Health inspection·July 14, 2025

F 0583 Keep residents' personal and medical records private and confidential. 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 review, the facility failed ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fourteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of thirty residents reviewed for privacy and confidentiality. 1. The facility failed to ensure LVN C pulled the privacy curtain while suctioning (mechanical aspiration of pulmonary secretions to clear the airway) Resident #1 on 07/12/2025. 2. The facility failed to ensure LVN C closed the door while suctioning Resident #2 on 07/12/2025. 3. The facility failed to ensure LVN D did not leave Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13's medical information on top of his cart on 07/12/2025. 4. The facility failed to ensure RN E closed, locked, or minimized his laptop's monitor, thus, showing Resident #14's medical information on 07/13/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck to allow air to fill the lungs). Record review of Resident #1's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 05/07/2025, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:10 AM revealed LVN C entered Resident #1's room to check on the resident. The resident signaled LVN C that she wanted to be suctioned. LVN C sanitized her hands, put on a pair of gloves, and put on a gown. She proceeded to suction the resident without pulling the privacy curtain. Resident #1 could not be seen from the hallway but could be seen by Resident #2, resident's roommate, who was sitting at the side of her bed and facing towards Resident #1's bed. Observation and attempted interview on 07/12/2025 at 10:54 AM, revealed Resident #1 did not reply when asked if it was okay for her that her roommate could see what the nurse was doing to her. 2. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident Residents Affected - Some Page 1 of 12 675779 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:25 AM revealed after LVN C was done suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to suction Resident #2 without closing the door or pulling the privacy curtain. Resident #2 could be seen from the hallway and the treatment being done could be seen from the hallway and her roommate. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she guessed she needed to close the door and pull the privacy curtain every time care or treatment was being done for the residents, not just for Resident #1 and Resident #2, to provide privacy. She said somebody from the hallway might see that they were being suctioned and the residents might be embarrassed. In an interview on 07/12/2025 on 10:54 AM, Resident #2 stated the nurses, not only LVN C, would not close the door or pull the privacy curtain when they were treating them. She said she already got used to it, but a change would be nice so that others would not see that a tube was being inserted in her throat. 3. Record review of Resident #3's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #3's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #3's Vital Signs, dated 07/12/2025, reflected BP: 98/60 mmHg, Temp: 97.6, Pulse: 86, Respiration: 20, O2 sats: 99.0%. Record review of Resident #4's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #4's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #4's Vital Signs, dated 07/12/2025, reflected BP: 100/65 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #5's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #5's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #5's Vital Signs, dated 07/12/2025, reflected BP: 81/52 mmHg, Temp: 97.5, Pulse: 80, Respiration: 21, O2 sats: 99.0%. Record review of Resident #6's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #6's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #6's Vital Signs, dated 07/12/2025, reflected BP: 105/68 mmHg, Temp: 97.5, Pulse: 87, Respiration: 21, O2 sats: 100.0%. Record review of Resident #7's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #7's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #7's Vital Signs, dated 07/12/2025, reflected BP: 97/61 mmHg, Temp: 97.6, Pulse: 57, Respiration: 20, O2 sats: 100.0%. Record review of Resident #8's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #8's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 8 hours. Record review of Resident #8's Vital Signs, dated 07/12/2025, reflected BP: 141/84 mmHg, Temp: 97.5, Pulse: 100, Respiration: 24, O2 sats: 99.0%. Record review of Resident #9's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the 675779 Page 2 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #9's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #9's Vital Signs, dated 07/12/2025, reflected BP: 129/72 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #10's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #10's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours. Record review of Resident #10's Vital Signs, dated 07/12/2025, reflected BP: 99/68 mmHg, Temp: 97.4, Pulse: 54, Respiration: 16, O2 sats: 100.0%. Record review of Resident 11's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #11's Physician Order, dated 07/03/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #11's Vital Signs, dated 07/12/2025, reflected BP: 109/69 mmHg, Temp: 97.5, Pulse: 97, Respiration: 20, O2 sats: 97.2%. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #12's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #12's Vital Signs, dated 07/12/2025, reflected BP: 89/56 mmHg, Temp: 97.1, Pulse: 64, Respiration: 18, O2 sats: 99.0%. Record review of Resident #13's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #13's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #13's Vital Signs, dated 07/12/2025, reflected BP: 122/80 mmHg, Temp: 97.7, Pulse: 68, Respiration: 17, O2 sats: 98.0%. Observation on 07/12/2025 at 10:19 AM revealed a clipboard was on top of a nurse's cart. On the clipboard were the names of the residents, their room numbers, and their respective vital signs (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation). In an interview on 07/12/2025 at 10:22 AM, LVN D stated he went to attend to one of the residents that was why he left his cart. He said he should have flipped the clipboard before leaving his cart because the vital signs were medical information and should be secured and not exposed for everybody to see. He said it was a HIPAA violation and the information should be confidential. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the doors should be closed or the privacy pulled when providing treatment to the residents to promote dignity and privacy. She said Resident #1 and Resident #2 might be roommates but they are still entitled for privacy and dignity. She said other staff, other residents, or even visitors could see the treatment being done and might speculate the medical condition of the residents. She said it did not matter if the residents cared or not, the treatment should be done in privacy. ADON A said the staff had been trained about HIPAA over and over again and she did not know why the incident still happened. She said it was a HIPAA violation to leave the residents' health information out for everyone to see. She said the expectation was for the staff to provide privacy during treatment and to secure the residents' medical information. She said the vital signs were examples of medical information. She said she already started an in-service about dignity and privacy as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. 4. Record review of Resident #14's Face Sheet, dated 07/13/2025, reflected a [AGE] year-old male who was 675779 Page 3 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath). Record review of Resident #14's Comprehensive MDS Assessment, dated 05/01/2025, reflected the resident had moderated impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had COPD and emphysema and was on oxygen therapy. Record review of Resident #14's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had oxygen therapy and the interventions were administer oxygen and medications as ordered. Record review of Resident #14's Physician Order, dated 07/10/2025, reflected Oxygen LPM: 1-5 LPM to maintain O2 sats greater than 92%. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Symbicort Inhalation Aerosol 80 - 4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for COPD, emphysema. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Ipratropium Bromide Nasal Solution 0.03 % (Ipratropium Bromide (Nasal)) 2 spray in both nostrils two times a day for nasal congestion. Record review of Resident #14's Physician Order, dated 01/29/2025, reflected Artificial Tears Ophthalmic Solution 0.1-0.3 % (Dextran 70-Hypromellose) Instill 2 drop in both eyes every 4 hours as needed for eye itching. Record review of Resident #14's Physician Order, dated 05/13/2025, reflected Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 8 hours as needed for pain, ** hold for sedation Not to exceed 3 gms APAP in 24 hour period. Observation on 07/13/2025 at 10:00 AM revealed a cart was parked at the nurses' station and was facing the hallway. On top of the cart was an open laptop and displayed Resident #14's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, emergency instructions, and physician orders. Also seen from the computer were physician orders for the resident. The screen of the computer was facing the hallway. It was also observed that RN E was sitting inside the nurses' station. In an interview on 07/13/2025 at 10:02 AM, RN E stated he was the one using the computer. He saw that his monitor was open and Resident #14's medical information. He said he was not aware that he left his computer open and did not minimize the monitor of the computer. He said the information should be secured and only the resident, family members, and providers could see the resident's information. He said he went inside the nurses' station because he needed to notify a doctor about some laboratory result. He said he would make sure to that his computer was close every time he would leave it. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the privacy issues and ADON A already did an in-service about privacy during treatment and confidentiality of medical records. She said the expectation was for the staff to make sure that the residents were provided privacy during any treatment to prevent humiliation and to secure their medical records so that unauthorized individuals would not see the residents' medical information. She said they would continue to remind the staff about providing privacy and confidentiality. In an interview on 07/14/2025 at 1:00 PM, The DON stated she already knew about the incidents of not providing privacy and not securing the medical records. She said the door should be closed or the privacy curtain pulled when doing a medical procedure so other people would not see what was being done for the resident. She said if confidential information were exposed, non-nursing staff, other resident, and visitors could be able to see it. She said all staff, including her, were expected to provide full privacy during treatment and confidentiality of all the residents' medical information. She said providing privacy is a form of respect to the residents that entrusted their care to the facility. She said ADON A already started the in-service about privacy and confidentiality but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy, RESIDENT RIGHTS 675779 Page 4 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0583 Level of Harm - Minimal harm or potential for actual harm undated, revealed The resident has a right to a dignified existence . Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . 1. Personal privacy includes accommodations, medical treatment . 3. The resident has a right to secure and confidential personal and medical records. Residents Affected - Some 675779 Page 5 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

