Health inspection·August 10, 2023

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 have physician orders for the resident's immediate care at the time the resident was admitted for 2 of 5 (Resident #41 and Resident #116) residents whose records were reviewed for physician orders in that: Residents Affected - Few The facility failed to ensure there was an active order for PICC Line dressing changes for Resident #41. The facility failed to clarify physician orders for Heparin Flushes for Resident #41. The facility failed to clarify physician orders for Resident #116. These failures could place residents at risk of inadequate monitoring of medical conditions and not receiving the care and services to meet their needs. Findings included: Record review of Resident #41's face sheet, dated and admitted on [DATE] reflected a [AGE] year-old female with diagnoses that included orthopedic aftercare following surgical amputation of toes, diabetes, high blood pressure, and malnutrition. A record review of Resident #41's MDS dated [DATE] documented a BIMS of 15, which indicated no cognitive impairment. Record review of Resident #41's care plan, dated 07/24/23, documented on page 6, a focus of the resident was on IV medication initiated and revised on 07/25/23, and interventions of IV dressing, PICC Line, observe dressing, change dressing and record observations of site-initiated and revised 07/25/23. Observation of Resident #41's PICC Line dressing and interview on 08/08/23 at 11:44 AM revealed a date of 08/05/23. Resident #41 stated PICC Line dressing was changed every Friday. Observation of Resident #41's MAR and interview with RN A on 08/09/23 at 2:39 PM revealed there were no orders documented for the PICC Line dressing changes. RN A stated there should be an order for the PICC Line dressing changes at least weekly and she had changed the dressing on the 5th of August 2023. RN A stated she did not have any documentation about the PICC Line dressing change or observations of the PICC Line site in the skilled assessments. RN A stated it was important to have orders for dressing changes and assessments so they would not be missed and possibly create an infection if Page 1 of 17 675637 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dressing was never changed and if there were no assessments of the site, there would be no way to track if the site was getting infected. In an interview with the DON on 08/09/23 at 2:42 PM revealed she could not find the order for dressing changes on the PICC Line for Resident #41 and stated there should be an order for dressing changes for every PICC line every Sunday. The DON stated staff should know about the dressing changes and should have gotten an order. The DON stated no one reviewed the orders except the person who ordered them. In an interview with the DON on 08/09/23 at 3:46 PM, she stated the staff followed whatever order was on the MAR, and there was no order on the MAR for PICC Line dressing changes. The DON stated the negative outcome could be placing residents at risk for infection if there was no order for dressing changes. The DON stated there had to be an order for a dressing change. The DON stated dressing changes should be documented. The DON stated the nurses should have gotten an order for the dressing changes because, without an order, the electronic charting system would not trigger to document, and the staff would not document-they could put something in the progress notes, but there would still be no order for the dressing change. A record review of Resident #41's physician orders, dated 07/24/23-08/09/23, revealed no orders to change the dressing for the PICC Line. A record review of the facility policy, Central Vascular Access Device Dressing Change, revised 06/01/21, documented under Considerations: 2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Under Guidance: 1. Perform sterile dressing changes 1., 1.2 At least weekly. Under Procedures: 24. Documentation in the medical record includes but is not limited to Date and time, site assessment, length of the external catheter, arm circumference, the reason for dressing change, patient response to the procedure, and patient/other teaching. Record review of Resident #41's care plan, dated 07/24/23, documented on page 4, a focus of the resident was on anticoagulant therapy, initiated 07/25/23. The goal was: INR (International Normalized Ratio) and/or Protime (prothrombin time) within specified limits through the next review initiated on 07/25/23. Interventions included: Labs, as ordered, initiated on 07/25/23. (These lab values are used when a patient is on anticoagulant therapy to determine if their blood is clotting too fast or too slow. Depending on the value, the physician will order the anticoagulant dose to increase, decrease, or stay the same to maintain a therapeutic level) Record review of Resident #41's physician orders, dated 07/24/23, reflected: -Heparin Lock Flush Solution 10 Unit/ml Use 5 cc intravenously every shift (every 8 hours) Flush PICC line after post-medication Normal Saline flush. - On hand heparin flush 10 unit/ml disposable syringe flush 5ml (10 units) each lumen every 12 hours. Observation of Heparin Flush to Resident #41's PICC Line, on 08/09/23 at 02:39 PM, with RN A revealed10ml Normal Saline expiration date 08/31/23 and Heparin 10U /ml, 3ml with expiration date of 10/31/23. Gathered supplies, washed hands >30 seconds, Donned gloves, disconnected IV tubing (Vancomycin), 675637 Page 2 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doffed gloves, placed a paper barrier beneath RUE, used ABHR, donned gloves, primed NS saline, used alcohol swipe, and