Health inspection·August 29, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents and hazards, in that: Resident #1 was able to exit the facility without staff knowing on 08/13/2024. Staff were unaware that Resident #1 had walked out of the facility until they received a call from local police informing them Resident #1 was with the Police at a restaurant located .3 miles from the facility. An IJ was identified on 08/27/2024. The IJ template was provided to the facility on [DATE] at 06:45 PM. While the IJ was removed on 08/29/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death. Findings were: Record review of Resident #1's face sheet, dated 08/27/24, revealed Resident #1 was a [AGE] year-old female diagnosed with dementia originally admitted to the facility 03/01/2021. Record review of Resident #1's MDS assessment, dated 08/08/2024, revealed Resident #1 had a BIMS score of 5. Resident #1 used a walker when ambulating. Record review of Resident #1's care plan, dated 06/03/2024, revealed Resident #1 was identified as an elopement risk with no exit seeking behaviors. One intervention was identified as involve resident in group activities. Record Review of Resident #1's Elopement Risk Assessment, dated 06/12/2024, revealed Resident #1 was identified as At Risk for elopement with a score of 5. Resident #1's Elopement Risk Assessment was marked Yes for questions 1. Does the resident have a diagnosis of Dementia, OBS, Alzheimer's, Intellectual/ Developmental Disability, Delusions, Hallucinations, Anxiety Disorder, Depression, Bipolar, and/or Schizophrenia?, 2.Does the resident ambulate independently, with or without the use of an assistive device? (i.e. Page 1 of 11 675428 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Level of Harm - Immediate jeopardy to resident health or safety walker, cane or wheelchair)?, 3. Does the resident have any hearing, vision or communication problems?, 7. Is the resident cognitively impaired with poor decision-making skills (i.e. disorientation, cognitive deficits, disorganized thinking)?, 10. Does the resident display wandering without a sense of purpose (i.e. going in and out of other resident's rooms and explore their belongings, confused, aimless movements)?. The incident Residents Affected - Few Record review of facility in-service training named Abuse & Neglect, Elopement/Wandering, and ensuring doors closed after letting visitors in/out, dated 8/13/2024, revealed 67 staff had signed the in-service. Record review of facility's employee roster revealed the facility had 75 employees. Record review of staff's clock-ins revealed 68 staff had worked from the time Resident #1 eloped from the facility on 08/13/2024 (around 9:00 PM) to morning shift (6 AM to 2 PM) on 08/27/2024. Out of the 68 staff who worked, 16 staff had not signed the in-service. Interview with DON on 08/27/2024 at 10:24 AM revealed Resident #1 eloped from the facility on 08/13/2024. DON stated that the medication aide passed Resident #1's medications about 9:00 PM and then asked resident if she wanted to go lay down. Resident #1 then walked to her room and entered. DON stated that Resident #1 was not seen leaving the facility and the staff were unaware that Resident #1 had left until the local police called the facility. Local police informed the facility that Resident #1 was with them at a restaurant .3 miles from the facility. Local police returned Resident #1 to the facility around 9:30 PM. DON stated that she completed a head-to-toe assessment on Resident #1 and then started to in-service on Abuse/Neglect, Elopement/wandering and ensuring doors are closed with all staff that were on shift. Interview with Administrator on 08/27/2024 at 10:34 AM revealed Resident #1 eloped from the facility on 08/13/2024 after receiving her 9:00 PM medications. Administrator stated the facility received a call from the local police informing them Resident #1 was at a restaurant .3 miles from the facility and would be escorted back to the facility. Administrator stated that resident was returned to the facility about 9:30 PM by local police. Administrator stated she was unsure how resident was able to elope from the facility but speculated that Resident #1 followed another resident's family out of the facility. Administrator stated that resident did not have exit seeking behaviors prior to her elopement. Interview with Resident #1's responsible party on 08/27/2024 at 11:30 AM revealed Resident #1 had been at the facility since 2021. Resident #1's responsible party stated Resident #1 had never had exit seeking behaviors. Resident #1's responsible party stated that Resident #1 was happy at the facility and had never expressed concerns with her care. Observation of all facility exit doors on 08/27/2024 starting at 11:45 AM revealed all exit doors were locked and unlocked with a keypad. All exit door alarms were working properly. Observation of Resident #1 on 08/27/2024 at 12:15 PM revealed resident sitting in the living room close to nursing station. Resident had a small band with a white square (wander guard) on her left ankle. 