Health inspection·April 4, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #21) reviewed for care plans: The facility failed to ensure Residents #21's Care Plan reflected he was on EBP (Enhanced Barrier Precautions). This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included: Record review of Resident #21's face sheet, dated 4/4/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acquired absence of other right toe, infection following a procedure deep surgical site, methicillin resistant staphylococcus aureus infection, and atherosclerosis of native arteries (the buildup of fats, cholesterol, and other substances in and on the artery walls. This buildup is called plaque. The plaque can cause arteries to narrow, blocking blood flow.) of right leg with ulceration (ulcer or break in skin) of other part of foot. Record review of Resident #21's quarterly MDS assessment, dated 3/4/25, revealed Resident #21's cognition was moderately impaired for daily decision making. Section M revealed Resident #21 had 1 arterial ulcer (painful injuries in the skin caused by poor circulation) present. Record review of Resident #21's Care Plan, dated 4/2/25, last revised 4/1/25 revealed he had an arterial wound of the right posttrial (sic) heel and was at high risk for infection and/or pain/discomfort. Approaches included assess the arterial ulcer for stage, size (length, width, and depth), exudate (the material composed of serum (an amber-colored, protein-rich liquid that separates out when blood coagulates), fibrin (an insoluble protein formed from fibrinogen during the clotting of blood), and white blood cells that escapes from blood vessels into a superficial lesion or area of inflammation), necrotic tissue (premature death of body tissue), presence/absence of granulation tissue and epithelization (regenerating the epidermis (skin) over a partial-thickness wound surface or the formation of scar tissues on a full-thickness wound), and condition of surrounding skin weekly and as needed. The care plan did not reflect the resident was on EBP. Page 1 of 17 675532 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0656 Record review of Resident #21's physician orders, dated 4/4/25, revealed orders for: Level of Harm - Minimal harm or potential for actual harm - Arterial wound to right posterior heel. Cleanse wound with hypochlorous acid solution, pat dry, moleculight (handheld imaging device that uses fluorescence imaging to help detect bacterial presence in wounds. It is often used to guide wound cleaning), apply cadexomer iodine (antimicrobial gel) to wound cover with border gauze foam dressing 3 times a week, as needed, or when dislodged or soiled. Once a day on Monday, Wednesday, Thursday, with a start date of 2/8/25, and no end date. Residents Affected - Few -Enhanced Barrier Precautions based on open draining wound to right foot, with a start date of 12/1/24, and no end date. During an observation on 4/1/25 at 4:22 p.m. Resident #21's room did not have any signage for EBP or PPE supply carts nearby. During an observation on 4/3/25 at 10:32 a.m. CNA A and another unidentified CNA were helping Resident #21 transfer to bed after bathing him. CNA A and the unidentified CNA did not have on a PPE gown. During an interview on 4/3/25 at 4:00 p.m. CNA A stated she had assisted Resident #21 back to bed earlier that day after she and another aide gave him a shower. CNA A stated Resident #21 was not on any type of precautions. During an interview on 4/3/25 at 5:06 p.m. LVN C stated Resident #21 was not on any type of precautions. LVN C stated residents with wounds would be on EBP. LVN C stated staff would know if residents were on EBP because there would be a sign and a PPE supply cart outside the residents' room. LVN C stated nurses such as her would be responsible for placing the sign and PPE supply cart if there was an order for EBP. LVN C stated she did not think Resident #21 had an active order for EBP and needed to check if it was discontinued. During an interview on 4/3/25 at 5:12 p.m. the DON stated Resident #21 should be on EBP. The DON stated Resident #21's wound was contained and not draining. The DON stated when Resident #21 was showered his wound was covered so staff did not need a PPE gown. The DON stated staff only needed a PPE gown for transferring Resident #21 if the wound was not contained. The DON stated if there was no EBP signage staff would not know the resident was on EBP and he could be exposed to infection. During an interview on 4/4/25 at 10:35 a.m. the MDS nurse stated the care plan should contain EBP under the wound on Resident #21's care plan. The MDS nurse stated EBP was not on the care plan because she thought she added it but forgot. The MDS nurse stated EBP was a precaution for draining wounds to protect the resident as well as preventing infections from spreading around the building. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 2001, revised 3/22, stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .7. The comprehensive, person-centered care plan: a. Includes measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, psychosocial well-being .e. Reflects currently organized standards of practice for problem areas and conditions .