Health inspection·March 21, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice to including but not limited to the residents right to make choices about aspects of his or her life in the facility that are significant to the resident, healthcare and providers of healthcare services consistent with his or her interest, assessments, and plan of care and other applicable provisions of this part for 1 (Resident #4) of 8 residents reviewed for resident rights. The facility failed to honor Resident #4's request to be assisted to shower on Saturdays. This failure could place residents at risk for lack of choices/decision making resulting in depression, and diminished quality of life. Findings included: Record review of Resident #4's face sheet dated 03/20/2025 revealed a [AGE] year-old admitted to the facility on [DATE] and latest re-admission date of 02/28/2025. His diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and eventually the ability to carry out simple tasks)Parkinson's disease (a nervous system disorder), diabetes, Metabolic encephalopathy (a change in how the brain works due to an underlying condition), dementia, polyneuropathy (peripheral nerve disease) and history of fungal infection of the skin and nails. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderate cognitive impairment. He had no rejection of care. He was feeling down, depressed, or hopeless for several days over a two-week period. He had functional limitations in range of motion to one side of lower extremity. He used a wheelchair for mobility. He required partial/moderate assistance from staff with showering self. He required supervision for personal hygiene and upper body dressing and substantial assistance with lower body dressing. He was always incontinent of bowel and bladder. Record review of Resident #4's undated care plan included Problem: the following tasks will be documented in POC (Point of Care) assist. Problem start date was 01/15/2025. -Goal: the resident will perform the following tasks at their highest practicable level. Target date was 05/28/2025. - Approach included: I prefer to take my bath/shower on Tuesday, Thursday, and Saturday. Last reviewed/revised on 3/04/2025. Problem: Resident #4 had refusals of ADL incontinent care, baths/showers, changing clothes and taking medications. Problem start date was 07/03/2023. Goal: maintain skin integrity issue. Target date was 05/28/2025. Approach included: educate as needed, explain benefits, explain risk, Page 1 of 7 675229 675229 03/21/2025 Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304

F 0561 update MD as needed and skin checks per schedule. Last reviewed/revised on 3/04/2025. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's POC History for dates 3/1/2025 to 3/20/2/2025 revealed CNA A documented a shower was done on Saturday 03/15/2025 at 6:06 AM. Residents Affected - Few Record review of the facility's Shower Logbook revealed Resident #4 received a shower on 3/20/25 by CNA A and on 3/18/2025 by Shower Tech. There was no shower sheet for 3/15/2025. Record review of Resident #4's progress notes dated 03/06/2025 to 03/20/2025 revealed no refusals of showers. There was no documentation that resident did not shower on 03/15/2025. In an interview on 03/20/2025 at 10:23 AM, Resident #4 stated he was not getting showers three times a week like he is scheduled to on Tuesdays, Thursdays, and Saturdays. He stated he preferred showers after the afternoon smoke break. He stated he did not receive a shower on Saturday 3/15/2025. He stated they don't care, and it made him mad that he had to beg for showers. He stated that he did not refuse showers. He stated he reported the missed shower to the Administrator on Tuesday. He stated he did get a shower on Tuesday 3/18/2025. In an interview on 3/21/2025 at 10:40 AM, CNA A denied showering Resident #4 on Saturday 3/15/2025. CNA A stated there were no clean slings for the mechanical lift so she did not provide a shower for Resident #4. CNA A stated she did not offer him a bed bath but did wipe him down. CNA A stated sometimes she clicks on everything really quickly on the POC and did not intend to document that a shower was completed on 3/15/2025. In an interview on 3/21/2025 at 10:45 AM, the Shower Tech stated she worked Monday to Friday and had no issues getting all her assigned showers completed. In an interview on 3/21/2025 at 10:40 AM, LVN B stated that she worked on Saturday 3/15/2025 and did not recall if anyone told her Resident #4 missed a shower. LVN B stated the CNAs were responsible to provide the showers when there are no shower techs and that there was no shower tech available that day. She stated she worked from 6:00 AM to 6:00 PM shift. In an interview on 3/21/2025 at 10:50 AM, Resident #4 denied getting washed down on Saturday 3/15/2025. In an interview on 3/21/2025 at 11:00 AM, the RN Supervisor stated he was the weekend supervisor and stated sometimes the showers would be split between the CNAs and himself. He stated no one notified him that Resident #4 did not receive a shower on 3/15/2025. He stated he escorted Resident #4 to smoke breaks on 3/15/2025 and Resident #4 had the opportunity to tell him of any issues but did not. RN Supervisor stated the risk of not getting showers as scheduled would be health issues such as skin infection. He stated that he himself would feel uncomfortable if he did not shower. RN Supervisor stated there was a shower logbook the CNAs would record showers. He stated the CNAs would inform the nurse and then the nurse would notify him of any issues. He stated the residents deserve the right to shower anytime. He stated it was his job to ensure Saturday showers schedules were completed even if he had to be the one to do it. He stated moving forward he would ensure Resident #4 and other residents receive their showers on Saturdays. In an interview on 3/21/2025 at 12:00 PM, the Director of Housekeeping/Laundry stated he worked on Saturday 3/15/2025 during the day and did not receive any notifications from staff regarding 675229 Page 2 of 7 675229 03/21/2025 Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304