675428 Page 2 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview attempted with Resident #1 on 08/27/2024 at 12:16 PM revealed resident was confused and unable to answer surveyor's questions. Resident #1 was unable to tell surveyor the day of the week or what she had for breakfast. Interview with MA D on 08/27/2024 at 2:17 PM revealed Resident #1 received her medications on 08/13/2024 just after 9 PM and then went back to her room. MA D stated she did not see Resident #1 leave her room or the facility the night she eloped. Resident #1 was returned to the facility by local police around 9:30 PM. MA D stated the facility exit doors are locked and have an alarm when opened without being unlocked. MA D stated resident had no exit seeking behaviors prior to her elopement. This was determined to be an Immediate Jeopardy (IJ) on 08/27/2024 at 6:45 PM. Administrator was provided with the IJ template on 08/27/2024. The following Plan of Removal was accepted on 08/28/2024 at 1:13 PM. Plan of Removal: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On August 27, 2024 an investigation was initiated at [facility name and address]. At approximately 6:45p.m determined the conditions at [the facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrections Implemented for Removal of Immediate Jeopardy. On August 13,2024 at approximately 9:20pm Resident#1 returned to the facility from the Emergency Department. Action: Resident #1 is a current resident and was brought back to facility on 8/13/2024. The director of nursing reassessed Resident #1 for Elopement risk and Wander guard was placed 8/15/2024 to monitor for resident exiting facility. IDT reviewed and interventions initiated, and care plan updated reflect elopement risk. On August 27, 2024, at approximately 7:00pm the following actions were taken; Action: Education initiated Elopement risk, Abuse/Neglect/Exploitation, Signs to watch for with residents exhibiting potential for elopement, increased wandering, exit seeking, increased behaviors. Education will be completed prior to staff working the next scheduled shift, and ongoing with general orientation for all new hires. 675428 Page 3 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Start Date: 8/27/2024 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Action: Administrator validated that exit doors are functioning with wander guard system for notification of opening doors and residents attempting to exit that have been identified as High risk of elopement. Responsible: Director of Nursing/designee Start Date: 8/27/2024 Responsible: Administrator/Designee IDENTIFICATION OF OTHER AFFECTED: All residents have the potential to be affected. Action: Completed Elopement Risk Assessment on all residents and validated all residents at risk of elopement, score of 3 or greater, have appropriate interventions and plan of care in place per risk assessment. Start Date: 8/27/2024 Responsible: Director of nursing/designee SYSTEMIC CHANGES AND/OR MEASURES: Action: In-service and education was provided to facility staff regarding the process for residents who have been identified as an elopement risk and proper steps to take to assure residents remain safe without risk for elopement, including monitoring, care plan updates, wander guards as indicated. Start Date: 8/27/2024 Responsible Party: Director of Nursing/Designee Action: Signage to be placed at exit door to notify all persons exiting to watch for residents to assure they are not followed out by potentially wandering or unsafe residents. Start Date: 8/28/2024 675428 Page 4 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Responsible Party: Administrator Residents Affected - Few Start Date: 8/27/2024 Action: Education was provided to all staff on Elopement policy, Abuse/Neglect/Exploitation. shift. Responsible Party: Director of Nursing/Designee Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on Elopement, Abuse and neglect, and Plan of removal/response to Immediate Jeopardy Citation on 8/27/2024 Start Date: 8/27/2024 Responsible: Administrator/Designee Tracking and Monitoring Director of Nursing/Designee will review residents with At Risk for wandering or elopement identified or newly admitted with history of elopements to assure appropriate interventions and plan of care are in place 5 times per week beginning 8/28/2024 for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. Director of Nursing/Designee will complete audits for those residents who wear a wander guard to ensure electronic monitoring device is functioning every shift for 7 days beginning 8/28/2024 then will monitor electronic monitoring devices daily 5 times per week for 12 weeks or until sufficient compliance if found. This will be documented in daily clinical meeting with use of electronic log and reviewed monthly in QAPI meeting. Administrator/designee will complete random audit every shift for 7 days, beginning 8/28/2024 for appropriate staff response to wandering or potentially exit seeking residents, immediate education will be provided, if necessary, then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed in QAPI Meeting Monthly. Administrator/designee will complete audit of exits for proper functioning of doors, alarms and wander guard system for proper functioning every shift for 7 days, beginning 8/28/2024 then will monitor random shifts, 5 times a week for 12 weeks or until sufficient compliance if found. This will be documented on log to be reviewed monthly in QAPI. Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review 675428 Page 5 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Verification: Level of Harm - Immediate jeopardy to resident health or safety Interview with Administrator on 08/28/2024 at 1:25 PM revealed the facility started in-servicing its staff on 08/27/24. Administrator stated the facility would continue to in-service its staff prior to the start of their shifts until all staff have been in-serviced. Administrator also stated the DON started to re-assess all residents on their elopement risk and would be complete on 08/29/2024. Administrator stated she hung signs on all exit doors instructing anyone exiting to ensure that residents do not follow them out. Administrator stated she tested all exit doors to ensure the alarms and wander guards worked properly. Residents Affected - Few Observation of the facility's exit doors on 08/28/2024 starting at 1:45 PM revealed all 8 exit doors had a sign that read Caution For the safety of our residents please ensure doors properly close behind you. All exit doors were locked, and alarm sounded when release bar was pressed. Interview with Administrator on 08/29/2024 at 9:54 AM revealed DON and Administrator worked on re-assessing the residents to identify those at risk for elopement. Administrator stated she