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, 675532 Page 2 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0656 and relevant clinical decision making. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675532 Page 3 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #1's oxygen concentrator filter was cleaned and free of debris. This deficient practice could place residents at risk for an increase in respiratory complications. The findings included: Record review of Resident #1's admission Record, dated 4/4/25, revealed a [AGE] year-old male admitted on [DATE] with diagnoses wheezing, cough, end stage renal disease, and atherosclerotic heart disease native coronary artery (accumulation of plaque within the arterial walls, leading to narrowed or blocked arteries) without angina pectoris (chest pain that comes and goes). Record review of Resident #1's Annual MDS assessment, dated 1/2/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #1's care plan, dated 4/4/25, revised 4/1/25 revealed the resident was at risk for ineffective breathing related to congestion to lung fields with approach to notify MD of shortness of breath (SOB) not relieved by oxygen, nebulizers, or medications. Record review of Resident #1's physician order summary, dated 4/3/25, revealed an order for oxygen at 2-3 liters per minute via nasal cannula as needed for SOB/Dyspnea, with an order date of 6/23/24, and no end date. During an observation on 4/1/25 at 12:00 p.m. Resident #1 had an oxygen concentrator in his room. A layer of built-up lint/dust was noted on the filter. During an interview on 4/1/25 at 12:01 p.m. Resident #1 stated he used the oxygen sometimes and had never seen anyone clean it. During an interview on 4/3/25 at 4:55 p.m. LVN C stated there was dust on the oxygen concentrator filter in Resident #1's room. LVN C stated she was unsure if maintenance or housekeeping was responsible for cleaning the oxygen filters. During an interview on 4/3/25 at 4:59 p.m. the Housekeeping Supervisor stated housekeeping staff was expected to clean the oxygen filters daily when they cleaned the resident rooms. The Housekeeping Supervisor stated the filter on Resident #1's concentrator looked dirty and looked like it had not been cleaned recently. The Housekeeping Supervisor stated the resident could breathe in the dust and have breathing issues from it. During an interview on 4/3/25 at 5:12 p.m. the DON stated nursing staff should be checking the oxygen concentrators and can clean them. The DON stated a resident is at risk for a respiratory 675532 Page 4 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0695 infection if they do not keep the filters clean. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Departmental (Respiratory Therapy)- Prevention of Infection, dated 2001, revised 11/2011, stated The Purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff . Steps in the Procedure .9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry . Residents Affected - Few 675532 Page 5 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #20) reviewed for dialysis: Residents Affected - Few The facility failed to fully complete the dialysis communication forms for Resident #20 on 3/24/25 and 3/31/25. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #20's face sheet, dated 4/4/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic (lack of oxygen) brain injury, end stage renal disease (ESRD) (your kidneys can no longer support your body's needs), and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic neuropathy (nerve damage that affects people with diabetes. The most common type is peripheral neuropathy, which often affects your feet.). Record review of Resident #20's quarterly MDS assessment, dated 1/22/25, revealed Resident #20's cognition was moderately impaired for daily decision making. Section O revealed Resident #20 received dialysis. Record review of the Resident #20's Care Plan, dated 4/3/25, last revised 4/1/25 revealed she required dialysis related to ESRD with approaches to obtain vital signs/weight as needed. Report significant changes in pulse, respiration, and blood pressure immediately. Record review of Resident #20's physician orders, dated 4/3/25, revealed orders for: - [dialysis center] .chair time 11:15 a.m.once a day on Monday, Wednesday, and Friday, with a start date of 12/17/24, and no end date. -Left AV (arteriovenous fistula) shunt (a passage or anastomosis between two natural channels, especially between blood vessels): Monitor for +bruit (the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery) and thrill (An abnormal vibration that is felt on the skin overlying a loud cardiac murmur or an arteriovenous fistula.) every shift day and night, with a start date of 4/29/23, and no end date. Record review of Resident #20's dialysis communication forms revealed: -On 3/24/25 the post dialysis section did not have vitals and a line was drawn through the area for vitals. The section was signed by LVN D. -On 3/31/25 the post dialysis section to be completed by the nursing facility was blank. There was no vitals, assessment for presence of bruit or thrill, assessment for infection or bleeding, and 675532 Page 6 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0698 assessment of the dressing. There was no nurse signature. