Health inspection·October 12, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and injuries of unknown source, to include identifying and investigating any such allegations for 1 (Resident #1) of 4 residents reviewed for abuse and neglect. Residents Affected - Few The facility failed to conduct an investigation and report an injury of unknown origin to the appropriate State agency when notified Resident #1 had an injury of unknow origin of a large purple and yellow bruise on the right side of her forehead. This failure could place residents at risk of repeated injuries and abuse and/or neglect. Findings include: Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced Supracondylar (break to the lower part of the bone) fracture of lower end of left femur (thigh bone), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases) without current pathological fracture (a break in a bone that is caused by an underlying disease, without), and Nutritional Anemia (a lack of healthy red blood cells caused by a lower than usual amounts of vitamin B-12 and folate). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, which indicated a severe cognitive impact. In the area of functional status, Resident #1 required extensive assistance with two or more persons physical assistance in the areas of bed mobility and dressing. In the area of transfers, Resident #1 required total dependence with two or more persons physical assistance. Record review of Resident #1's Care Plan, dated 08/17/2023, revealed Resident #1 was totally dependent on staff for repositioning and turning in bed for bed mobility and required the use of a Hoyer lift with two or more staff in the area of transfers. The Care Plan revealed Resident #1 required moderate 1- to 2- staff assistance with dressing. Record review of Resident #1's Progress Note entry, dated 09/11/2023 at 10:39 a.m., documented by RN G, revealed Resident #1's family member B informed RN G Resident #1 had an old bruise on her left forehead, yellow in color, no swelling or c/o discomfort. Record review of the progress notes revealed RN G did not make any additional notifications after being informed by Resident #1's family member B of the bruise and RN G's Progress Note entry was the initial documentation concerning Resident #1's bruise. Page 1 of 23 675645 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/06/2023 at 9:20 a.m., Resident #1's family member B said she was at the facility on 09/11/2023 and observed a large bruise on the right side of Resident #1's forehead. Resident #1's family member B said the bruise was yellow in color with a purple color on right edge. Resident #1's family member B said she took pictures and reported the bruise to RN G, who was the nurse on duty. Resident #1's family member B said the nurse reported she did not know how the injury had occurred. Resident #1's family member B said she contacted the DON on 09/11/2023, and the DON told her she did not know how the bruise occurred but would look into the cause. Resident #1's family member B said the DON told her she needed to speak to a staff that worked at night. Resident #1's family member B said she followed-up with the DON on several occasions after her initial report until the DON informed her on 9/30/2023 that the bruise was never investigated, and the facility did not know how the bruise on Resident #1's forehead occurred. During an interview on 10/04/2023 at 10:23 a.m., RN G said she was notified by Resident #1's family member B that Resident #1 had a large bruise on her forehead on or about 09/11/2023. RN G said she observed a large bruise on Resident #1's forehead that was yellow and slightly purple around the edge on the right side, approximately the size of a baseball. RN G said she documented what she observed in a progress note but did not fill out an incident report because the bruise was already in the healing process. RN G said that was the first time she saw the bruise. RN G said she did not report the bruise to the Administrator because she did not think the bruise was suspicious. RN G said she did not know how Resident #1 obtained the bruise and did not see any previous documentation in regard to the bruise. RN G said Resident #1 was non-interviewable and was not able to describe how the bruise occurred. During an interview on 10/05/2023 at 2:25 p.m., the DON said she was not aware of the yellow bruise until Resident #1's family member B brought the pictures of the bruise to her and asked how the injury had occurred on 09/11/2023. The DON said the yellow bruise was in the same spot as a red mark she had been informed by a CNA when she worked an overnight shift as a charge nurse and said the bruise could have been the same injury. The DON said she was the nurse on duty when CNA H notified her that Resident #1 had a red spot on her forehead. The DON said she could not remember the date or time, but the DON said she went to Resident #1's room and observed a very small red mark, smaller than the size of a pencil eraser, on the right side of her forehead and observed Resident #1's face was red and flushed. The DON said she took Resident #1's temperature and said the temperature was normal. The DON said she took Resident #1's temperature because her face was flushed and turned her attention away from the red spot located on Resident #1's forehead. The DON said she did not document the incident in the clinical progress notes or on an incident report form and did not follow-up on the small red spot. The DON said she did not investigate the bruise after the family had reported the presence of the bruise on Resident #1's forehead on 09/11/2023 because she did not think the bruise met the definition of an injury of unknown source as defined by the facility policy. The DON said Resident #1 flailed when the staff transferred her in the Hoyer lift, took blood thinners, and had thin skin. During an interview on 10/05/2023 at 6:09 p.m., CNA H said he did not remember seeing a large bruise on Resident #1's forehead but he worked as needed and did not work on a consistent basis. CNA H said he was on duty when he noticed a red mark on Resident #1's right side of her forehead. CNA H said he could not remember the date or time of the observation, but CNA H said he reported the red mark to the nurse on duty, who was the DON. CNA H said he made a verbal report to the nurse on duty and was not required to document the incident. During an interview on 10/06/2023 at 11:39 a.m., the Administrator said she was notified of the 675645 Page 2 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few large, yellow bruise on Resident #1's forehead when Resident #1's family member B reported the bruise on Resident #1's forehead on 09/11/2023. The Administrator said she did not report the incident because Resident #1's bruise was already healing, and she had a history of flailing when in the Hoyer lift and could have bumped her head on the Hoyer lift or on the handrail on Resident #1's bed. The Administrator said she was the facility's designated person that reports abuse and neglect to the state agency, and she used the state's provider guidelines to define injuries of unknown origin and to determine what injuries to report. The Administrator said an injury of unknown source was defined in the facility's policy and she knew what the definition was. Record review of the facility's policy, Abuse: Prevention of and Prohibition Against, dated 11/28/2017, revealed in Section E. Identification, that the facility would assist staff to identify abuse, neglect, and exploitation. 