Health inspection·April 30, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 residents (Resident #'s 2 and 4 ) reviewed for accuracy of records, in that: RN A failed to document the wound care for Resident #2's open areas to his right and left buttocks on 4/12/25 during the 6 AM to 6PM shift. RN A failed to document that Resident # 2 had a privacy bag on his catheter bag , a catheter securement device to hold his catheter tubing in place, and that he had a size 16 French to beside drainage and catheter care was administered during the 6 AM to 6 PM shift on 4/12/25. RN B failed to document the wound care for Resident #4's open areas to her right and left buttocks on 4/12/25 during the 6 AM to 6 PM shift. LVN B failed to document the wound care for Resident #2's open areas to his right and left buttocks on 4/24/25 during the 6 AM to 6 PM shift. LVN B failed to document that Resident #2 had a privacy bag on his catheter bag , a catheter securement device to hold his catheter tubing in place ,that he had a size 16 French catheter to beside drainage and catheter care was administered during the 6 AM to 6 PM shift on 4/24/25. LVN B failed to document the wound care for Resident #4's open areas to her right and left buttocks on 4/24/25 during the 6 AM to 6 PM shift. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care. The findings included: Review of Resident #2's electronic face sheet reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included: hemiplegia ( paralysis on one side of the body), and prostate cancer. Review of Resident #2's care plan last revised 7/8/24 reflected: Page 1 of 7 675350 675350 04/30/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0842 Level of Harm - Minimal harm or potential for actual harm Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Residents Affected - Some Bed Mobility: dependent X2 Transfers: dependent assist of 2 [mechanical] lift Eating: supervision Toileting: Dependent Ambulation: NA Wheelchair: supervision independent mobility in electric wheelchair Dressing: Dependent on staff x 1 Personal Hygiene: Dependent on staff x1 Resident has a urinary catheter and is at risk for urinary tract infections and injury. Urinary catheter related to: Obstructive & Reflux Uropathy (urinary tract condition that occurs when urine flow is obstructed, either structurally or functionally) The resident will be/remain free from catheter-related trauma and complications through next review date. Catheter care: as ordered Device: indwelling foley cath. 16Fr Catheter cover: privacy bag while up in chair Monitor for and report to the physician any signs or symptoms of a urinary tract infection such as pelvic pain, burning with urination, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, urinary frequency, foul smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. Revised 8/15/24. Resident has moisture associated skin damage to his buttocks 26 x 30 cm clean with normal saline or wound cleanser revised 7/11/24 Review of Resident #2's 0rder recap report dated 4/20/25 reflected: Cleanse moisture associated skin damage to buttocks with wound cleanser, pat dry, apply collagen flakes, cover with silicone foam dressing every day until healed, dated 2/13/25. 16 French catheter with 30 cc bulb to gravity bedside drainage. Perform catheter care every shift 675350 Page 2 of 7 675350 04/30/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0842 Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's electronic progress notes reflected: 04/02/2025 2:53 pm noted pressure wound to sacrum measuring 2 by 4 cm, signed by wound care nurse. Record review of the treatment administration record for Resident #2 for the dates 4/1/25 to 4/30/25 reflected the following: Residents Affected - Some No documentation on 6Am to 6 PM shift on 4/12/25 and 4/24/25 for the following : Treatment for moisture associated skin damage to right buttocks Treatment for moisture associated skin damage to the left buttocks Catheter privacy bag in place in bed or chair. Catheter securement device in place Urinary catheter to bedside drainage Review of Resident #4's electronic face sheet reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included: right side hemiplegia ( paralysis on one side of the body), and aphasia ( inability to understand or produce speech). Review of Resident #4's care plan revised 4/29/25 reflected: The resident has the following acute skin issue: open areas caused by skin traumaLeft superior buttock Left inferior buttock Right Superior buttock Right middle buttock #1 Right middle buttock #2 Right inferior buttock The resident's skin issue will resolve by the next review date. Administer analgesics as needed for discomfort or pain. If necessary provide pain management before care tasks such as repositioning or dressing. Encourage the resident not to scratch, pick, or rub the affected area. Monitor for signs of infection such as increased drainage, foul odor, pain, swelling or redness at 675350 Page 3 of 7 675350 04/30/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0842 the site. Report any findings to the practitioner. Treat the skin issue per order. Level of Harm - Minimal harm or potential for actual harm Review of Resident #4's 0rder recap report dated 4/30/25 reflected: Residents Affected - Some Cleanse moisture associated skin damage to right and left buttocks with normal saline or wound cleanser and pat dry with gauze. Apply triad zinc paste to compromised skin and apply calcium alginate over and cover with foam border dressing. Record review of the Treatment administration record for Resident #4 for the dates 4/1/25 to 4/30/25 on the 6 AM to 6 PM shift reflected the following: No documentation on 4/12/25 and 4/24/25 for the following : Treatment for moisture associated skin damage to right buttocks Treatment for moisture associated skin damage to the left buttocks Catheter privacy bag in place in bed or chair. Catheter securement device in place Urinary catheter to bedside drainage During an interview with RN A on 4/30/25 at 1:45 PM, she stated she did perform wound care on Resident #2 and Resident # 4 on 04/12/25. She stated she did not recall what happened but stated she must have been called away from her documentation and forgot to document the Catheter privacy bag in place in bed or