flushed line. Used another alcohol swipe, flushed with Heparin, and placed an antiseptic cap on the PICC Line. RN A doffed gloves removed the IV tubing and bag and disposed of them. Washed hands for 20 seconds, then again for 30 seconds. Observation of the MAR and interviews with the DON and RN A on 08/09/23 at 2:42 PM reflected the order documented 5cc of Heparin every 12 hours. The DON stated that according to the order, we should give 5cc, but the facility did not have any 5cc heparin syringes. RN A stated the MAR documented heparin was administered 4 times on 08/08/23 and 3 times on the rest of the dates in August. The DON stated Heparin was given 5cc at least every 8 hours. Observation of the 200/400 medication cart and interview with LPN B on 08/10/23 at 9:12 AM revealed there were prefilled 5cc heparin syringes. LPN B stated they always had the 5cc prefilled heparin syringes. LPN B stated she did not know about the 3cc pre-filled heparin syringes; she only knew what was in her cart. Interview with LPN A on 08/09/23 at 2:45 PM, LPN A stated according to the order, it (the MAR) documented 5cc every 12 hours but was given every 8 hours. LPN A stated the MAR was confusing, as it documented 2 different orders, and the order documented 5cc of heparin, but they only had 3cc syringes of heparin. She stated it looked like 2 different orders for the heparin and the saline flushes. She stated the orders definitely needed to be clarified. LPN A stated staff only followed the orders on the MAR. LPN A stated the orders were not customized and therefore were not complete. LPN A stated the nurses should have changed the heparin order to 3cc or used 2 syringes to get the 5cc-the orders should have been clarified. An interview with RN A on 08/09/23 at 2:48 PM revealed she would need to find out from the doctor what the order should be because the discrepancy was that heparin was ordered 5cc and heparin should be 3cc-the facility gave the 3cc and they were not following the doctor's orders. RN A stated she should have called the doctor as soon as she discovered the discrepancy but did not. Interview with the DON on 08/09/23 at 3:46 PM, the DON stated the negative outcome could be a medication error, and the staff followed whatever order was on the MAR. The DON did not know what the correct order should have been. Record review of Resident #41's Central Venous Catheter- Physician/Licensed Independent Practitioner Order Sheet, dated 07/26/23, under Treatment Orders: Change Administration set was checked through, and no box was checked to indicate the timing. Under Flushing Orders, Intermittent Meds were checked, but the amount, type, and frequency of fluid to flush were not checked. A record review of Resident #116's face sheet, dated and admitted on [DATE] reflected a [AGE] year-old female with diagnoses that included encounter for surgical aftercare following surgery on the circulatory system, pneumonia, COPD, high blood pressure, nicotine dependence, lack of coordination, reflux, heart failure, and A-Fib . A record review of Resident #116's MDS, dated [DATE], reflected a BIMS of 13, which indicated no cognitive impairment. Record review of Resident #116's care plan, dated 07/28/23, documented on page 18 with a focus on the resident having oxygen therapy related to respiratory illness initiated and revised on 07/28/23. 675637 Page 3 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0635 Level of Harm - Minimal harm or potential for actual harm Interventions included Oxygen settings: O2 via nasal prongs at 3 L (liters) continuous. Humidified as ordered. Observation of Resident #116's oxygen on 08/08/23 at 1:48 PM revealed O2 continuous 5L/NC. There was a humidifier bottle near the O2 concentrator, but it was not connected to anything. Residents Affected - Few Interview and record review with LPN/MDS on 08/10/23 at 1:55 PM, the LPN/MDS stated there was no way to know what the original order was for Resident #116's oxygen because it could not be found in Resident # 116's chart. There were no discharge orders from the hospital found in the chart as well. The LPN/MDS showed the State Surveyor a physician's note dated 07/26/23 (prior to admission) that documented 3L NC but there was no definitive order. The LPN/MDS stated the discrepancy between the care plan and the physician's order was human error but could not say if the physician's order was correct or if what was documented on the care plan was correct. The LPN/MDS stated whoever the nurse was who admitted any resident, that nurse would input in the orders. LPN/MDS stated that the ADON checked all the orders for clarification the next day. In an interview with the DON on 08/10/23 at 2:22 PM, the DON stated the admission orders were in the computer but could not say where those orders came from. The DON stated the nurse reconciled medications with either the MD or the NP but still could not explain or produce the original admission orders. The DON stated medication orders came from the hospital, but no oxygen orders were on them. The DON stated the admitting nurse should call the MD or NP for oxygen orders. The DON explained verbal orders or phone orders could be placed directly into the EHR, and there was nowhere medication reconciliation for admission or discharge orders was visible in the EHR. Record review of physician orders dated 07/27/23-08/10/23, documented Oxygen at 3 liters/minute continuously per nasal cannula. Document every shift, dated 07/28/23. A record review of Resident #116's discharge Medication Report from the local hospital, dated 07/27/23, did not have oxygen orders listed. Record review of admission Progress notes, dated 07/27/23 documented Resident #116 arrived at the facility with O2 at 3 lpm (liters per minute) via nasal cannula .medications were verified with the NP (nurse practitioner) . 