F 0561 unavailability of clean slings. He stated he keeps 20 slings for the mechanical lift. Level of Harm - Minimal harm or potential for actual harm In an interview on 3/21/2025 at 11:15 AM, the Administrator stated Resident #4 notified him last week to complain about not getting showers as scheduled. The Administrator stated he expected the staff to call him on the weekend if there was a supply issue such as no clean slings. He stated he was unaware of any issues over the weekend of 3/15/2025. He stated a possible risk to Resident #4 would be skin breakdown and agitation if he did not receive showers. He stated there were times the staff could not find Resident #4 after a shower time was agreed upon or if he refused. The Administrator stated moving forward he would conduct staff Inservice on shower schedules. Residents Affected - Few In an interview on 3/21/2025 at 1:15 PM, the DON stated the weekend supervisor was responsible to ensure showers were done on Saturdays and the charge nurse oversees it as well. She stated the CNAs assigned to the resident were responsible for showers when no shower techs were available. She stated she did not know why Resident #4 did not receive a shower on 3/15/2025. The DON stated the risks of not getting showers as expected would be a decreased feeling of well-being. Record review of the facility's policy for Resident Rights, revised in February 2021 read in part: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .e. self-determination . 675229 Page 3 of 7 675229 03/21/2025 Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304

F 0583 Keep residents' personal and medical records private and confidential. 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 the residents' right to personal privacy and confidentiality of his or her personal medical records for 2 (Resident #34 and Resident #18) of 8 residents reviewed for personal privacy. Residents Affected - Few The facility failed to ensure LVN C protected resident's right to privacy by verbalizing that Resident #34 was going to receive Insulin within earshot of Resident #18. This failure could place residents' protected HIPPA information at risk of being overheard resulting in low self-esteem and a diminished quality of life. Findings included: Record review of Resident #34's face sheet dated 03/20/2025 revealed a [AGE] year-old admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included orthopedic aftercare following surgical amputation, stroke, diabetes, and cognitive communication deficit. Record review of Resident #34's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 out of 15 indicating severe cognitive impairment. Resident #34 was dependent on staff for ADLs. Record review of Resident #34's Continuity of Care Document dated 03/20/2025 revealed a physician order with start date of 03/05/2025 for Lantus insulin 20 units subcutaneous once a day for diabetes. Record review of Resident #18's face sheet dated 3/20/2025 revealed a [AGE] year-old admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included diabetes, schizophrenia (a serious mental disorder, characterized by symptoms such as hallucinations, delusions and disorganized thinking) and depression. Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. He required a wheelchair for mobility. Record review of Resident #18's physician orders revealed an order for Lispro Insulin 5 units subcutaneous with meals at 7:00 AM, 12:00 PM and 5:00 PM, with a start date of 02/24/2025. Observation on 03/20/2025 at 6:50 AM, LVN C brought Resident #18 from the dining room to the medication cart in the 200 hall across from Resident #34's room. The room door was open, and Resident #34 was in the bed. LVN C asked Resident #18 if he was OK with checking his blood glucose level in the hallway. Resident #18 said yes. LVN C told Resident #18 she would first give Resident #34 his insulin. Resident #18 was sitting in his wheelchair next to LVN C. LVN C verbalized that she would administer 20 units of insulin to Resident #34. In an interview on 03/20/2025 at 7:03 AM after Resident #18 left the medication cart, LVN C stated she did not know if Resident #34 was OK with other residents hearing about his insulin. She stated she was nervous and should not have done so in front of another resident. In an interview on 3/20/2025 at 9:50 AM, Resident #18 stated he did hear LVN C say that she would give Resident #34 his insulin shot before she checks his blood sugar. Resident #18 stated she should 675229 Page 4 of 7 675229 03/21/2025 Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have kept that information to herself. He stated a similar situation happened to him in the past and said it made him feel terrible knowing that other resident's had knowledge of his medical status. Record review of the facility's policy for Resident Rights, revised in February 2021 read in part: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .e. self-determination .h. be supported by the facility in exercising his or her rights .t. privacy and confidentiality .3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues . Record review of the facility's example of a staff checklist for trainings and topics included HIPPA. 675229 Page 5 of 7 675229 03/21/2025 Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304