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #20's vitals, dated 4/3/25, revealed vitals from the previous 30 days. No vitals were found for dates 3/24/25 and 3/31/25 at the time the resident returned from dialysis in the afternoon. Residents Affected - Few During an interview on 4/4/25 at 10:26 a.m. LVN D stated he worked the 6 a.m. shift to 6 p.m. shift. LVN D stated he would assess residents before dialysis and upon return from dialysis which included assess for thrill, bruit, assesses the access site, and obtaining vitals. LVN D stated the dialysis center would let the nursing facility know if there was a change in status for the resident during dialysis. LVN D stated he should also take the residents vitals upon return from dialysis to see there was no changed in the residents status. LVN D stated he forgot to mark the vitals on the communication form from 3/24/25. LVN D stated it was important to assess the resident upon return from dialysis to make sure the resident was stable. During an interview on 4/4/25 at 10:32 a.m. the DON stated nursing staff should take vitals before a resident goes to dialysis and upon return and document it on the dialysis communication form. The DON stated they assess the resident and take vitals to make sure their blood pressure if not dropping and to see how they feel after. Record review of the facility's policy titled Hemodialysis Catheters- Access and Care of, dated 2001, revised 2/23, stated Purpose Hemodialysis catheters will only be accessed by medical staff who have received training and demonstrated clinical competency regarding use of this catheter. Guidelines .Care of AVFs .3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 4. To prevent infection and/ or clotting .d. check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing routine care and at regular intervals .g. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. h. Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access .Documentation. The nurse should document in the resident's medical records every shift as follows: 1. Location of the catheter. 2. The condition addressing (interventions if needed). 3. If dialysis is done during shift. 4. Any part of the report from dialysis nurse post dialysis being given. 5. Observations post dialysis. 675532 Page 7 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review revealed the facility failed to ensure correct use of bed rails including but not limited to the following elements. Assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation for 1 of 8 Residents (Resident #20) whose records were reviewed for bed rails. The facility failed to ensure staff obtained informed consent (the facility has explained to the resident or RP the risk and benefits of using bedrails) for the use of 1/4 bed rails for Resident #20. These deficient practices could affect residents who used bed rails and could put the residents at risk for potential injuries. Findings Included: Record review of Resident #20's face sheet, dated 4/4/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic (lack of oxygen) brain injury, muscle weakness, and rheumatoid arthritis (chronic, condition that causes pain, swelling and irritation, called inflammation, in the joints). Record review of Resident #20's quarterly MDS assessment, dated 1/22/25, revealed Resident #20's cognition was moderately impaired for daily decision making. Section P revealed Resident #20 used bed rails. Record review of the Resident #20's Care Plan, dated 4/3/25, last revised 4/1/25 revealed she used side rails and was at risk for injury with approach assess for the use of side rails quarterly and as needed. Record review of Resident #20's physician orders, dated 4/3/25, revealed an orders for ¼ rails x2 to promote independence, aid in repositioning. Special instructions: ¼ rails x2 to promote independence with repositioning, with a start date of 10/31/24, and no end date. Record review of Resident #20's side rails assessment and consent, dated 4/27/21 showed the side rails were not in use and had no resident or family signature for consent. During an observation on 4/1/25 at 12:33 p.m. Resident #20's bed had ¼ rails on it. During an interview on 4/4/25 at 11:22 a.m. the MDS nurse stated nursing staff would normally fill out a consent form at the time the side rail order was initiated. The MDS nurse stated there should be a consent for Resident #20's side rails. The MDS nurse stated it was important to obtain a consent to show the family and resident were aware of the risk of using side rails. Record review of the facility's policy titled Bed Safety and Bed Rails, dated 2001, revised 8/22, stated use of bed rails is prohibited unless the criteria for use of bed rails have been met .The Use of Bed Rails .8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed 675532 Page 8 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0700 Level of Harm - Minimal harm or potential for actual harm consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with use of bed rails; b. The resident's risk from the use of bed rails and how these will be mitigated . Residents Affected - Few 675532 Page 9 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 6 (1/18/25, 1/19/25, 1/25/25, 1/26/25, 2/8/25, and 