Health inspection·November 18, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plan of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 12 nursing staff (RN K) reviewed for nursing services. RN K did not demonstrate competency when she failed to identify and document a left heel DTI upon readmission from the hospital on [DATE] for Resident #1.This failure could place residents at risk of staff not providing nursing or related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. Findings include: Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included cerebral infarction (a disruption in the brain's blood flow), type 2 diabetes (a condition where the body has difficulty regulating blood sugar levels) , congestive heart failure (a condition in which the heart doesn't pump blood as well as it should) and anemia (a low number of blood cells). Record review of Resident #1's admission MDS assessment, dated [DATE], revealed Resident #1 had a BIMS score of 15, indicating intact cognition. Section GG - Function Abilities revealed Resident #1 had impairments on both sides of Resident #1's upper and lower extremities and required substantial to maximum assistance with bed mobility and transfers. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers and revealed that Resident #1 did not have any pressure ulcers or any other ulcers, wounds, or skin problems. Record review of Resident #1's undated comprehensive care plan revealed Resident #1 has a care plan that stated Resident #1 was at risk for the potential development of a pressure ulcer, dated [DATE] and revised [DATE]. Record review of Resident #1's weekly skin assessment, dated [DATE], revealed a head-to-toe assessment was completed and Resident #1 did not have an impairment in skin integrity. Record review of Resident #1's SBAR Communication Form, dated [DATE], revealed Resident #1 was transferred to the hospital on [DATE] for an evaluation related to a change in condition. Record review of Resident #1's hospital discharge documentation, dated [DATE] revealed, Extremities: well healed incision of R BKA, L heal pressure ulcer-skin intact. Record review of Resident #1's Clinical admission Assessment, dated [DATE] by RN K, revealed Resident #1 readmitted to the facility from the hospital. The document revealed a skin assessment that stated Resident #1 had no skin issues. Record review of Resident #1's progress notes by the Wound Treatment Nurse, [DATE], revealed, Skin observation performed. DTI present to left heel, non-blanchable (a condition where skin redness persists even when pressure is applied) persistent maroon area. Edema (swelling) present to left upper extremity. Discoloration present to Page 1 of 5 675437 675437 11/18/2025 Advanced Rehabilitation & Healthcare of Live Oak 8221 Palisades Drive Live Oak, TX 78233

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bilateral hip area. Friction/shear markings present to left hip. Healing shear marks present to bilateral breast folds. Record review of Resident #1's [DATE] medication administration record revealed and order, Clean left heel with wound cleanser, pat dry. Skin prep. Offload. Every day shift for PI, start date, [DATE]. The administration record revealed Resident #1 received the treatment on [DATE], [DATE] and [DATE]. Record review of Resident #1's progress note, dated [DATE] at 1:42 p.m., revealed Resident #1 was transferred to the hospital related to hypoglycemia. During an interview with Resident #1's responsible party, [DATE] at 12:53 p.m., the responsible party stated Resident #1 was deceased and passed away on [DATE] at the hospital on hospice services. During an interview with the Wound Treatment Nurse, [DATE] at 11:09 a.m., the Wound Treatment Nurse stated when a resident admits/readmits to the facility, the admitting nurse would complete an assessment of the resident and part of the assessment included a head-to-toe skin assessment. The Wound Treatment Nurse stated she would be notified by the admitting nurse if a resident admitted with any skin concerns, reviewed the admitting clinical assessment, and then completed a skin assessment of each new admission/readmission within 24 hours of the admission. The Wound treatment Nurse stated the admitting nurses should document any skin concerns on the clinical admission assessment. The Wound Treatment Nurse stated Resident #1 did not have any skin concerns prior to Resident #1's hospitalization from [DATE] to [DATE], and Resident #1 returned from the hospital with a left heel DTI. The Wound Treatment Nurse stated the DTI should have been identified on the Clinical admission Assessment completed by RN K, and when the Wound Treatment Nurse identified the left heel DTI, the Wound Treatment Nurse obtained physician orders for treatment. During an interview with RN K, [DATE] at 11:20 a.m., RN K stated she completed Resident #1's clinical admission assessment on [DATE]. RN K stated when she received a new admission, she was responsible for getting report from the hospital, reviewing hospital discharge paperwork, getting the resident settled into when they admit, completing an initial clinical assessment, getting orders from the physician, and scheduling any follow up appointments. RN K stated the initial clinical assessment was the assessment form completed when a resident admitted /readmitted to the facility and included a section for skin observations. RN K stated that when residents admitted to the facility, they had hospital linen, so RN K assisted with changing resident linen and brief and completed a head-to-toe assessment at that time. RN K stated she would document any obvious skin concerns like surgical wounds and pressure wounds on the clinical admission assessment, and notify the Wound Treatment Nurse of RN K's findings. RN K stated she would not contact the physician to get any treatment orders and would wait for the Wound Treatment Nurse to assess the patient. RN K stated she completed a head-to-toe assessment including the heels on Resident #1 when she readmitted to the facility and identified, nothing obvious. She stated, there might be different levels of it [skin concerns] but sometimes there was redness and I don't know exactly if that counts. RN K stated she did not see documentation in the discharge documentation regarding a left heel wound for Resident #1. RN K stated not identifying skin concerns in a timely manner could cause a wound to worsen. RN K stated she had received an overview on wound care and identifying skin concerns, and stated if wounds were not identified on the clinical admission assessment and treated upon admission the wounds, could get worse and lead to infections. During an interview with the DON, [DATE] at 11:30 a.m., the DON stated the admitting nurse should complete an initial skin assessment by completing a head-to-toe assessment when a resident admitted /readmitted from the hospital, document the findings on the clinical admission assessment, and notify the treatment nurse of any findings. The DON stated the Wound Treatment Nurse should complete an additional head-to-toe assessment within 24 hours of admission and document the findings. The DON stated Resident #1's DTI to the left heel should have been documented on the 675437 Page 2 of 5 675437 11/18/2025 Advanced Rehabilitation & Healthcare of Live Oak 8221 Palisades Drive Live Oak, TX 78233