2. Because some cases of abuse are not directly observed, understanding residents' outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tear, and injuries of unknown source; Extensive injuries; Injuries in an unusual location; Section F. Investigation, revealed: 1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. 3. All allegations of abuse and neglect will be promptly and thoroughly investigated by the Administrator or his/her designee. Record review of facility policy, Nursing Administration: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, dated 11/28/2017, revealed the facility would ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source would be reported immediately but no later than 2 hours after the allegation was made that involves serious bodily harm or no later than 24 hours after the allegation was made that does not involve serious bodily injury. Ensure that all alleged violations involving abuse, neglect, and mistreatment, including injuries of unknown source were reported to: 675645 Page 3 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0607 - Level of Harm - Minimal harm or potential for actual harm The Administrator of the Facility - Residents Affected - Few The State Survey Agency 675645 Page 4 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency, one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to report an alleged injury of unknown origin to the State Survey Agency when Resident #1 was discovered with a purple and yellow bruise on the right side of her forehead approximately two inches in diameter This failure could place residents residing in the facility at risk of abuse/neglect not being reported. Findings include: Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced Supracondylar (break to the lower part of the bone) fracture of lower end of left femur (thigh bone), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases) without current pathological fracture (a break in a bone that is caused by an underlying disease, without), and Nutritional Anemia (a lack of healthy red blood cells caused by a lower than usual amounts of vitamin B-12 and folate). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, which indicated a severe cognitive impact. In the area of functional status, Resident #1 required extensive assistance with two or more persons physical assistance in the areas of bed mobility and dressing. In the area of transfers, Resident #1 required total dependence with two or more persons physical assistance. Record review of Resident #1's Care Plan, dated 08/17/2023, revealed Resident #1 was totally dependent on staff for repositioning and turning in bed for bed mobility and required the use of a Hoyer lift with two or more staff in the area of transfers. The Care Plan revealed Resident #1 required moderate 1- to 2- staff assistance with dressing. Record review of Resident #1's Progress Note entry, dated 09/11/2023 at 10:39 a.m., documented by RN G, revealed Resident #1's family member informed RN G Resident #1 had an old bruise on her left forehead, yellow in color, no swelling or c/o discomfort. Record review of the progress notes revealed RN G did not make any additional notifications after being informed by Resident #1's family member B of the bruise and RN G's Progress Note entry was the initial documentation concerning the Resident #1's bruise. During an interview on 10/06/2023 at 9:20 a.m., Resident #1's family member B said she was at the facility on 09/11/2023 and observed a large bruise on the right side of Resident #1's forehead. Resident #1's family member B said the bruise was yellow in color with a purple color on right edge. Resident #1's family member B said she took pictures and reported the bruise to RN G, who was the nurse on duty. Resident #1's family member B said the nurse reported she did not know how the injury had occurred. Resident #1's family member B said she contacted the DON on 09/11/2023, and the DON told 675645 Page 5 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0609 Level of Harm - Minimal harm or potential for actual harm her she did not know how the bruise occurred but would look into the cause. Resident #1's family member B said the DON told her she needed to speak to a staff that worked at night. Resident #1's family member B said she followed-up with the DON on several occasions after her initial report until the DON informed her on 9/30/2023 that the bruise was never investigated, and the facility did not know how the bruise on Resident #1's forehead occurred. Residents Affected - Few During an interview on 10/04/2023 at 10:23 a.m., RN G said she was notified by Resident #1's family member B that Resident #1 had a large bruise on her forehead on or about 09/11/2023. RN G said she observed a large bruise on Resident #1's forehead that was yellow and slightly purple around the edge on the right side, approximately the size of a baseball. RN G said she documented what she observed in a progress note but did not fill out an incident report because the bruise was already in the healing process. RN G said that was the first time she saw the bruise. RN G said she did not report the bruise to the Administrator because she did not think the bruise was suspicious. RN G said she did not know how Resident #1 obtained the bruise and did not see any previous documentation in regard to the bruise. RN G said Resident #1 was non-interviewable and was not able to describe how the bruise occurred. During an interview on 10/05/2023 at 2:25 p.m., the DON said she was not aware of the yellow bruise until Resident #1's family member B brought the pictures of the bruise and asked how the injury had occurred on 09/11/2023. The DON said the yellow bruise was in the same spot as a red mark she had been informed by a CNA when she worked an overnight shift as a charge nurse and said the bruise could have been the same injury. The DON said she was the nurse on duty when CNA H notified her that Resident #1 had a red spot on her forehead. The DON said she could not remember the date or time, but the DON said she went to Resident #1's room and observed a very small red mark, smaller than the size of a pencil eraser, on the right side of her forehead and observed Resident #1's face