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 provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #12) of five residents reviewed for feeding tube (a process of providing nutrition directly to the stomach). The facility failed to ensure LVN C checked Resident #12's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering the resident's medications and failed to administer the resident's medication one by one on 07/12/2025. These failures could place residents with g-tubes at risk for aspiration and drug-to-drug interaction. Findings included: Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident required tube feeding and one of the interventions was to check for tube placement and gastric contents/residual volume. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65ml/hr, flush 200 ml H2O q 4 hrs. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check placement prior to feeding and medication administration. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check residual before medications and feedings; return contents after each check. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet via PEG-Tube (a flexible feeding tube inserted directly to the stomach) every 6 hours for pain, hold for sedation. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet via PEG-Tube every 24 hours as needed for constipation. Record review of Resident #12's Physician Order on 07/12/2025 reflected no order that her medications could be cocktailed (could be given altogether at the same time). Observation and interview on 07/12/2025 at 10:38 AM revealed LVN D was preparing Resident #12's medication on his cart. LVN D said he wound administer the resident's 11:00 AM medication. He went inside the room with one small plastic cup with crushed medications in it and a big plastic cup with some water in it and placed them on the resident's overbed table. When inside the room, he incorporated some water on the small cup to dissolve the crushed medications. LVN D sanitized his hands and put on a pair of gloves. He took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. He raised the bed, lifted the resident's gown to expose the g-tube site. He pulled the plunger of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, he poured the dissolved medication. He did not check for the placement of the g-tube and the gastric content before flushing and administering the medication. After pouring the medications, he flushed the g-tube, and detached the syringe. He cleaned the syringe, took off his gloves, and sanitized his hands. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he forgot to check for the g-tube placement and to check the residual of both residents. He said the right procedure was to check the placement and the residual every medication administration. He said g-tube placement was checked to ensure the tube was correctly positioned. He said the residual was also checked before administering medications to check if the stomach could accommodate the medications and fluid to be given and 675779 Page 6 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to prevent aspiration. He said he knew he needed to check for the placement and residual but failed to do so because he was nervous. He said he administered Resident #12's midday medications, which were oxycodone and docusate. He said he crushed the medications and put them both in a single cup. He said he was not sure if the resident had an order that would say her medications could be cocktailed. He said if there was no order to cocktail, then the medications should have been administered one by one. He said the reason for giving one by one was to prevent drug-to-drug interaction or drug-to-formula interaction that could impede the medication's effectiveness. In an interview on 07/12/2025 at 3:33 PM, ADON A stated both the gastric residual and the g-tube placement should be checked before administering the medications. She said g-tube placement should be checked to ensure the g-tube was in the right place. She said even though the residents were on continuous feeding, the placement should still be checked. She said the gastric residual was also checked to prevent aspiration and also to assess if the rate of the formula should be modified. She said the expectation was for the staff to check for g-tube placement and to check for gastric residual every time they administer medications. She said there were two ways to check for placement, one would be through auscultation and the other one was through aspiration of the gastric content. She said the second one could be used to check for placement and at the same time to check for the residual. She said if there was no order that the medications could be mixed, then the medications should be given one at a time to ensure there were no interactions between the drug. She said, as one of the ADONs, she was responsible in ensuring that the staff were following the procedures in administering medications via g-tube. She said she already started an in-service about g-tube as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if they do not understand something about the in-service. She said aside from the in-service, they would randomly check the staff's medication administration via gtube. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the issues pertaining to g-tube and ADON A already started an in-service relating to g-tube. She said the expectation was for the staff to follow the right procedures in administering medications via g-tube. She said she was not a clinician but she would coordinate with the DON to continually remind the staff about providing proper care for residents with g-tube. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the incidents of not checking the placement of the g-tube and not checking for the residual. She said the placement should be checked to ensure the medications and the fluid would enter the stomach and not the lungs that could cause aspirations. She said the gastric residual should be checked before medication administration to assess if the resident's stomach was emptying properly. She said the medications should be given one at a time, if there was no order to cocktail them, so that if there were reactions, they could pinpoint what medication were causing the reactions. She said the expectation was for the staff to follow the right procedure for medication administration via g-tube. She said ADON A already started the in-service about g-tube but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy ENTERAL (food or medication administration directly through the digestive system) MEDICATION ADMINISTRATION Pharmacy Policy & Procedure Manual revised 01/25/2013 revealed 6. Check the placement of the tube by aspiration of contents or auscultation . 8. Administer one medication at a time. Record review of the facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual revised February 13, 2007 revealed Procedure . 7. Perform intermittent feeding . b. Aspirate gastric contents with a 60 ml syringe and if the residual is less than 50%. 675779 Page 7 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