was reviewing care plans for residents identified as at risk for elopement and ensuring care plans included interventions to prevent elopement. Interview with LPN A on 08/29/2024 at 9:24 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN A was able to demonstrate an understanding of the in-service materials. Interview with RN B on 08/29/2024 at 9:35 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. RN B was able to demonstrate an understanding of the in-service materials. Interview with CNA C on 08/29/2024 at 9:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA C was able to demonstrate an understanding of the in-service materials. Interview with MA D on 08/29/2024 at 10:17 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. MA D was able to demonstrate an understanding of the in-service materials. Interview with CNA E on 08/29/2024 at 10:32 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA E was able to demonstrate an understanding of the in-service materials. Interview with LPN F on 08/29/2024 at 10:36 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN F was able to demonstrate an understanding of the in-service materials. 675428 Page 6 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with LPN G on 08/29/2024 at 10:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN G was able to demonstrate an understanding of the in-service materials. Interview with MA H on 08/29/2024 at 11:08 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. MA H was able to demonstrate an understanding of the in-service materials. Interview with RN I on 08/29/2024 at 11:17 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. RN I was able to demonstrate an understanding of the in-service materials. Interview with CNA J on 08/29/2024 at 11:22 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA J was able to demonstrate an understanding of the in-service materials. Interview with CNA K on 08/29/2024 at 11:22 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA K was able to demonstrate an understanding of the in-service materials. Interview with CNA L on 08/29/2024 at 11:28 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA L was able to demonstrate an understanding of the in-service materials. Interview with CNA M on 08/29/2024 at 11:31 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA M was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping N on 08/29/2024 at 11:32 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping N was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping O on 08/29/2024 at 11:36 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping O was able to demonstrate an understanding of the in-service materials. Interview with DA P on 08/29/2024 at 11:42 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. DA P was able to demonstrate an understanding of the in-service materials. 675428 Page 7 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with [NAME] Q on 08/29/2024 at 11:42 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] Q was able to demonstrate an understanding of the in-service materials. Interview with DS R on 08/29/2024 at 11:43 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. DS R was able to demonstrate an understanding of the in-service materials. Interview with [NAME] S on 08/29/2024 at 11:46 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] S was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping T on 08/29/2024 at 11:48 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Housekeeping T was able to demonstrate an understanding of the in-service materials. Interview with Human Resources Director U on 08/29/2024 at 11:50 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Human Resources Director U was able to demonstrate an understanding of the in-service materials. Interview with CNA V on 08/29/2024 at 11:52 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. CNA V was able to demonstrate an understanding of the in-service materials. Interview with LPN W on 08/29/2024 at 11:54 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN W was able to demonstrate an understanding of the in-service materials. Interview with Activities Director X on 08/29/2024 at 11:57 AM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. Activities Director X was able to demonstrate an understanding of the in-service materials. Interview with PT Assistant Y on 08/29/2024 at 12:00 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. PT Assistant Y was able to demonstrate an understanding of the in-service materials. Interview with [NAME] Z on 08/29/2024 at 12:04 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. [NAME] Z was able to demonstrate an understanding of the in-service materials. 675428 Page 8 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with LPN AA on 08/29/2024 at 12:10 PM revealed they received training before their next shift after the IJ was identified on 08/27/2024. Inservice was on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out. LPN AA was able to demonstrate an understanding of the in-service materials. Observation of the facility's wander guard system on 08/29/2024 at 3:02 PM revealed alarm sounds when resident got about 5 feet from the front door in the living room. The alarm turned off when resident moved closer to the nurse's station at the end of the living room. Record review of in-service training on Abuse & Neglect, Elopement/Wandering, ensuring doors closed after letting visitors in/out, dated 08/27/2024, on 08/29/2024 revealed 63 out of 69 staff have signed the in-service training. Record review of all resident's Elopement Risk assessments on 08/29/2024 revealed the facility re-assessed each resident's risk of eloping starting 08/27/2024. The facility completed the re-assessments on 08/29/2024. Record review of facility's monitoring logs on 08/29/2024 revealed DON/Designee reviewed resident's identified as elopement risk care plans for