was red and flushed. The DON said she took Resident #1's temperature and said the temperature was normal. The DON said she took Resident #1's temperature because her face was flushed and turned her attention away from the red spot located on Resident #1's forehead. The DON said she did not document the incident in the clinical progress notes or on an incident report form and did not follow-up on the small red spot. During an interview on 10/05/2023 at 6:09 p.m., CNA H said he did not remember seeing a large bruise on Resident #1's forehead but he worked as needed and did not work on a consistent basis. CNA H said he was on duty and noticed a red mark on Resident #1's right side of her forehead. CNA H said he could not remember the date or time of the observation, but CNA H said he reported the red mark to the nurse on duty, who was the DON. CNA H said he made a verbal report to the nurse on duty and was not required to document the incident. During an interview on 10/06/2023 at 11:39 a.m., the Administrator said she was notified of the large, yellow bruise on Resident #1's forehead when Resident #1's family member B reported the bruise on Resident #1's forehead on 09/11/2023. The Administrator said she did not report the incident because Resident #1's bruise was already healing, and she had a history of flailing when in the Hoyer lift and could have bumped her head on the Hoyer lift or on the handrail on Resident #1's bed. The Administrator said she was the facility's designated person that reports abuse and neglect to the state agency, and she used the state's provider guidelines to define injuries of unknown origin and to determine what injuries to report. The Administrator said an injury of unknown source was defined in the facility's policy and she knew what the definition was. Record review of the facility's policy, Abuse: Prevention of and Prohibition Against, dated 675645 Page 6 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11/28/2017, revealed in Section E. Identification, that the facility would assist staff to identify abuse, neglect, and exploitation. 2. Because some cases of abuse are not directly observed, understanding residents' outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tear, and injuries of unknown source; Extensive injuries; Injuries in an unusual location; Section F. Investigation, revealed 1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Section H. Reporting/Response: 1. All allegations of abuse or neglect should be reported immediately to the Administrator. 2. Allegations of abuse or neglect will be reported be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations Record review of facility policy, Nursing Administration: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, dated 11/28/2017, revealed the facility would ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source would be reported immediately but no later than 2 hours after the allegation was made that involves serious bodily harm or no later than 24 hours after the allegation was made that does not involve serious bodily injury. Ensure that all alleged violations involving abuse, neglect, and mistreatment, including injuries of unknown source were reported to: The Administrator of the Facility 675645 Page 7 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0609 The State Survey Agency Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675645 Page 8 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injury of unknown origin, were thoroughly investigated for 1 (Resident #1) of 4 residents reviewed for abuse and neglect. Residents Affected - Few The facility failed to investigate when Resident #1's family reported a large purple and yellow bruise on the right side of her forehead that was unknown how the injury occurred. This failure could place residents residing in the facility at risk of not being protected or having a thorough investigation. Findings include: Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced Supracondylar (break to the lower part of the bone) fracture of lower end of left femur (thigh bone), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases) without current pathological fracture (a break in a bone that is caused by an underlying disease, without), and Nutritional Anemia (a lack of healthy red blood cells caused by a lower than usual amounts of vitamin B-12 and folate). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, which indicated a severe cognitive impact. In the area of functional status, Resident #1 required extensive assistance with two-persons or more physical assistance in the areas of bed mobility and dressing. Record review of Resident #1's Care Plan, dated 08/17/2023, revealed Resident #1 was totally dependent on staff for repositioning and turning in bed for bed mobility and required the use of a Hoyer lift with two or more staff in the area of transfers. The Care Plan revealed Resident #1 required moderate1- to 2- staff assistance with dressing. Record review of Resident #1's Progress Note entry, dated 09/11/2023 at 10:39 a.m., documented by RN G, revealed Resident #1's family member informed RN G Resident #1 had an old bruise on her left forehead, yellow in color, no swelling or c/o discomfort. Record review of the progress notes revealed RN G did not make any additional notifications after being informed by Resident #1's family member B of the bruise and RN G's Progress Note entry was the initial documentation concerning the Resident #1's bruise. During an interview on 10/06/2023 at 9:20 a.m., Resident #1's family member B said she was at the facility on 09/11/2023 and observed a large bruise on the right side of Resident #1's forehead. Resident #1's family member B said the bruise was yellow in color with a purple color on the edges. Resident #1's family member B said she took pictures and reported the bruise to RN G, who was the nurse on duty. Resident #1's family member B said the nurse reported she did not know how the injury had occurred. Resident #1's family member B said she contacted the DON on 09/11/2023, and the DON told her she did not know how the bruise occurred but would look into the cause. Resident #1's family member B said the DON told her she needed to speak to a staff that worked at night. Resident #1's family member B said she followed-up with the DON on several occasions until the DON informed her on 9/30/2023 that the bruise was never investigated, and the facility did not know how the bruise on Resident 675645 Page 9 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0610 #1's forehead occurred. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/05/2023 at 2:25 p.m., the DON said she was not aware of the yellow bruise until Resident #1's family member B brought the pictures of the bruise and asked how the injury had occurred on 09/11/2023. The DON said she did not consider the bruise an injury of unknown origin that needed to be investigated because Resident #1 had a history of flinging her body when being transferred in the Hoyer lift. The DON said she knew what an injury of unknown origin was as defined by the facilities policy and did not consider Resident #1's bruise as unknown because she had thin skin and took blood thinners. Residents Affected - Few During an interview on 10/06/2023 at 11:39 a.m., the Administrator said she was notified of the large, yellow bruise on Resident #1's forehead when Resident #1's family member B reported the bruise on Resident #1's forehead on 09/11/2023. The Administrator said she did not report the incident because Resident #1's bruise was already healing, and she had a history of flailing when in the Hoyer lift and could have bumped her head on the Hoyer lift or on the handrail on Resident #1's bed. The Administrator said she was the facility's designated person that reports abuse and neglect to the state agency and used the state's reference to define injuries of unknown origin and what to report to the State Survey Agency. The Administrator said injuries of unknown source was defined in the facility's policy and she knew what the definition was. Record review of the facility's policy, Abuse: Prevention of and Prohibition Against, dated 11/28/2017, revealed in Section E. Identification, that the facility would assist staff to identify abuse, neglect, and exploitation. 2. Because some cases of abuse are not directly observed, understanding residents' outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tear, and injuries of unknown source; Extensive injuries; Injuries in an unusual location; Section F. Investigation, revealed 1. All identified events are reported to the Administrator immediately. 2. After receiving the allegation, and during the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. 3. All allegations of abuse and neglect will be promptly and thoroughly investigated by the Administrator or his/her designee. 675645 Page 10 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility policy, Nursing Administration: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, dated 11/28/2017, revealed in order to comply with the Facility's obligations, the facility would conduct a prompt, thorough and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, and exploitation. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported and investigated, with the results reported to the State Survey Agency. 675645 Page 11 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 1 (Resident #6) of 3 residents reviewed for care plans. The care plan for Resident #6 did not adequately address his interventions to describe how to meet his needs when transferring resulting in a fracture to right arm. This deficient practice placed residents at risk of not having care needs met, which could cause a decline in physical and psychosocial health and serious injury. Findings include: Record review of Resident #6's Face Sheet, dated 10/04/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6's diagnoses included Unspecified displaced fracture (pieces of the bone moved so much that a gap formed around the fracture) of the surgical neck (a bony narrowing at the proximal or nearer to the center end of the shaft of the upper arm or forelimb) of the right humorous subsequent encounter (receiving routine care) for fracture with routine healing, Urinary Tract Infection (infection when bacteria enter the urethra and infect the urinary tract), repeated falls, and Type II Diabetes (problem in the way the body regulates and uses sugar as a fuel). The Face Sheet revealed Resident #6's most recent hospital stay was 04/22/2023 through 04/27/2023. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. Section G, Function Status, revealed Resident #6 required extensive assistance (resident involved in activity, staff provided weight-bearing support) with 2-persons or more with physical assist in transfers. Record review of Resident #6's Care Plan, dated 07/24/2023, revealed Resident #6 had a focus of on ADL Self Care Performance Deficit due to recent surgical repair of right humerus fracture due to fall from recliner at home on [DATE]. Resident #6's goal was to improve current level of transfers and the interventions included Resident #6 required 1-person staff participation with transfers. Record review of Resident #6's Progress Note, dated 07/19/2023 at 10:28 a.m., documented by LVN N revealed Resident #6 had x-rays that determined an impression of acute fractures of the proximal right humerus per the PCP, who ordered an immobilizer and referral to orthopedic doctor. Record review of the progress notes dated on/or about 7/19/2023 revealed there was no documentation in the record of who Resident #6 reported pain in his right shoulder to or who reported the injury or complaint of pain to the nurse or who contacted the doctor. There was no documentation in the clinical progress notes that documented why x-rays were orders or what precursor occurred to warrant the need for x-rays. Record review of Resident #6's Progress Note, dated 07/19/2023 at 7:14 p.m., documented by LVN N, revealed Resident #6 had new orders from the orthopedic doctor to wear a sling on right arm due to new right Humeral shaft fracture. Record review of the progress notes dated on/or about 7/19/2023 675645 Page 12 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0656 Level of Harm - Actual harm Residents Affected - Few revealed there was no documentation in the record of details of how the fracture occurred or what event preceded prior to Resident #6's injury up to the x-ray results and the orthopedic doctor's orders. Record review revealed the was no incident report completed. During an interview on 10/04/2023 at 11:45 a.m., Resident #6 said he broke his arm in two places when CNA H picked him up under his arms. Resident #6 said CNA H helped him transfer from his wheelchair to his bed and CNA H grabbed him under his arms and picked him up in a bear hug. Resident #6 said he heard two pops, and his arm was broken. Resident #6 said staff would use the gait belt sometimes during transfers and Resident #6 said he used the gait belt in therapy. Resident #6 said CNA H had transferred him using the bear hug in the past and he was comfortable with him using it because CNA H was strong. Resident #6 said two staff would assist him to move from his wheelchair to his bed when he felt like he needed support because his legs would get weak. Resident #6 said since he broke his arm in two places, there was supposed to be two staff in his room, but one staff could transfer him. During an interview on 10/03/2023 at 4:34 p.m., CNA O said she did not have access to residents' care plans. During an interview on 10/05/2023 at 4:42 p.m., CNA F said Resident #6 was able to pivot and transfer with the assistance of one staff for several weeks prior to the new