2/9/25) of 90 days reviewed for RN hours reviewed, for the months January 1st, 2025, through March 31st, 2025. The facility failed to have RN coverage for 6 days on Saturday 1/18/25, Sunday 1/19/25, Saturday 1/25/25, Sunday 1/26/25, Saturday 2/8/25, and Sunday 2/9/25. This failure could place residents at risk for harm by denying residents the advanced critical thinking skills a registered nurse could provide. The findings were: Review of the facility's RN timesheets, no date, revealed there were no RN hours for Saturday 1/18/25, Sunday 1/19/25, Saturday 1/25/25, Sunday 1/26/25, Saturday 2/8/25, and Sunday 2/9/25. During an interview on 4/3/25 at 2:45 p.m. the BOM stated there were gaps on the weekend where they did not have RN coverage. During a joint interview on 4/3/25 at 4:07 p.m. the DON and Administrator stated it was difficult to find RNs. They stated they now had an RN who was working weekends and the DON filled in when needed. They stated the DON was working weekends previously when there was no RN but did not clock in to document those days. They stated no resident went without care on the times no RN hours were logged. They both stated the facility did not have a policy for RN coverage and went by CMS guidelines. 675532 Page 10 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0759 Ensure medication error rates are not 5 percent or greater. 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 medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.67% based on 2 out of 30 opportunities, which involved 2 of 3 Residents (Resident #1 and Resident #35) reviewed for medication administration, in that: Residents Affected - Few 1. The facility failed to ensure LVN C administered Resident #1's insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) correctly. 2. The facility failed to ensure MA B administered the full dose of Resident #35's polyethylene glycol 3350 (osmotic laxative that attracts water into the colon to ease, hydrate, and soften stool). These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Record review of Resident #1's admission Record, dated 4/4/25, revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, wheezing, cough, end stage renal disease, and atherosclerotic heart disease native coronary artery (accumulation of plaque within the arterial walls, leading to narrowed or blocked arteries) without angina pectoris (chest pain that comes and goes). Record review of Resident #1's Annual MDS assessment, dated 1/2/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #1's care plan, dated 4/4/25, revised 4/1/25 revealed the resident was at risk for S&A of hyper/hypoglycemia [refer to blood sugar levels that are too low or too high] related to diagnosis of diabetes mellitus with approaches to monitor blood sugar as ordered by the MD. Record review of Resident #1's physician order summary, dated 4/3/25, revealed an order for insulin lispro pen, 100 unit/mL, amount 10 units, subcutaneous. Hold if blood sugar less than 100 mg/dL before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m., with a start date of 7/11/24, and no end date. During an observation on 4/3/25 at 10:37 a.m. LVN C cleaned Resident #1's insulin pen with an alcohol swab, turned the pen to 10 units, placed the needle on the pen, went into the resident's room, removed the needle cover, and administered the insulin into the resident right side of his abdomen. LVN C did not prime the insulin pen prior to administration. During an interview on 4/3/25 at 10:44 a.m. LVN C stated she did not prime the insulin pen prior to administering the insulin to the resident. LVN C stated she had not had any training on using insulin pens and was not aware they needed to be primed. During an interview on 4/3/25 at 12:11 p.m. the DON stated it was recommended staff prefill or prime an insulin pen prior to administering it. The DON stated she had not gone over any training with 675532 Page 11 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0759 Level of Harm - Minimal harm or potential for actual harm nursing staff because she was waiting on new training books to come in and had not had an opportunity to use them yet. The DON stated they did not have a specific policy for insulin pen administration. 2. Record review of Resident #35's admission Record, dated 4/4/25, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of dementia, other lack of coordination, and chronic pain. Residents Affected - Few Record review of Resident #35's Quarterly MDS assessment, dated 3/10/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #35's MAR, dated 4/3/25, revealed an order for 1 cap or 17 grams of polyethylene glycol once a day. During an observation on 4/3/25 at 8:03 a.m. MA B pour the polyethylene glycol for Resident #35 into a cap from the bottle. The cap had one line halfway and a second line at the top of the cap for 17 grams. MA B pour to the first line in the cap and only poured half the dose. MA B then mixed the polyethylene glycol with water and administered it to the resident. During an interview on 4/3/25 at 9:01 a.m. MA B stated she thought she poured a cap full. MA B stated she should pour to the top of the white cap to ensure the resident gets the full dose of medication so he can have normal bowels. During an interview on 4/3/25 at 12:07 p.m. the DON stated aides could use a graduated cup to measure the medication amount. The DON stated if staff only pour half the dose, they would not be administering the full amount for full effect, so they would need to notify the doctor and follow any recommendations. Record review of the facility's policy titled Administering medications, dated 2001, revised 4/19, stated medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . Record review of manufacturer instructions for (insulin lispro) Instructions for Use, dated 8/2023, stated .Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the needle, and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose . 675532 Page 12 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview and record review with the Dietary Manager on 04/03/25 at 12:30 pm, the Dietary Manager was asked about her certification as a Dietary Manager. The DM stated she had started a course that was being paid for by an employer a couple of years ago when she was working as a Dietary Manager but then quit her job and did not continue school. When she was hired for this job, she was told she would have to pay for her own course so she said she had begun making payments and once she had the course paid for she could take the classes. The DM provided her information from her previously started school which was an online course from University F. The document showed an enrollment date of 02/28/2022. There was no evidence provided that the DM was currently enrolled in the required coursework. The DM stated they do have a Dietician who comes in once a month but the DM is in charge of the overall kitchen duties. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12. 675532 Page 13 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

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 disease and infection for 2 of 8 residents (Resident #1 and Resident #21) reviewed for infection control: Residents Affected - Some 1. The facility failed to ensure CNA A and another unidentified CNA wore the proper PPE while transferring Resident #21 who was on EBP. 2. The facility failed to ensure LVN C did not touch the sink handle in Resident #1's bathroom with her bare hands after washing her hands. 3. The facility failed to ensure laundry aide E did not have food and drinks in the laundry room on the laundry folding table. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #21's face sheet, dated 4/4/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acquired absence of other right toe, infection following a procedure deep surgical site, methicillin resistant staphylococcus aureus infection, and atherosclerosis of native arteries (the buildup of fats, cholesterol, and other substances in and on the artery walls. This buildup is called plaque. The plaque can cause arteries to narrow, blocking blood flow.) of right leg with ulceration (ulcer or break in skin) of other part of foot. Record review of Resident #21's quarterly MDS assessment, dated 3/4/25, revealed Resident #21's cognition was moderately impaired for daily decision making. Section M revealed Resident #21 had 1 arterial ulcer (painful injuries in the skin caused by poor circulation) present. Record review of Resident #21's Care Plan, dated 4/2/25, last revised 4/1/25 revealed he had an arterial wound of the right posttrial (sic) heel and was at high risk for infection and/or pain/discomfort. Approaches included assess the arterial ulcer for stage, size (length, width, and depth), exudate (the material composed of serum (an amber-colored, protein-rich liquid that separates out when blood coagulates), fibrin (an insoluble protein formed from fibrinogen during the clotting of blood), and white blood cells that escapes from blood vessels into a superficial lesion or area of inflammation), necrotic tissue (premature death of body tissue), presence/absence of granulation tissue and epithelization (regenerating the epidermis (skin) over a partial-thickness wound surface or the formation of scar tissues on a full-thickness wound), and condition of surrounding skin weekly and as needed. The care plan did not reflect the resident was on EBP. Record review of Resident #21's physician orders, dated 4/4/25, revealed orders for: - Arterial wound to right posterior heel. Cleanse wound with hypochlorous acid solution, pat dry, moleculight (handheld imaging device that uses fluorescence imaging to help detect bacterial presence in wounds. It is often used to guide wound cleaning), apply cadexomer iodine (antimicrobial gel) to 675532 Page 14 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0880 Level of Harm - Minimal harm or potential for actual harm wound cover with border gauze foam dressing 3 times a week, as needed, or when dislodged or soiled. Once a day on Monday, Wednesday, Thursday, with a start date of 2/8/25, and no end date. -Enhanced Barrier Precautions based on open draining wound to right foot, with a start date of 12/1/24, and no end date. Residents Affected - Some During an observation on 4/1/25 at 4:22 p.m. Resident #21's room did not have any signage for EBP or PPE supply carts nearby. During an observation on 4/3/25 at 10:32 a.m. CNA A and another unidentified CNA were helping Resident #21 transfer to