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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #31) reviewed for infection control. Residents Affected - Few -CNA A failed to change gloves and perform hand hygiene during incontinent care on Resident #31. This failure could place residents who required incontinent care at risk for cross contamination and infection. Findings included: Record review of Resident #31's face sheet dated 3/20/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included: traumatic brain injury (a serious condition that occurs when an external force causes damage to the brain),stage 4 pressure ulcer of the sacrum (a deep wound that exposes underlying muscle, tendon, cartilage or bone to the tailbone),adult failure to thrive (a gradual decline in health and functional abilities), neuromuscular dysfunction of bladder (nerves to the bladder are damaged) vitamin deficiency, blindness to the left eye, elevated blood pressure and depression. Record review of Resident #31's significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a BIMS score of 13 indicating he was cognitively intact. Resident #31 had impairment to one side of the upper and lower body. Resident #31 was dependent on staff for all ADLs. He was always incontinent of bowel and bladder. Record review of Resident #31's undated care plan, last reviewed/revised on 03/12/25, revealed in part; -Focus: Resident #31 had a stage 4 pressure ulcer to his sacrum. Interventions included: Resident #31 will be repositioned off his sacrum every 2 hours. He will have wound care daily by nursing. -Focus: Resident #31 required enhanced barrier precautions due to wounds. He was at increased risk of a MDRO (multidrug resistant organism) acquisition due to having a wound. Interventions included: Staff will wear PPE (personal protective equipment) during high-contact activities such as dressing bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing. -Focus: Resident #31 is at risk for pressure ulcers d/t failure to thrive, vitamin deficiency, abnormal weight loss, low calcium, GERD, dysphagia (difficulty swallowing) and decreased oral intake. Interventions included: Follow facility skin care protocol. Observation and interview on 3/21/2025 at 7:15 AM, CNA A performed incontinent care on Resident #31. The resident was on EBP (enhanced barrier precautions) as evidenced by the signage on the door to the resident's room. CNA A gathered supplies, performed hand hygiene, donned PPE prior to entering resident room, then closed the door and drew the privacy curtain. CNA A unfastened Resident #31's brief. She then used disposable wipes to cleanse the front of the resident's peri areas. She then rolled the resident to his left side. The resident had a (BM) bowel movement. Using clean wipes, she cleansed Resident #31 from front to back using a fresh wipe for each pass until skin was clear. The 675229 Page 6 of 7 675229 03/21/2025 Woodland Manor Nursing and Rehabilitation 99 Rigby Owen Rd Conroe, TX 77304

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had a large white dressing adhered to his skin just above the sacrum. The sacrum had an open wound that was clean and dry. The dressing was no longer covering the wound. The BM did not extend up to the sacral area. CNA A then touched the clean brief and positioned it under the resident then secured. CNA A touched the bedding to cover the resident. CNA A removed gloves, placed in trash bag, reached underneath her gown and into the pocket of her scrubs for hand sanitizer, then sanitized hands. She then removed a pair of gloves from her pocket, donned the gloves, gathered the trash, removed PPE and secured the trash bag. CNA A then performed hand washing at the sink. CNA A then opened door, picked up trash bag, deposited trash bag into dirty utility closet. CNA A hand sanitized her hands. CNA A said she was nervous and should have removed the dirty gloves, hand sanitized then put on clean gloves. She said the risk is cross contamination and risk of transferring dirt to the resident's wound area. CNA A stated she would notify the nurse about the loose dressing. In an interview on 3/21/2025 at 7:45 AM, the DON stated that she expected the staff to hand wash before going into the room and put clean gloves on. She stated she expected soiled gloves to be removed before touching anything clean to prevent cross-contamination. She stated she had been working hard on inservicing the staff on infection control. Record review of CNA A Nurse Aide Proficiency Audit signed and dated on 12/07/24 by CNA A and observed and signed by RN Supervision on 12/07/24, indicated CNA A's Hand Hygiene Competency, Perineal Care Return Demonstration, Personal Protective Equipment (PPE) Competency was validated. Record review of the facility policy for Handwashing/Hand Hygiene, revised on 1/20/23 read in part: Policy Statement - This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .5. Hand hygiene must be performed prior to donn (putting on) and after doffing (removing) gloves . Record review of the facility policy for Perineal Care, revised on 1/20/23 read in part: Policy Statement Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated containers. 13. Perform Hand Hygiene. 14. Reposition the bedcovers . 675229 Page 7 of 7