fractures of his right arm that occurred in July 2023. CNA F said Resident #6 was now a 2-person transfer due to the fractures of his arm that occurred in July. CNA F said she was verbally instructed by the DON that Resident #6 was a 2-person transfer. During an interview on 10/05/2023 at 6:09 p.m., CNA H said he had worked at the facility for two years and had always transferred Resident #6 using a bear hug. CNA H said he had never been told to not use the bear hug to transfer Resident #6 or that the bear hug was an inappropriate way to transfer Resident #6 or any of the other residents. CNA H said on the day of the incident when Resident #6 suffered two fractures to his right arm, CNA H said that he used the bear hug technique to attempt to transfer Resident #6. CNA H said he picked Resident #6 up chest to chest and with Resident #6's hands on his arms. CNA H said he heard Resident #6 say ouch when Resident #6 was picked up about a foot off his wheelchair, and CNA H said he immediately sat Resident #6 back down. CNA H said he then retrieved a gait belt and assisted Resident #6 to a sitting position on his bed with a pivot transfer. CNA H said Resident #6 did not immediately complain of pain and responded he was ok when CNA H asked. CNA H said he did not report the incident to the nurse on duty because Resident #6 said he was ok and was not in pain. CNA H said he left Resident #6 in bed and went off shift a short time later. CNA H said he was told by another staff member that Resident #6 complained of pain in his arm a couple of hours after CNA H was off shift, but CNA H did not know who Resident #6 told or what time Resident #6 reported the pain. CNA H said he had been trained on how to use a gait belt but did not remember being instructed to use a belt when transferring Resident #6. CNA H said Resident #6's care plan did not have details on how to transfer Resident #6 and only reflected Resident #6 required 1 staff assistance with transfers. During an interview on 10/06/2023 at 10:51 p.m., the MDS Coordinator said she was notified of Resident #6's injury in the morning meeting the day after the fracture occurred. The MDS Coordinator said Resident #6's arm fracture alone would not cause an update to the MDS assessment and/or care plan. The MDS Coordinator said the IDT would discuss the injury to determine if there was a change in Resident #6's ability to complete daily living activities. The MDS Coordinator said the interventions in the care plan were determined by the therapy department. The MDS Coordinator said an updated care 675645 Page 13 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0656 plan with the accurate interventions would be beneficial to the resident and staff to ensure the resident's safety during a transfer. Level of Harm - Actual harm Residents Affected - Few During an interview on 10/10/2023 at 9:11 a.m., the PT said he was familiar with Resident #6 and completed his physical therapy progress reports and certifications. The PT said functionally the bear hug should not have been used with Resident #6 because Resident #6 could bear weight and transfer. The PT said the bear hug technique could cause additional injury to Resident #6's arm because Resident #6's arm had previously been fractured upon admission into the facility. The PT said the use of a gait belt should be in Resident #6's care plan because Resident #6's Plan of Treatment in therapy included gait training therapy to address safe transfers. Record review of Resident #6's Physical Therapy PT Evaluation & Plan of Treatment, dated 4/28/2023, revealed Resident #6 had treatment approaches that included gait training therapy. Review revealed Resident #6's #3.0 Goal was, Patient will improve ability to safely and efficiently transfer to and from a bed to a chair (or wheelchair) with Partial/Moderate Assistance. The evaluation revealed Resident #6 could bear weight as tolerated. During an interview on 10/10/2023 at 9:35 a.m., the OT said he did not reevaluated Resident #6 after he had suffered the new fractures on or around 7/19/2023. The OT said when Resident #6 was admitted to the facility because Resident #6 fell out of his recliner at home and fractured his right shoulder, Resident #6 was very sensitive during transfers and a gait belt was always used. The OT said Resident #6 had chronic anxiety issues. The OT said when Resident #6 broke his arm the second time, Resident #6 went back to the status of non-weight bearing in the right arm and a sling was added. The OT said Resident #6 continued to do stand-to-pivot transfers with the use of a gait belt and clarified with 1 to 2 staff assist as documented in the MDS Assessment. The OT said the facility used an encrypted message system and if a change in condition occurred, the OT said he would have been notified by the message system either through the facility's electronic platform that stored residents' clinical records or text message on his phone with an application that was linked to the electronic platform. The OT said the care plan was updated when he provided residents' OT evaluations to the MDS Coordinator, and the information was entered into the electronic platform used for therapy clinical records. During an interview on 10/11/2023 at 10:10 a.m., the Director of Rehab said Resident #6 was very anxious with transfers and may have been more comfortable when staff used a bear hug, which was an acceptable way to transfer Resident #6. The Director of Rehab said she made the determination to make Resident #6 non-weight bearing on the right-side torso when the encrypted messaging system informed her, the charge nurse, the DON, and all administration staff attached to the message regarding Resident #6 that he was a 2-person assist transfer with a gait belt after Resident #6's right arm was established to be fractured. The Director of Rehab said the nurse would be responsible for letting the CNAs know verbally that there was a change in the way Resident #6 was transferred. The Director of Rehab said she did not consider Resident #6's fracture a change in condition because Resident #6's fracture occurred in the same arm as the dislocated shoulder Resident #6 was originally admitted for . The Director of Rehab said the same interventions were in place in his care plan from the original injury. The Director of Rehab said the therapy assessment information that was completed for Resident #6 that included goals and recommendations was entered into the MDS assessment and care plan by the MDS Coordinator, who had access to therapy's electronic record-keeping platform. The Director of Rehab said Resident #6's care plan intervention was correct that he needed a 1-person assist with transfer and provided enough information for the CNAs to properly transfer Resident #6. 