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 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 four (Resident #1, Resident #2, Resident #12 and Resident #15) of twenty residents reviewed for infection control. 1. The facility failed to ensure LVN C did not re-use a gown to provide treatment for some residents at hall 400 on 07/12/2025. 2. The facility failed to ensure LVN C changed her gown in between Resident #1 and Resident #2 who were with tracheostomy on 07/12/2025. 3. The facility failed to ensure LVN C changed her gloves and performed hand hygiene when changing Resident #2's tracheostomy dressing on 07/12/2025. 4. The facility failed to ensure LVN D wore a gown while administering Resident #12's medication via g-tube on 07/12/2025 5. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinent care to Resident #15 on 07/12/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and gastrostomy (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake < 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation and interview on 07/12/2025 starting at 9:05 AM revealed gowns were hanging on some of the rooms in hall 400. One of the rooms with a gown hanging on the door was for Resident #1 and Resident #2. LVN C went inside the residents' room, took the gown hanging on the door, and proceeded to do a medical procedure. She said she would hang her gown after use and would just discard the gowns at the end of her shift. She said the other gowns hanging on the doors of the other residents were also hers. 2. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy and gastrostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Residents Affected - Some 675779 Page 8 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and required tube feeding. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake < 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to ensure that trach ties are secured at all times. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation on 07/12/2025 at 9:10 AM revealed LVN C entered Resident #1 and Resident #2's room to check on the residents. Resident #1 signaled LVN C that she wanted to be suctioned. She sanitized her hands, put on a pair of gloves, and donned the gown that was hanging on the residents' door. After suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to prepare Resident #2's suction machine without changing the gown that she used to suction Resident #1. When she was about to suction Resident #2, she noticed that the suction machine did not have a canister. She said she would get a canister and would come back. She removed her gown and hung it on the door. She came back with the canister and connected it to the suction machine. When the suction machine was ready, she put on the gown that she hung on the door, and suctioned Resident #2. In an interview on 07/12/2025 at 10:54 AM, Resident #2 stated the staff that would care for her did not always put on a gown. Some did but some did not. 3. Observation on 07/12/2025 at 9:35 AM revealed when LVN C was done suctioning Resident #2, she checked the resident's dressing on her tracheostomy. She told the resident that she would change the dressing. She removed the soiled dressing from the tracheostomy, took a new dressing, and put it on the resident's tracheostomy. She did not change her gloves and perform hand hygiene after suctioning the resident, before inspecting the stoma, and before touching the new dressing. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she should have changed her gown after suctioning Resident #1 and before suctioning Resident #2 to prevent transfer of microorganism from one resident to another. She said she might get some germs from Resident #1 and would unnecessarily give it to Resident #2. She said the gowns should be disposed after every use and not re-used to reduce reproduction of microorganisms and its spread. She said she should have changed her gloves before touching the new dressing because her gloves were already dirtied when she touched the soiled dressing. She said her actions could cause probable infections and she would be mindful the next time she provided treatment to residents on enhanced barrier precautions. 4. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to gtube because the resident had a g-tube. Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment 675779 Page 9 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident was on enhanced barrier precautions and one of the interventions was to don (put on) gloves and gowns . during enteral feeding . or other high-contact activity. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected Enteral Feed Order every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65 ml/hr, flush 200 ml H2O q 4 hrs. Observation on 07/12/2025 at 10:38 AM revealed LVN D was preparing resident #12's medication via g-tube. After preparing the medications, LVN D went inside the room and proceeded to administer the medications via g-tube. He did not wear a gown while administering the medications. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he should wear a gown during medication administration if the resident had a g-tube because the resident had an indwelling device and was on enhanced barrier precautions. He said the purpose of the gown was to minimize transfer of microorganism since the g-tube site could be a potential entry of microorganism. He said he did had an in-service about infection control including enhanced barrier protection but could not remember when. 5. Record review of Resident #15's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #15's Comprehensive MDS Assessment, dated 06/25/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was provide pericare after each incontinent episode. Record review of Resident #15's Comprehensive Care Plane, dated 07/12/2025, reflected the resident had an indwelling catheter and one of the interventions was to position the catheter and tubing below the level of the bladder. Record review of resident #15's Physician Order, dated 07/12/2025, reflected Provide catheter