appropriate interventions on 08/28/2024 and 08/29/224. Record review of facility's monitoring logs on 08/29/2024 revealed DON/Designee completed audits for residents wearing wander guards on 08/28/2024 on all shifts and 08/29/2024 6 AM-2 PM shift. Record review of facility's monitoring logs on 08/29/2024 revealed Administrator/Designee completed random audits of staff's response to resident's wandering on 08/28/24 on each shift and on 08/29/2024 on the 6 AM-2 PM shift as well as the 2 PM- 10 PM shift. Record review of facility's monitoring logs on 08/29/2024 revealed Administrator/Designee reviewed completed audits of exit for proper functioning of door alarms and wander guard system on 08/28/2024 and 08/29/2024. The Administrator was informed the Immediate Jeopardy was removed on 08/29/2024 at 3:29 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal. 675428 Page 9 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

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 reviews 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 of 4 residents (Resident #2) reviewed for infection control. Residents Affected - Few CNA-AB failed to follow EBP by not wearing a gown while providing incontinent care for Resident #2 on 08/27/2024 This failure could place residents at risk for cross contamination and infection. Findings: Record review of Resident #2's face sheet dated 08//27/2024 revealed Resident #2 was a 76- year-old female who had an initial admission date of 06/22/2024 and a re-admission date of 08/14/2024 with diagnoses that included: MRSA (a bacterial infection that is resistant to certain antibiotics) as cause of disease classified elsewhere; Fracture of unspecified part of neck of right femur (region just below the ball of the hip joint); unspecified dislocation of unspecified hip; dementia; functional urinary incontinence; pressure ulcer of sacral region (portion of spine between lower back and tailbone) - stage 3; pressure ulcer of right buttock - stage2; and pressure ulcer of left buttock - stage 2. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 6, suggesting severe cognitive impairment and was coded under assistance needed for toileting as a 1, indicating total dependence on others. Record review of Resident #2's Physician Orders dated 08/27/24 revealed an order to Initiate isolation and educate resident/family and staff on handwashing, meals and activities and therapy in room while on isolation every shift r/t MRSA effective 07/23/2024. Record review of Resident #2's Care Plan dated 06/23/3034 revealed a focus area for .enhanced barrier precaution r/t pressure ulcer of sacral and buttocks, has surgical incision to right hip, with date initiated of 07/05/2024, and interventions which included: Don [put on] gown and gloves during high-contact resident care activities and Enhanced Barrier Precautions. Observation on 08/27/2024 at 11:08 a.m. in the hallway outside Resident #2's room, revealed a Contact Precautions sign posted on the door, and a small PPE supply storage unit outside the door. Observation of the contents inside this PPE supply storage unit revealed there were no gowns available. During an observation on 08/27/2024 at 11:11 a.m., CNA- AB was observed in Resident #2's room, in the process of tying a plastic trash bag, wearing gloves, but no gown. During an interview with CNA-AB at 08/27/2024 at 11:11a.m., CNA-AB stated she had just finished providing incontinent care to Resident #2 , and that she did not wear a gown while providing this incontinent care because there were no gowns available in the PPE supply drawer. CNA-AB further stated that she was aware that Resident #2 was on contact precautions and that she should have worn both a gown and gloves to provide the incontinence care. CNA-AB stated there were additional gowns available 675428 Page 10 of 11 675428 08/29/2024 Pleasanton South Nursing and Rehabilitation 905 West Oaklawn Rd Pleasanton, TX 78064

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the medical supply closet, but she did not go to supply closet to get a gown before entering Resident #2's room, because Resident #2 was asking to be changed and she did not want to make her upset by making her wait while she went to go get more gowns. CNA-AB stated that by not wearing both gown and gloves when she provided incontinent care to Resident #2, she could catch what she has. During an interview the DON on 08/28/2024 at 1:16 p.m., the DON confirmed that Resident #2 was on Enhanced Barrier Precautions due to MRSA, and that the sign posted outside of Resident #2 's room on 08/27/2024 should have been for EBP and not contact precautions. The DON noted that the correct EBP sign has now been placed on Resident #2's room, but also stated that both EBP and Contact precautions required use of both gown and gloves for high-contact activities such as incontinence care. The DON stated that adequate supply of PPE should be maintained in the PPE supply units outside rooms requiring enhanced-barrier precautions and that it was the responsibility of all the staff to ensure they were kept stocked. The DON stated that failure to use the correct PPE during high-contact activities could result in the spread of infection. The DON confirmed CNA-AB had received training in infection control procedures. Record review of CNA-AB's facility training record dated 06/17/2024 revealed CNA-AB had initialed her training record next to infection control, indicating she had receiving training on infection control procedures. Record review of the facility Enhanced Barrier Precautions policy dated August 2022 revealed EBP's employ targeted gown and glove use during high contact resident care activities and gloves and gown are applied prior to performing the high contact resident care activity . The policy further includes examples of high-contact activities including .providing hygiene and changing briefs or assisting with toileting. 675428 Page 11 of 11