675645 Page 14 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0656 Level of Harm - Actual harm Residents Affected - Few During an interview on 10/11/2023 at 10:45 a.m., the DON said that Resident #6 was non-weight bearing in his right upper body after his arm fracture that occurred in the facility. The DON said the CNAs would have been informed verbally by the charge nurse or therapy that Resident #6 required 1 to 2 staff with gait belt to transfer. The DON said from that point, the information would be communicated when staff did walking rounds at shift change. The DON said the information should be in Resident #6's care plan that he needed 1 or 2 staff assist but the specific steps on how to carry out the 1 to 2 staff transfer would be verbally communicated to staff. The DON said the CNAs did not have time to read a 23- to 24- page care plan. The DON said she was aware the facility policy on transfers included the use of gait belt in the steps that described the Sit-to-Stand-to-Chair transfer and the Bed-to-chair (to Bed) transfer. During an interview on 10/06/2023 at 11:39 a.m., the Administrator said Resident #6's injury should have been documented on an incident report. The Administrator said the information on the incident report would have been entered into the electronic clinical records that would notify the MDS Coordinator to review the information and the determine if a need to update the MDS or care plan was warranted. The Administrator said this would be important in ensuring the care plans were up to date and accurate. The Administrator said the therapy department used a different electronic computer system to document and store therapy records. The Administrator said the therapy computer platform system linked with the nursing computer platform system and used the assessment to create the goals and interventions in the care plan. Record review of facility policy, Comprehensive Person-Centered Care Planning, dated 01/2022, revealed it was the policy of the facility that the IDT would develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. Record review of facility policy, Transfers, Types of, not dated, revealed the steps of types of transfer were: Sit-to-Stand-to-Chair Transfer 1. Position chair at a slight diagonal to the bed. Make sure the chair is stable, footrest removed or foot plates up. 2. Place the gait belt around the resident. 3. Stand facing the resident. 4. Tell the resident to move to the edge of the bed. 5. 675645 Page 15 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0656 Block the resident's feet and knees. Grasp the gait belt. Level of Harm - Actual harm 6. Residents Affected - Few Ask the resident to lean forward and stand on the count of three. 7. Bring the resident to a full standing position. 8. Have the resident reach with his/her hand to far side of the wheelchair as he/she pivots. Sit down gently. Bed-to-Chair (to Bed) Maximal Assist Pivot Transfer 1. Resident slides to edge of bed, placing feet apart, flat on floor. 2. You stand facing the resident the resident, grasping the safety belt with both hands at the resident's side. Block resident's knee. 3. At 1-2-3, stand resident up by straightening you knees. 4. Pivot resident, then guide him to sitting position in chair. Resident's strong-rm position is up to your preference and resident's physical ability. 5. When resident is in position in front of wheelchair, resident reaches back to grasp middle of arm rest and lowers himself into wheelchair. 6. You must steady the wheelchair as it has a tendency to move even with the brakes locked. 675645 Page 16 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviews, the facility failed to maintain complete, accurately documented and readily accessible medical records, in accordance with accepted professional standards and practices, on each resident for 2 out of 3 (Resident #1 and Resident #6) reviewed for clinical records 1. The facility failed to document in Resident #1's clinical record the details involved around the incident when Resident #1's family member reported a large bruise on the right side of her forehead. 2. The facility failed to document in Resident #6's clinical record the details involved in the incident when Resident #6 was picked up to be transferred from his wheelchair to his bed and sustained 2 fractures in his right arm. This failure could place residents at risk for inaccurate or incomplete clinical records. Findings include: 1. Record review of Resident #1's Face Sheet, dated 10/03/2023, revealed a [AGE] year-old female who was admitted into the facility on [DATE]. Resident #1's diagnoses included Displaced Supracondylar (break to the lower part of the bone) fracture of lower end of left femur (thigh bone), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases) without current pathological fracture (a break in a bone that is caused by an underlying disease, without), and Nutritional Anemia (a lack of healthy red blood cells caused by a lower than usual amounts of vitamin B-12 and folate). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 00, which indicated a severe cognitive impact. In the area of functional status, Resident #1 required extensive assistance with two or more persons physical assistance in the areas of bed mobility and dressing. In the area of transfers, Resident #1 required total dependence with two or more persons physical assistance. Record review of Resident #1's Care Plan, dated 08/17/2023, revealed Resident #1 was totally dependent on staff for repositioning and turning in bed for bed mobility and required the use of a Hoyer lift with two or more staff in the area of transfers. The Care Plan revealed Resident #1 required moderate1- to 2- staff assistance with dressing. Record review of Resident #1's Progress Note entry, dated 09/11/2023 at 10:39 a.m., documented by RN G, revealed Resident #1's family member B informed RN G Resident #1 had an old bruise on her left forehead, yellow in color, no swelling or c/o discomfort. Record review of the progress notes revealed RN G did not make any additional notifications after being informed by Resident #1's family member B of the bruise and RN G's Progress Note entry was the initial documentation concerning the Resident #1's bruise. During an interview on 10/06/2023 at 9:20 a.m., Resident #1's family member B said she was at the facility on 09/11/2023 and observed a large bruise on the right side of Resident #1's forehead, approximately the size of a baseball, that was yellow and green in color from the middle of the forehead 675645 Page 17 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back to Resident #1's hairline. Resident #1's family member B said the bruise was yellow and green in color with a purple color around the right edge of the discoloration. Resident #1's family member B said she took pictures and reported the bruise to RN G, the nurse on duty. Resident #1's family member B said RN G informed her she did not know how the injury had occurred and after RN G reviewed the