Nepro available. Observation on 11/05/25 at 10:18AM on Resident #2's door entrance was an EBP signage on the door with the door closed. The signage instructed staff to don PPE gown and gloves. There was a 3-drawer plastic storage bin by resident door entrance with gloves and blue disposable gowns inside of the drawers. Coming out of Resident # 2's room was CNA D with clear plastic bags in her hand. Inside of bag the surveyor did not see a blue disposable gown in the bag. Interview 11/05/25 at 10:18AM with CNA D, she said she had just finished providing incontinent care for Resident #2. CNA D said she did not put on a disposable gown while providing direct care for Resident #2. CNA D said she was supposed to do this for infection control and got in a hurry to get resident ready to go to dialysis. CNA D said she placed resident and herself at risk for infections. Observation on 11/05/25 at 10:20AM of Resident #2 resting in bed awake with feeding pump on the left of bed with feeding disconnected from resident. CNA D said she was about to transfer resident from bed to chair. Resident had a gastrostomy tube with dressing around gastrostomy site dated 11/05/25. Interview on 11/06/25 at 2:50PM the ADON said she was the facility's Infection Control Preventionist. The ADON said all nursing staff should be practicing Enhanced Barrier Precaution when providing direct care for a resident that had the following: gastrotomy tubes, Foley catheter tube, tracheostomy, IV lines, etc. ADON said the staff should be wearing gloves and gowns. The ADON said when the staff was not donning correct PPE there was risk for cross contamination. Record of the NF policy on Infection Prevention and Control Prevention revised April 04, 2025 reflected in part: .This facility has established and maintains 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 as per accepted national standards and guidelines . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675078 If continuation sheet Page 8 of 8