675637 Page 4 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 services provided by the facility met professional standards of quality of care for 1 of 5 residents (Resident #54,) reviewed for quality of care. Residents Affected - Few Wound Care Nurse did not follow the doctor's orders (pat dry wound) for treatment of wound care for Resident #54. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving the care and services to meet their needs. Findings included: Review of R #54's Face sheet dated 08/09/2023 documented age [AGE] year-old female admitted on [DATE] with a diagnosis of Displaced Fracture of right lower leg, Glaucoma (condition where the eye's optic nerve is damaged with or without raised intraocular pressure), Hypertension (high blood pressure), and Muscle weakness. Record Review of R #54's Minimum Data Set, dated [DATE] documented a BIMS score of 15 (Cognition Intact) and requires limited assistance with bed mobility, transfer, dressing, personal hygiene, and toilet use. Record review of R #54's Care plan dated 07/13/2023 documented R #54 had Right ankle fracture, non-weight bearing to right ankle and break in skin integrity due to incision to right ankle. Interventions include, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, follow doctor's orders for weight bearing status. See doctor orders and/or physical therapy treatment plan, give analgesics as ordered by the physician, and observer for and report PRN (as needed) s/sx (signs and symptoms) or complications related to arthritis: joint pain; joint stiffness, usually worse on wakening; swelling; decline in mobility; decline in self care ability; contracture formation/joint shape changes; crepitus (creaking or clicking with joint movement); pain after exercise or weight bearing. Record review of R #54's orders stated; -Cleanse wound to right medial lower leg with normal saline, pat dry, and apply xeroform and cover with dry dressing daily. -Cleanse pin sites (R #54 has external fixator) to right lower extremity with normal saline, pat dry with gauze, then wrap in gauze and secure with paper tape daily, dated 7/13/2023. During observation of wound care for R #54 on 08/09/23 at 07/19/23 at 3:04 PM revealed, upon pin site care, wound care nurse cleansed pin site area with normal saline on gauze for each pin site while changing gloves and performing hand hygiene in-between. After cleansing site with normal saline, wound care nurse did not pat dry as per orders prior to placing new gauze to each pin site. Wound care nurse then applied new gauze and secured with paper tape. Interview with wound care nurse on 08/10/23 9:01 AM revealed she forgot to pat dry after cleansing 675637 Page 5 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pin sites with normal saline. Wound care nurse stated, moisture can stay there (wound site) and can lead to an infection. Wound care nurse stated it is important to follow doctors' orders as it is individualized prescribed for that specific resident. Wound care nurse stated she was nervous and normally does pat dry the pin site area for R #54 but, forgot during observation. Wound care nurse stated she has been in the wound care position for about a year and did perform a skills check off prior to treating wounds at the facility with Staffing Development Coordinator. Interview with DON on 08/10/23at 10:33 AM stated it is always in the best interest of the resident to follow doctors' orders to avoid adverse reactions or outcomes. DON stated the wound site for R #54 could retain moisture from not pat drying and could cause irritation to site. Interview with Staffing Development Coordinator on 08/10/23 at 10:38 AM stated ongoing wound care education is conducted and is done on their Health Care Academy and wound care nurse is up to date with academy training requirements. Record Review of Skin Integrity and Pressure Ulcer/Injury Prevention and Management dated 8/25/21 and revised on 3/31/2023 stated: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurses Society). Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 3.The physician order is followed, as are the manufacturer's instructions for use for each product ordered. 675637 Page 6 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, based on the comprehensive assessment of a resident, a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of three residents (Resident #1) reviewed for pressure ulcer care and prevention. Residents Affected - Few The facility failed follow physician orders and did not apply the hydrafera blue dressing to Resident #1's stage 4 right lateral ankle pressure ulcer. This failure could place residents at risk of improper wound management, the development of new pressure ulcers, deterioration in existing pressure ulcers, infection, sepsis, and pain. The findings included: Record review of Resident #1's face sheet, dated 08/09/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture), stage 4 pressure ulcer of right ankle, stage 4 pressure ulcer of sacral region, schizoaffective disorder (mental health disorder ), and depression . Record review of Resident #1's Physician's Order, dated 05/23/2023, stated cleanse right lateral ankle with Vashe, pat dry with gauze, apply hydrafera blue, ready use cut to size and cover with foam dressing, every dayshift, every Monday, Wednesday, Friday for Stage 4. Record review of Resident #1's Wound Observation Tool, dated 05/23/2023, the woundcare nurse documented right lateral ankle pressure ulcer stage 4. Granulation tissue present, and 40% slough tissue present. Wound measurements: length (cm ): 4.5; width (cm): 3.0; depth (cm): 0.3. Record review of Resident #1's Wound Observation Tool, dated 08/04/2023, the woundcare nurse documented right lateral ankle pressure ulcer stage 4. Granulation tissue present and 40% slough tissue present. Wound measurements: length (cm):1.0; width (cm):1.2; depth (cm): 0.2. Record review of Resident #1's Minimum Data Set, dated [DATE], revealed Resident#1 had a BIMS score of 12/15 which indicated the resident was cognitively intact. Resident #1 had two stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers that were present upon admission/entry. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfer, dressing, and personal hygiene, and was at risk for pressure ulcer development. Record review of Resident #1's comprehensive care plan, dated 05/23/2023, documented Has break in skin integrity . open wounds to sacrum and right ankle. Interventions: Educate resident and/or family regarding skin problem and treatment. Pressure reducing mattress. Treatment as ordered. Use of low Air Loss Mattress, setting 3. An observation and interview on 08/10/2023 at 10:36 AM, upon entering Resident #1's room, revealed Resident#1's right ankle area was open to the air, with visible red with yellow color in the middle 675637 Page 7 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0686 Level of Harm - Minimal harm or potential for actual harm of the wound opening with no dressing on right lateral ankle wound. Interview with Resident #1 stated she recalled receiving wound care yesterday (08/09/2023) but was not sure if dressing was applied to her wound. Resident #1 stated she did notify the Wound Care Nurse that there was no dressing on right ankle wound but was told the Wound Care Nurse had to pick up her kids and did not come back to apply dressing on right ankle. Residents Affected - Few During an interview on 08/10/2023 at 11:30 AM, the Wound Care Nurse stated she arrived to work early in morning at 6AM on 08/09/2023 and performed wound care to Resident #1's sacrum and right lateral ankle. The Wound Care Nurse stated it took about an hour to perform wound care to Resident #1. The Wound Care Nurse stated on 08/09/2023 she left around 7:00-7:30AM to drop her kids off to school and returned to the facility around 9AM. The Wound Care Nurse stated she did apply a wound care dressing to the right lateral ankle and when questioned about why Resident #1 did not have a dressing on the right lateral ankle, the wound care nurse stated she could not recall being notified on 08/09 about the residents concern for not having a wound dressing, nor did she provide an answer as to why Resident #1 had no dressing on her right ankle. The Wound Care Nurse stated she applied a wound dressing to the right lateral ankle on 08/10/2023 at 11:25 AM. The Wound Care Nurse stated she could not perform any wound care without a physician order, and stated it was imperative to follow and specifically execute care as directed by the physician's order. The Wound Care Nurse stated by not complying with physician orders, could jeopardize the healing process for any resident. The Wound Care Nurse stated she attended monthly wound care meetings that specifically went over physician orders. The Wound Care Nurse stated she was in the process of finishing her wound care certification training and would prioritize completion. During an interview on 08/10/2023 at 11:12AM, CNA A stated she did not remember the last time she saw Resident's #1 ankle dressing, but knew to notify the nurse of any observed skin abnormalities. During an interview on 08/10/2023 at 1:16 PM, the DON stated it was the expectation of the facility for the clinical nursing staff which included the Wound Care Nurse to follow physician orders. The DON stated by not following orders, errors could occur and lead to small or large detrimental issues for Resident #1 which included Resident #1's wound getting bigger or increased tissue damage. The DON stated the Wound Care Nurse did attend monthly meetings with a Regional Wound Care Consultant and maintained current knowledge-based courses. Record review of the facility's Treatment Orders, revised 04/19/2022 and reviewed 03/31/2023, stated 3. The physician order is followed as are the manufacturer's instruction for use for each product ordered. 675637 Page 8 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of two residents (Resident #17) reviewed for feeding tube care. The facility failed to follow Resident #17's physician's order of documenting Gastric Residual Volume. This deficient practice could place residents at risk of aspiration pneumonia or vomiting. The findings include: Record review of Resident #17's face sheet, dated 08/10/2023, reflected a [AGE] year-old female who was admitted to the facility 05/13/2021 and readmitted [DATE]. Resident #17 had diagnoses which included aphasia (loss of ability to understand or express speech), schizoaffective disorder (mental health problem that experience psychosis as well as mood symptoms), gastrostomy (artificial external opening into the stomach for nutritional support), dysphagia (swallowing difficulties), and diabetes mellitus (insulin resistance). Record review of Resident #17's Quarterly Minimum Data Set, dated [DATE], revealed Resident #17 had a BIMS score of 14/15, which indicated she was cognitively intact. The MDS also coded Resident #17 for requirement of extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene, as well as always incontinent, and a feeding tube. Record review of Resident #17's August 2023 