chair, Catheter securement device in place, and catheter care urinary catheter to bedside drainage. She stated this was all included in the care she had given Resident # 2 and Resident #4. She stated she always did her treatments, and she should document her treatments when they were done in order to avoid an error. She stated failure to document accurately could cause an error in the resident's care. During an interview with LVN B on 4/30/25 at 1:55 PM, she stated she did perform wound care on Resident #2 and Resident # 4 on 04/24/25. She stated she did not recall what happened but stated she must have gotten busy and just forgot to document the care she had given Resident # 2 and Resident #4. She stated she should always document care when it was done. She stated failure to document accurately could cause an error in the resident's care. During an interview on 04/30/25 at 03:17 PM, the Acting DON (who was also the treatment nurse) stated her expectation was for documentation to be completed accurately. She stated she felt the error was from staff not paying attention to what they were doing, and not documenting their work. She stated all nurses would be in-serviced regarding documentation. She stated the negative outcome could be residents not receiving the care that they need. Review of facility policy titled, Administration and Documentations Guidelines, revised 4/6/24, reflected in part: document PRN medication and treatment administration on the EMAR or ETAR along with the reason immediately following administration. Document effectiveness of the intervention on the EMAR/ETAR as indicated. Review the EMAR/ETAR after each medication and treatment administration is completed and prior to the end of the shift to validate documentation is completed and support 675350 Page 4 of 7 675350 04/30/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0842 services provided according to the physicians orders. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675350 Page 5 of 7 675350 04/30/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

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, interview 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 1(Resident # 4) of 2 residents observed for wound care. Residents Affected - Few The facility failed to ensure the wound care nurse washed or sanitized her hands between glove changes while performing incontinent care and wound care on Resident #4. These failures could place residents at risk of infections. The findings included: Review of Resident #4's electronic face sheet reflected the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included: right side hemiplegia ( paralysis on one side of the body), and aphasia (inability to understand or produce speech). Record review of Resident #4's Annual MDS assessment dated [DATE], revealed the following: Section K (Skin): Resident has moisture associated skin damage; Section H: resident is always incontinent of bowel and bladder. Record review of Resident #4's care plan dated revised 4/29/25 reflected the following information: The resident requires Enhanced Barrier Precautions d/t Wounds. The resident will remain free from active infection with MDROs through the review date. Educate the resident and family on the reason and procedure for enhanced barrier precautions. Ensure EBP signage is posted outside the resident's room and above the head of the resident's bed . Treat the skin issue per order. Ensure PPE is available for use on the resident; Notify the physician of any S/S of active infection; Wear gown and gloves during high-contact resident care activities. In an observation of peri care and wound care on Resident #4 on 4/30/25 at 10:00 AM , the wound Care Nurse/Acting DON entered Resident #4's room. There was an enhanced barrier precautions sign on Resident #4's door. She did not wash her hands but stated she had washed her hands prior to entering the room. She donned gloves and a gown. She removed a urine soiled brief from Resident #4 and disposed of the brief in the trash at bedside . She performed incontinent care, which included cleansing the areas around the urethra and then the anal area. She changed gloves but did not perform hand hygiene before applying clean gloves. She removed the soiled dressings and changed gloves again without performing hand hygiene. She cleansed the wound and performed the wound care as ordered, then removed her gloves and applied new gloves without performing hand hygiene. She applied a clean dressing and arranged the resident's covers and bed side table before leaving the room. In an interview with the wound care nurse/acting DON on 4/30/25 at 10:15 AM she stated she realized 675350 Page 6 of 7 675350 04/30/2025 Willowcreek Rehab and Nursing 4934 S 7th St Abilene, TX 79605

F 0880 Level of Harm - Minimal harm or potential for actual harm now that she did not perform hand hygiene between glove changes, and she should change gloves and perform hand hygiene when going from a dirty area to a clean area. She stated she failed to perform hand hygiene at the proper time because she was nervous. She stated failure to perform hand hygiene between glove changes could result in increasing the resident's risk of infection. She stated the resident was on enhanced barrier precautions because she had chronic wounds. Residents Affected - Few During an interview on 4/30/25 at 12:45 PM the RNC stated that her expectation was that hand sanitizer be used by all personnel as part of infection control between glove changes and after resident contact. She stated the Wound Care Nurse was extremely nervous and that was why the failure occurred. She stated a negative resident outcome of the failure to perform hand hygiene would be infection. Review of the facility policy titled Hand Hygiene dated revised 2/11/22 revealed the following: all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by hand washing with soap and water, or the use of an antiseptic hand rub (also known as alcohol-based hand rub). The use of gloves does not replace hand hygiene if your task requires gloves. Perform hand hygiene prior to donning gloves and immediately after removing gloves. Hand hygiene table: Hand hygiene should be used before applying and after removing personal protective equipment, including gloves. T 675350 Page 7 of 7