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few clinical admission assessment. The DON stated, even if the admitting nurse could not stage the wound, it should have been documented on the admission assessment and orders obtained to at least monitor the area on the date of admission. The DON stated it was important for the initial clinical assessment to be accurate and reveal documentation of any skin concerns, because we need to know what they admitted with so we can document it upon admission, and if a wound or skin issue was not identified upon admission, it could cause a wound infection or cause further skin break down. Record review of the facility's policy titled, Clinical Documentation Guideline, origination date [DATE], review date [DATE] and revision date [DATE] revealed a policy, The patient's clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing health care services provided to the patient. The document revealed the fundamental information, The clinical record is used by healthcare team to record, preserve and communicate the patient's progress and current treatment. 675437 Page 3 of 5 675437 11/18/2025 Advanced Rehabilitation & Healthcare of Live Oak 8221 Palisades Drive Live Oak, TX 78233

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 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 8 residents (Resident #2) reviewed for infection control in that: CNA D did not wear a gown when providing direct care to Resident #2 who had a foley catheter and was on enhanced barrier precautions (EBP). This deficient practice could affect residents on enhanced barrier precautions and place them at risk for infection. The findings were: Record review of Resident #2's undated face sheet revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes (a condition where the body has difficulty regulating blood sugar levels), Hemiplegia (paralysis of one side of the body) and chronic kidney disease (gradual loss of kidney function). Record review of Resident #2's quarterly MDS assessment, dated 10/30/2025, revealed a BIMS score of 14, indicating intact cognition. Section GG Functional Abilities revealed Resident #1 was dependent on facility staff for toileting hygiene. Section H Bladder and Bowel revealed Resident #2 had an indwelling foley catheter and was always incontinent of bowel. Record review of Resident #2's undated comprehensive care plan revealed a care plan that read, Resident #1 required enhanced barrier precautions due to a foley, date initiated 09/04/2025. Record review of Resident #2's November 2025 medication administration record revealed enhanced barrier precautions related to Resident #2's foley, start date 08/20/2025. Record review of Resident #2's November physician orders revealed Resident #2 had a physician order for enhanced barrier precautions, start date 08/20/2025. During an observation, 11/14/2025 at 11:40 a.m., Resident #2 had a sign on his door that said Enhanced Barrier Precautions. CNA D was observed walking out of Resident #2's room with a small clear bag that contained a brief and gloves. During an interview with Resident #2, 11/14/2025 at 11:50 a.m., Resident #2 stated CNA D had been in Resident #2's room changing his brief from an incontinent episode and emptied his foley catheter bag. Resident #2 stated CNA D wore gloves during the direct care but did not wear a gown. Resident #2 stated staff did not usually wear gowns when providing care to him. During an interview with CNA D, 11/14/2025 at 12:10 p.m., CNA D stated she had just changed Resident #2's brief and provided foley catheter care to Resident #2. CNA D stated she did not wear a gown while providing care. CNA D stated she had recently received training on infection control and EBP in a recent skills fair at the facility. CNA D stated she could identify which residents required EBP because they had a sign on their room door, and residents with wounds or foleys were on EBP and staff had to wear a gown and gloves when providing direct care. CNA D stated it was important to wear the appropriate PPE for EBP because, it was for the resident's safety and to not contaminate anything. CNA D walked over to Resident #2's dresser and opened the top drawer and revealed PPE gowns and stated PPE was located in resident rooms and accessible when providing direct care. During an interview with the DON, 11/18/2025 at 11:30 a.m., the DON stated staff had received training on EBP and the expectation was for staff to wear a gown and gloves when providing direct care to residents on EBP. The DON stated residents on EBP had a sign on their room door indicating the need for a gown and gloves when providing direct care, and a resident with a foley or a wound required the use of EBP. The DON stated it was important for staff to use the appropriate EBP when providing direct care, to help protect the patient from the transference of germs into open areas. The DON stated a resident could get an infection from the transference of germs. Record review of the facility's policy titled, Infection Prevention and Control Program, date implemented 10/24/2022 and revised 04/12/2025, revealed, this facility has established and maintains an infection prevention Residents Affected - Few 675437 Page 4 of 5 675437 11/18/2025 Advanced Rehabilitation & Healthcare of Live Oak 8221 Palisades Drive Live Oak, TX 78233

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Record review of a document provided by the facility Administrator as part of the facility EBP program revealed the document was a CMS Memorandum directed to State Survey Agency Directors, dated 03/20/2024, with the subject identified as Enhanced Barrier Precautions in Nursing Homes. The document revealed, Guidance - ‘Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. The document revealed, For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. 675437 Page 5 of 5