Physician Order Summary Report documented: Enteral Feed Order every shift check residual at beginning of shift and record amount. Notify MD if residual is greater than 60 ml or if resident has nausea, abdominal distension, or bleeding. Perform PEG tube site care every day shift and as needed. Every shift administers at least 15 ml free water flush before and after medication administration. Record review of Resident #17's Treatment Administration Record from 08/01/2023-08/08/2023, revealed check marks for checking gastric residuals for day, evening, and night shift, but with no actual quantifiable gastric residual amount documented. Record review of Resident #17's Nurse/Progress notes, presented no documented amount of gastric residual volume. Record review of Resident #17's Comprehensive Care Plan, dated 08/03/2023, documented: [Resident #17] requires tube feeding related to dysphagia. The resident needs the HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed. Enteral feeding as ordered. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Observe and report PRN any s/sx [signs or symptoms] of: Aspiration- fever, SOB , tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal 675637 Page 9 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few impaction, diarrhea, nausea/vomiting, dehydration. Lab/diagnostic work as ordered. Report results to MD and follow up as indicated. During an observation on 08/10/2023 at 10:10 AM, RN A grabbed an empty syringe, connected it to the Percutaneous Endoscopic Gastronomy tube and applied air while auscultating the stomach. RN A then retracted an undetermined amount of visible gastric content from the stomach, followed by returning the gastric amount into the stomach. During an interview on 08/10/2023 at 10:24 AM with RN A, she stated she did not input the residual amount in a progress/nurse's note due to not having the capability to add gastric residuals amount to the treatment administration record. RN A stated she did not know where she could locate previously recorded administration record documentation. RN A stated it was an important step to check gastric residuals to illuminate any digestive issues and minimize chance of aspiration which could lead to worse issues like aspirational pneumonia. RN A stated she was given, in report during shift change, that Resident #17 had gastric residuals but was not documented upon her review of Resident #17's chart. Upon RN A further investigation, she did conclude there was an area, in Resident #17's MAR, that allowed to input gastric residual amount. RN A stated she would, from now on, use the MAR documentation area to input gastric residual amount, and verbalized her apologies for not following physician orders. RN A stated she was given competency checkoffs recently by ADONs that covered gastric tubes. During an interview on 08/10/23 at 01:16 PM, the DON stated it was the expectation of the facility for the clinical nursing staff to follow physician orders. The DON stated by not following orders, errors could occur and lead to small or large detrimental issues for Resident #17, which could potentially include fluid overload or deficit that could affect the functionality of major vital organs. The DON stated the ADONs gave skill checkoffs monthly, annually, and as needed, and had one about a month ago regarding gastric tubes. The DON stated the best practice was to document gastric residual amount on a nurses note or progress notes but found that no such documentation was done for Resident #17. The DON stated she would facilitate additional education for her nursing clinical staff. Record review of the facility's competency skills checkoff regarding gastric tube maintenance, did have RN A in attendance on 06/02/2023. Record review of the facility's Enteral Access Device (EAD) Site Care and Management policy, issued date 08/08/2023, reflected: The facility will provide enteral access device site care and management in accordance with physician orders and professional standards of practice. 675637 Page 10 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Residents Affected - Few 1. The facility failed to ensure personal items were not stored in the refrigerator. 2. The facility failed to ensure spice containers were properly closed and sealed. 3. The facility failed to ensure utensils were in safe working order. 4. The facility failed to ensure the deep fryer was vented into the vent hood properly. 5. The facility failed to ensure the steam table wells was cleaned. 6. The facility failed to ensure the shelf above the steam table was cleaned. 7. The facility failed to ensure the thermometer was calibrated for food service. 8. The facility failed to ensure the cleaning schedule was being followed. These failures could place residents at risk of acquiring foodborne illnesses. The findings included: Observation during the initial tour of the kitchen on 08/08/23 at 9:15 am revealed a personal bag with a gallon of milk inside the refrigerator, seventeen, 16 oz. containers of spices were open to the air, four plastic soup bowls on the clean rack had a white residue in them, 4 large, and 1 small rubber spatula was cracked and had small pieces breaking off. The edge of the vent hood directly above the deep fryer was heavily soiled with a dark brown substance and where the vent hood met the wall, the wall was discolored with a yellowish-brown substance. The walls and bottoms of the steam table wells were heavily corroded. Follow-up observations of the kitchen on 08/10/23 at 11:21 am revealed the COOK did not calibrate the thermometer prior to temping the lunch service food. There was a half-full 16 oz. soda