records, RN G reported there was no documentation in Resident #1's clinical records concerning the injury or bruise on Resident #1's forehead. During an interview on 10/04/2023 at 10:23 a.m., RN G said she was notified by Resident #1's family member B that Resident #1 had a large bruise on her forehead on or about 09/11/2023. RN G said she observed a large bruise on Resident #1's forehead that was yellow and slightly purple around the edge on the right side, approximately the size of a baseball. RN G said that was the first time she had seen the bruise. RN G said she did not know how Resident #1 obtained the bruise and did not see any previous documentation in Resident #1's progress notes or clinical records in regard to the bruise on her forehead. During an interview on 10/05/2023 at 2:25 p.m., the DON said she was not aware of the yellow bruise until Resident #1's family member B brought the pictures of the bruise and asked how the injury had occurred on 09/11/2023. The DON said she was aware RN G had documented the facility was notified by Resident #1's family. The DON said she did not consider the need to document more about the bruise because she did not consider the bruise as an injury of unknown origin because Resident #1 flailed around when staff transferred her in the Hoyer lift and Resident #1 had thin skin and was on blood thinner. During an interview on 10/06/2023 at 11:39 a.m., the Administrator said the facility did not complete an incident report for every bruise or notify the family about every small issue. The Administrator said she was notified of the large, yellow bruise on Resident #1's forehead when Resident #1's family member B reported the bruise on Resident #1's forehead on 09/11/2023. The Administrator said Resident #1 had a history of flailing when in the Hoyer lift and could have bumped her head on the Hoyer lift or on the handrail on Resident #1's bed and did not document details or investigate. The Administrator said injuries are documented on an incident report and in the resident's progress notes. 2. Record review of Resident #6's Face Sheet, dated 10/04/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6's diagnoses included Unspecified displaced fracture (pieces of the bone moved so much that a gap formed around the fracture) of the surgical neck (a bony narrowing at the proximal or nearer to the center end of the shaft of the upper arm or forelimb) of the right humorous subsequent encounter (receiving routine care) for fracture with routine healing, Urinary Tract Infection (infection when bacteria enter the urethra and infect the urinary tract), repeated falls, and Type II Diabetes (problem in the way the body regulates and uses sugar as a fuel). The Face Sheet revealed Resident #6's most recent hospital stay was 04/22/2023 through 04/27/2023. Record review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognitive response. Section G, Function Status, revealed Resident #6 required extensive assistance (resident involved in activity, staff provided weight-bearing support) with 2-persons or more with physical assist in transfers. Record review of Resident #6's Care Plan, dated 07/24/2023, revealed Resident #6 had a focus of on ADL Self Care Performance Deficit due to recent surgical repair of right humerus fracture due to fall from recliner at home on [DATE]. Resident #6's goal was to improve current level of transfers and 675645 Page 18 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0842 the interventions included Resident #6 required 1-person staff participation with transfers. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #6's Progress Note, dated 07/19/2023 at 10:28 a.m., documented by LVN N revealed Resident #6 had x-rays that determined an impression of acute fractures of the proximal right humerus per the PCP, who ordered an immobilizer and referral to orthopedic doctor. Record review of the progress notes dated on/or about 7/19/2023 revealed there was no documentation in the record of who Resident #6 reported pain in his right shoulder to or who reported the injury or complaint of pain to the nurse or who contacted the doctor. There was no documentation in the clinical progress notes that documented why x-rays were orders or what precursor occurred to warrant the need for x-rays. Residents Affected - Few Record review of Resident #6's Progress Note, dated 07/19/2023 at 7:14 p.m., documented by LVN N, revealed Resident #6 had new orders from the orthopedic doctor to wear a sling on right arm due to new right Humeral shaft fracture. Record review of the progress notes dated on/or about 7/19/2023 revealed there was no documentation in the record of details of how the fracture occurred or what event preceded prior to Resident #6's injury up to the x-ray results and the orthopedic doctor's orders. Record review revealed the was no incident report completed. During an interview on 10/04/2023 at 12:25 p.m., the DON said Resident #6 told her that CNA H had lifted him in a bear hug with CNA H's arms under his arm pits and lifted him up when Resident #6 heard two pops and his arm was broken. The DON said she could not remember the date or time, that she would have to look in her encrypted secure messages. The DON said she did not document the injury on an Incident Report because Resident #6 was x-rayed in house. The DON said the circumstances surrounding the incident should have been documented in Resident #6's progress notes and on an incident report as part of Resident #6's clinical records. During an interview on 10/11/2023 at 10:45 a.m., the DON said the information of the details of the incident when Resident #6 fractured his arm were in an encrypted secure messaging system. The DON said the information included who reported the injury to the nurse, the name of the nurse who contacted the doctor, and the date and time the doctor was contacted. The DON said the information was secure and she was not able to pull the information up for state surveyors to read and validate the information. The DON said she knew the facility policy reflected all incidents and injuries would be documented in the progress notes and on an incident report, but Resident #6's injury was not documented per policy. The DON said there was no way to access the encrypted message system to show the details of the Resident #6's incident. During an interview on 10/06/2023 at 11:39 a.m., the Administrator said Resident #6 complained of his right arm hurting and x-rays were ordered, which determined Resident #6's arm was fractured in two places. The Administrator said the incident should have been documented on an incident report. The Administrator said the facility had always documented with the use of the encrypted message system and the facility policy had never been questioned. During an interview on 10/11/2023 at 11:10 a.m., the Clinical Resource staff said the information in the encrypted