bed after bathing him. CNA A and the unidentified CNA did not have on a PPE gown. During an interview on 4/3/25 at 4:00 p.m. CNA A stated she had assisted Resident #21 back to bed earlier that day after she and another aide gave him a shower. CNA A stated Resident #21 was not on any type of precautions. During an interview on 4/3/25 at 5:06 p.m. LVN C stated Resident #21 was not on any type of precautions. LVN C stated residents with wounds would be on EBP. LVN C stated staff would know if residents were on EBP because there would be a sign and a PPE supply cart outside the residents' room. LVN C stated nurses such as her would be responsible for placing the sign and PPE supply cart if there was an order for EBP. LVN C stated she did not think Resident #21 had an active order for EBP and needed to check if it was discontinued. During an interview on 4/3/25 at 5:12 p.m. the DON stated Resident #21 should be on EBP. The DON stated Resident #21's wound was contained and not draining. The DON stated when Resident #21 was showered his wound was covered so staff did not need a PPE gown. The DON stated staff only needed a PPE gown for transferring Resident #21 if the wound was not contained. The DON stated if there was no EBP signage staff would not know the resident was on EBP and he could be exposed to infection. During an interview on 4/4/25 at 10:35 a.m. the MDS nurse stated the care plan should contain EBP under the wound on Resident #21's care plan. The MDS nurse stated EBP was a precaution for draining wounds to protect the resident as well as preventing infections from spreading around the building. 2. During an observation on 4/3/25 at 10:37 a.m. LVN C planned to check Resident #1 blood sugar and administer insulin. LVN C washed her hands at the sink in Resident #1's room. LVN C used her bare hand to turn off the water and touched the handle. LVN C did not use a clean paper towel to turn off the water. During an interview on 4/3/25 at 10:48 a.m. LVN C stated she should have used a paper towel to turn off the sink faucet. LVN C stated she got her hands dirty again by touching the handle with her bare hand and there was risk of infection to the resident. During an interview on 4/3/25 at 12:11 p.m. the DON stated there was a risk of infection control if staff did not use a paper towel to turn off the sink faucet. The DON stated the sink handle could be dirty and you would contaminate your hands if you touched if after washing them. 3. During an observation on 4/2/25 at 3:39 p.m. in the laundry room there was a can soda, open cup of fresh ice and soda, a fast-food plastic cup with a brown liquid in it, and a bowl of food with a 675532 Page 15 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some spoon and napkin on the folding table. The room smelled like food. Laundry Aide E appeared to still be chewing food. During an interview on 4/2/25 at 3:40 p.m. Laundry Aide E stated she was done with the bowl of food and took it outside and threw it in the trash. Laundry Aide E stated she should not be eating in the laundry room. During an interview on 4/3/25 at 12:16 p.m. the DON stated staff should not be eating or drinking in the laundry room and they had a break room they could eat in. The DON stated laundry staff was dealing with clean linens, then if they eat and touch linens after they are not washing their hands and it could cross contaminate clean linens for the residents. Record review of the facility's policy titled Enhanced Barrier Precautions, dated 2001, revised 12/24, stated Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation. 1. Enhanced barrier precautions (EBPs) refer infection prevention and control intervention designed to reduce the transmission of multi drug resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and c. Contact precautions do not otherwise apply . 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); . wound care (any skin opening requiring a dressing) . 11. Outside the resident's room, EBPs are indicated when anticipating close physical contact, including performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym. 12. Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound or until discontinuation of the underlying medical device that place that higher risk .16. Staff are trained prior to caring for residents on EBPs. 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. 18. Personal protective equipment and alcohol-based hand-rub are readily accessible to staff . Record review of the facility's policy titled Handwashing/ Hand Hygiene, dated 2001, revised 8/19, stated .this facility considers hand hygiene the primary means to prevent the spread of infection . Washing hands .3. Raise hands with water and dry thoroughly with a disposable towel. 4. Use a towel to turn off the faucet . Record review of the facility's policy titled Departmental (Environmental Services)- Laundry and Linen, dated 2001, revised 12/14, stated The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . washing linen and other soiled items .7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering 675532 Page 16 of 17 675532 04/04/2025 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0880 linen carts . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675532 Page 17 of 17