in the refrigerator that was unlabeled and undated. Interviews with the DS and DA A on 08/08/23 beginning at 9:15 am revealed the personal items in the refrigerator belonged to DA A. DA A stated the bag belonged to her and she would keep it in the refrigerator until she went home. DA A stated she had kept personal items in the refrigerator before. The DS moved the bag from the back of the refrigerator to the front of the refrigerator but did not remove it. The DS stated there was no refrigerator for the kitchen staff to place their personal items, but there was a refrigerator for the regular staff in the break room. The DS stated the spatulas should be replaced when they started cracking, and she had new ones in her office. The DS stated the staff did not let her know about the spatulas and she had not had time to check the utensil drawer for items needing replacement. The DS stated the kitchen staff knew when items needed replacement and they should have told her. The DS placed the spatulas back in the drawer. The DS stated the steam 675637 Page 11 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0812 Level of Harm - Minimal harm or potential for actual harm table was cleaned two times a week and it needed to be chemically de-limed. The DS stated the staff did not sign off items on the cleaning schedule as they were cleaned like they were supposed to. The DS stated their process to remove the grease from the deep fryer was they funneled it into the original plastic container the grease came in, put the lid on the container, then threw the full container of used grease into the dumpster. The DS stated they did not use the facility grease trap and did not know why. Residents Affected - Few An interview with the MS on 08/09/23 at 8:15 am revealed the grease trap was used for facility water, not for directly emptying grease into it. The MS stated the deep fryer was attached to the ground and was supposed to vent directly into the vent hood, but the ventilation from the deep fryer was directly hitting the edge of the vent hood and was also on the wall below the edge of the vent hood. The MS stated the heat was hitting the vent hood and the thick brown substance was grease. The MS stated if the grease got too hot, it could catch fire. The MS stated the kitchen staff could not get to it easily to clean, so they did not clean it. In interviews with the COOK, DA B, and the DS on 08/10/23 at 11:23 am the COOK stated the DS calibrated the thermometers. The DS stated she had not calibrated the thermometer the cook used in about two weeks. The COOK stated he believed the thermometer should be calibrated before every food service. When asked why it was important to calibrate the thermometer, the COOK stated, I have to get back to my cheese sauce. The DS stated it was important to calibrate the thermometer to get accurate temperatures, to make sure the residents did not get sick. The DS stated she calibrated new thermometers every 4 months. The DS said nothing when asked what other times a thermometer should be calibrated. The DS stated she calibrated the thermometer the COOK used 2 days ago because one of the kitchen staff told her it was acting up-not staying on. When asked how she ensured the thermometer was still in working order, the DS stated she did not know. The DS stated, I am not going to tell you I calibrate the thermometer before every service because I don't. The DS stated the bottle of soda in the refrigerator belonged to one of the staff. DA B stated he did not know who the soda belonged to, but it was not his. The DS stated it was ok for staff to have personal drinks in the kitchen refrigerator if they had a lid on it. The DS stated, Kitchen staff did not have a refrigerator for themselves, and she did not see a reason why they had to walk all the way to the breakroom when there was a refrigerator right there (in the kitchen). An interview and observation with the RD on 08/10/23 at 4:10 pm revealed she thought thermometer calibration was bi-weekly or when it (the thermometer) may be not working. The RD stated no personal items should be kept in the kitchen refrigerator because the chance of cross-contamination could occur, or it could get mixed up with the other things in the refrigerator that was meant for the residents. The RD stated it sounded like the staff needed an in-service. Policies for Thermometer calibration and Personal Items in the kitchen refrigerator and in-services for the last three months were requested. Record review of the cleaning schedule for 08/06/23-08/08/23 revealed 2 of 66 opportunities to clean equipment on the cleaning schedule were checked off. Record review of the DS Certification documented Food Safety Manager Certification dated 05/15/23. Record review of the facility policy, Food from Outside Sources Policy revised 07/27/22 documented under #12. Associate and resident food items should not be stored together in the same refrigerator. In-services and thermometer calibration guidelines were not provided. 675637 Page 12 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on interviews and observation, the facility failed to dispose of garbage and refuse properly for 1 of 1 deep fryer reviewed for dispose of garbage and refuse properly. Residents Affected - Few The facility failed to dispose of grease properly. This deficient practice could place residents at risk of the attraction of vermin and rodents and affect residents by exposing them to germs and diseases carried by vermin and rodents. The findings were: Observation of the underground grease trap on 08/08/23 at 9:15 am with the MS revealed a large covered vat (large container to hold liquid) that was near full. There was no seepage on the ground. Interview with the DS on 08/08/23 at 9:15 am revealed the process to remove the grease from the deep fryer was to funnel it into the original plastic container the grease came in, put the lid on the container, then threw the full container of used grease into the dumpster. The DS stated they did not use the facility grease trap and did not know why. An interview with the MS on 08/09/23 at 8:15 am revealed the grease trap was used for facility water, not for directly emptying grease into. 675637 Page 13 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