messaging system was confidential and only available for employees of the facility. The Clinical Resource staff said the information in the messaging system contained conversations between employees of the facility that was private and not meant to be shared with others not associated with the facility. The Clinical Resource staff said she understood the information in the encrypted messaging system included documentation required to be recorded in residents' clinical records such as correspondences with the doctors, when injuries or incidents were reported, and other pertinent 675645 Page 19 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few information that detailed incident, accidents, and events was, but the information could not be shared. The Clinical Resource staff said the information should have been documented in the progress notes by the nurse or responsible party to be part of the resident's clinical record. Record review of the facility's policy, Documentation and Charting, dated 05/2007, revealed it was the policy of the facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 7. A legal record that protects the resident, physician, nurse, and the facility. 1. Accidents/Incidents: Documentation pertaining to accidents/incidents involving residents (as they apply) should include: A. The circumstances surrounding the accident/incident including the identity of any medical devices or equipment involved in the accident. B. Where the accident/incident took place. C. Date and time the accident/incident occurred. D. Name of witnesses and their account of the accident/incident. E. The resident's account of the accident/incident. F. The time the physician was notified. G. The date and time the family was notified. H. The condition of the resident, to include vital signs. I. Disposition of the resident. J. All pertinent observations. 675645 Page 20 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain infection control protocols to prevent infections for 1 of 1 resident (Resident #6) observed for catheter care needs. Residents Affected - Few CNA-A used a peri-care cleaning wipe and cleaned catheter tubing toward the resident and not away from toward catheter bag to clean catheter tubing. These failures place residents at risk for unnecessary infections while in the facility. Findings include: Record Review of the resident #6's Medical Records revealed: The Face Sheet dated 10/10/2023, revealed she was an 82 yr. old male, admitted to the facility on [DATE], with a Diagnoses of Urinary Tract Infection. Resident #6's MDS, dated [DATE], Section C (Cognitive Patterns) revealed a BIMS score of 15 (cognitively intact). Resident #6's most recent Care Plan revealed, Resident #6 has an Indwelling Catheter, to provide catheter care every shift and as needed. Resident # 14's Orders revealed CATHETER CARE EVERY SHIFT MONITOR. During an observation on 10/12/2023 at 9:51 the CNA A cleaned and wiped the catheter tubing toward Resident #6 instead of wiping away while observing catheter care. During an interview on 10/12/2023 at 9:51 AM the CNA A stated she had previously observed a lot of drainage that she believed to be pus and notified the nursing staff at that time. She also stated she did not feel she performed catheter care according to policies and procedures. During an interview on 10/12/2023 at 9:52 AM, Resident #6 stated he had been prone to UTI's most of his life and needed extra caution in pericare and catheter care. During an interview on 10/12/2023 at 10:06 AM, ADON C, stated the staff had notified her yesterday (10/11/2023) of pus being observed while performing pericare on Resident #6. She stated that labs and a culture were ordered and had not been resulted at this time of the interview. She stated the protocol for catheter care was to clean the tubing every day and if there was anything unusual or out of the ordinary, they were to report it to the charge nurse. The ADON C stated the proper way to clean the catheter tubing was to always wipe away from the resident and never towards. She stated if the staff were to wipe or clean toward the resident, it could cause a possible infection. In wiping or cleaning toward the resident, it could have possibly introduced bad bacteria into the urethra causing a UTI. ADON C stated the DON and ADON should monitor the agency staff, making sure their skills were accurate. During an interview on 10/12/2023 at 10:36 AM, DON D stated the agency staff had been at their facility before. She stated it was Agency Services that should have monitored the agency staff. She stated, there should have been a check off book but she had not been able to find it. She stated that the agency should have all of their check offs in a logbook and she could possibly get it from them. DON D stated she had spoken to ADON C about observing their skills, but she had not actually observed them performing their skills on the residents. She stated the facility policy and procedures were for the staff to always wipe away from the resident. DON D stated the negative impact would be a 675645 Page 21 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few possible infection if the catheter care was not done correctly. She stated she did not know what led to the failure, specifically, and maybe the CNA A was nervous. She stated her expectations were for catheter care to be done every shift and to perform it appropriately, and for staff to have followed Infection Control guidelines as well as using the proper procedure for catheter care. Record Review of facility policy titled Indwelling Urinary Catheter Care dated with the revised date of 01/2022. Policy: It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed for soiling. Purpose: To promote hygiene, comfort, and decrease the risk of infection for a resident with an indwelling urinary catheter. Procedure: .9 . using moistened disposable wipes, clean the catheter in a downward motion beginning at the urinary meatus (insertion point) and at least 4 inches down (from resident toward the collection bag). Use a clean portion of the washcloth or fresh disposable wipe for one cleansing motion. Record Review of facility policy titled Infection Prevention and Control Program dated with the revised date of 10/2022. Policy: The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight . Goals: Decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. Identify and correct problems relating to infection control. Ensure compliance with state and federal regulations related to infection control. 675645 Page 22 of 23 675645 10/12/2023 Mesa Springs Healthcare Center 7171 Buffalo Gap Rd Abilene, TX 79606

F 0880 Level of Harm - Minimal harm or potential for actual harm Promote individual residents rights and well-being while trying to prevent and control the spread of infection. Monitor personnel health and safety. Residents Affected - Few 675645 Page 23 of 23