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 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 two of five residents (Resident #1 and Resident #17) reviewed for infection control. Residents Affected - Some 1. RN A did not perform hand hygiene nor glove change prior to administering medication via PEG-tube, as well as did not perform hand hygiene nor change of gloves prior to inserting tube feeding into peg tube for Resident #17. 2. CNA A did not perform hand hygiene nor glove changes during perineal care for Resident #1 These failures could place residents at risk for infection through cross contamination of pathogens. The findings include: 1. Record review of Resident #17's face sheet, dated 08/10/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #17 had diagnoses which included aphasia (loss of ability to understand or express speech), schizoaffective disorder (mental health problem that experience psychosis as well as mood symptoms), gastrostomy (artificial external opening into the stomach for nutritional support), dysphagia (swallowing difficulties), and diabetes mellitus (insulin resistance). Record review of Resident #17's Quarterly Minimum Data Set, dated [DATE], reflected Resident #17 had a BIMS score of 14/15, which indicated she was cognitively intact. The MDS also coded Resident #17 for requirement of extensive assistance with two-person physical assist for bed mobility, transfers, dressing, and personal hygiene, as well as always incontinent, and a feeding tube. Record review of Resident #17's August 2023 Physician Order Summary Report documented: Enteral Feed Order every shift check residual at beginning of shift and record amount. Notify MD if residual is greater than 60 ml or if resident had nausea, abdominal distension, or bleeding. Perform PEG tube site care every day shift and as needed. Every shift administers at least 15 ml free water flush before and after medication administration. Record review of Resident #17's August 2023 Physician Order Summary Report documented: Enulose Solution 10 GM /15ML Give 15 milliliter via PEG-Tube one time a day for constipation. Record review of Resident #17's Comprehensive Care Plan, dated 08/03/2023, documented: [Resident #17] requires tube feeding related to dysphagia. The resident needs the HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed. Enteral feeding as ordered. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Observe and report PRN any s/sx [signs or symptoms ] of: Aspiration- fever, SOB , tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Lab/diagnostic work as ordered. Report results to MD and follow up as indicated. 675637 Page 14 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 08/09/2023 at 8:47AM revealed RN A commenced medication administration for Resident #17. RN A performed hand hygiene, applied clean gloves, and retrieved a large bore syringe from Resident #17's clothes drawer, by opening the drawer using the same initial pair of gloves. RN A continued by inserting the large bore syringe into percutaneous endoscopic gastrostomy tube. RN A administered medication via PEG-Tube, followed by flushing 15 ml of free water flush. No change of gloves or hand hygiene was performed after touching Resident #17's clothes drawer. During an observation on 08/10/2023 at 10:10 AM, RN A performed an assessment for Resident #17 by auscultating the stomach, checking gastric residual volume, followed by flushing with 15 ml of water. RN A proceeded to return large bore syringe to Resident #17's clothes drawer, by opening and closing the drawer with previously used gloves. RN A proceeded to retrieve the feeding tube and inserted into the peg tube, no hand hygiene or glove change performed after touching Resident #17's clothes drawer. During an interview on 08/09/2023 at 8:56AM RN A stated she did not realize she did not perform a glove change or hand hygiene after touching Resident #17's clothes drawer. RN A stated she usually changed gloves and performed hand hygiene prior, during, and after resident care, after touching different surfaces, and medication administration, but it slipped her mind. RN A stated by not performing hand hygiene and glove changes, after touching surfaces could potentially infect Resident #17 with infectious microorganisms that lived on surfaces. RN A did recall attending skills check off regarding hand hygiene. RN A apologized for the error and stated she would be more aware of her actions. During an interview on 08/10/2023 at 10:18 AM, RN A stated she was remorseful for forgetting to perform hand hygiene and change of gloves after touching Resident #17's clothes drawer and prior to administering Resident #17s tube feeding. RN A stated gloves changes and hand hygiene prior, during, and after residential care were efforts to aide in infection control. RN A stated by performing hand hygiene and glove changes, she would minimize the risk of potentially exposing Resident #17 to bacteria and infectious organisms that lived on surfaces. RN A stated she attended competency skills check off on 06/02/2023 regarding hand hygiene. RN A stated she was sorry and would make every effort to be conscientious of her actions Record review of the facility's Infection Control: Hand hygiene competency/skills checklist, dated 06/02/2023, documented RN A in attendance. 2. Record review of Resident #1's face sheet, dated 08/09/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture), stage 4 pressure ulcer of right ankle, stage 4 pressure ulcer of sacral region, schizoaffective disorder (mental health disorder), and depression (elevation or lowering of a person's mood) . Record review of Resident #1's Minimum Data Set, dated [DATE], revealed Resident #1 had a BIMS score of 12/15, which indicated the resident was cognitively intact. Resident #1 was documented with frequent urinary incontinence. Resident #1 required extensive assistance with two-person physical assist for bed mobility, transfer, dressing, and personal hygiene, and was at risk for pressure ulcer development. Record review of Resident #1's Care Plan, dated 05/22/2023, reflected Resident #1 with urinary incontinence and functional incontinence. Goal: will have no skin breakdown related to urinary incontinence. Interventions: Assist with toileting as needed, and peri care as needed, clean peri-area with 675637 Page 15 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some each incontinence episode, and observe for /document for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature , urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. During an observation on 08/10/2023 at 10:46 AM revealed CNA A performed perineal care on Resident #1. CNA A began by performing hand hygiene with antibacterial hand rub and applied clean gloves. CNA A touched the bed rails, positioned bed using bed remote buttons, removed pillows on Resident #1's left flank area, removed blankets, elevated feet, took pillow out, unlatched Resident #1'sbrief, retrieved clean wipes and cleaned Resident #1's perineum. CNA A proceeded to turn Resident #1 to left side, removed visibly soiled sheet, cleaned bed with antimicrobial wipe and wiped bed. CNA A continued by putting a new sheet on the bed, turned Resident #1 to the supine (on back) position and applied a new clean brief. CNA A did not perform any hand hygiene or glove changes during perineal care. During an interview on 08/10/23 at 11:12 AM, CNA A stated she should have changed gloves and performed hand hygiene prior to cleaning Resident #1's perineum area. CNA A stated by performing hand hygiene and glove changes would be a preventative measure to minimize bacteria and infection from encountering Resident #1. CNA A stated she only carried a certain number of clean gloves in her pockets , and that was what kept her from changing gloves. CNA A did not definitively answer as to why she kept clean gloves in her pocket. CNA A stated she could potentially have exposed Resident #1 to bacterial infection in the area, which could have led to sepsis in perineal area. CNA A stated she was not prepared to perform perineal care and would be prepared going forward. CNA A stated she attended skills check-off and in-service regarding perineal care about a week ago. During an interview on 08/10/23 at 1:16 PM, the DON stated ADONs did skill competencies yearly and as needed for infection control. The DON stated hand hygiene was a standard of care and must be performed prior to medication administration, as well as prior, during, and after perineal care. The DON stated performance of hand hygiene would lower the risk of infection. The DON stated RN A should have performed hand hygiene and glove changes after touching Resident #17's clothes drawer and before touching Resident #17's peg tube. The DON stated by not performing hand hygiene RN A potentially exposed Resident #17 to infectious organisms that lived on the surface of the clothes drawer. The DON stated CNA A should have performed hand hygiene and glove changes after touching the multiple surfaces as well as during, and after performing perineal care on Resident #1. The DON stated CNA A may have exposed Resident #1 to microorganisms that lived on the multiple surfaces. The DON stated it was the expectation of the facility that hand hygiene was performed prior, during, and after care. The DON stated the ADONs conducted in-services regarding infection control and hand hygiene upon hire, monthly, annually, and as needed. The DON stated the ADONs also administered to the clinical staff, competency skill checkoffs annually and as needed. The DON stated the facility would attempt additional in-services regarding hand hygiene and infection control to clinical staff . Record review of the facility's Infection Control: Hand hygiene competency/skills checklist, dated 06/01/2023, documented CNA A in attendance. Record review of the facility's Hand Hygiene Policy, revised: 07/15/2022, stated the facility should provide education to associates on hand hygiene routinely and this education should include but is not limited to; When to perform proper hand hygiene with (ABHR ) and with soap and water o 675637 Page 16 of 17 675637 08/10/2023 Wooldridge Place Nursing Center 7352 Wooldridge Rd Corpus Christi, TX 78414

F 0880 Before and after all resident contact; Level of Harm - Minimal harm or potential for actual harm o After contact with blood, body fluids, or visibly contaminated surfaces; Residents Affected - Some o After contact with objects in the resident's room; o Before applying gloves, o After removal or gloves; o Before putting on and after removing PPE , including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. 675637 Page 17 of 17