care. Observation on 07/12/2025 at 11:39 AM revealed CNA F was about to provide incontinent care to Resident #15 prior to wound care. She washed her hands, wore a gown and gloves, and proceeded with incontinent care. She positioned herself on the left side of the resident and placed a plastic bag, with a brief and beddings inside, on the foot part of the bed. She unfastened the resident's brief and pushed it between the resident's thighs. She changed her gloves and sanitized her hands. She pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. She did it five times. After cleaning the perineal area, she instructed and assisted the resident to roll towards the right side. Before rolling the resident, CNA F adjusted the resident's catheter. After adjusting the catheter, she pulled the brief from inside the plastic bag, and placed it beside the resident. She did not change her gloves before touching the new brief. CNA F rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief and threw it on the trash can. After throwing the soiled brief, she pulled the new brief from the resident's side and placed it under the resident. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She then instructed and assisted the resident to roll to the other side so the WCN could do the wound care before fastening the brief. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the staff must wear a gown every time they provide care or treatment to residents with tracheostomy, g-tube, catheter, colostomy, and with open wound. She said EBP is a new thing but staff were expected to adhere to the EBP policy. She said she was made aware by LVN C and LVN D on the issues of EBP. She said LVN C should not re-use the gown and should have changed her gown her gown from one resident to another. She said the reason for that was to prevent cross contamination and probable infection. She said if one resident had an infection or had any undesirable microorganism, she 675779 Page 10 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would transfer it to the next resident that she would care for. She said the disposable gowns were not re-used because it could already be contaminated by bacteria or viruses. She said LVN C should have changed her gloves when she took off the dressing on the resident's tracheostomy because her gloves were already soiled. She said the same reason why CNA F changed her gloves after touching the catheter and after cleaning the resident's bottom. She said LVN D should have worn a gown when he administered medications via g-tube because the staff might introduce any germs to the resident's g-tube and also to protect the staff from any secretions from the resident. She said, as one of the ADONs, she was responsible in ensuring that the staff were compliant with the policy and procedures of infection control. She said she already started an in-service about infection control, hand hygiene, and EBP as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. She said she would randomly check the staff if they were practicing infection control. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the infection control issues and ADON A already did an in-service about it. She said she the expectation was for the staff to be mindful in preventing the development of infection in the facility and to their family, as well. She said she was not a clinician but would coordinate with the DON to continually remind the staff about preventing infection control. In an interview on 07/13/2025 at 11:39 AM, CNA F stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she should have changed her gloves after touching Resident #15's catheter and after cleaning her bottom because her gloves became dirty on both incidents, thus rendering the new brief to be dirty, too. She said on top of changing the gloves, she should also sanitize her hands every time she would change her gloves. She said she would be mindful the next time she does incontinent care to change her gloves after touching something soiled during incontinent care. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the infection control issues. She said all the issues observed would contribute to cross contamination and development of infection. She said gowns should never be re-used, staff should change their gowns in between residents, staff should wear gown if the resident was on EBP, and staff should change their gloves after handling something soiled. She said the expectation was for the staff to do what was right to inhibit the development and spread of infection. She said with regards to Resident #16' catheter, the resident just came back from the hospital and she had it when she was admitted back to the facility on [DATE]. She said she already did the orders and the care plan regarding her catheter. Record review of facility policy, Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual updated 03/2024 revealed Hand hygiene continues to be the primary means of preventing the transmission of infection . Before and after changing a dressing . After contact with a resident's mucous membranes and body fluids or excretions . After handling soiled or used linens, dressings, bedpans, catheters and urinals . After removing gloves . Gloving . To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Record review of facility policy, Enhanced Barrier Precautions undated, revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . EBP are used . to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of 675779 Page 11 of 12 675779 07/14/2025 Marine Creek Nursing and Rehabilitation 3600 Angle Ave Fort Worth, TX 76106

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some MDROs to staff hands and clothing . A single set of PPE cannot be used for more than 1 patient . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, andTracheostomies . Donning PPE for Residents on EBP Based on Activity Provided . Administer medications enterally . must don gloves and gown. Record review of facility policy, Perineal Care Female Nursing Policy and Procedure Manual revised December 08,2009 revealed Purpose: To clean the female perineum without contaminating the urethral area . J. Cleaning the rectal and buttocks area . b. Gently wash the rectal area and buttocks . c. Change gloves. Record review of facility policy, Catheter Care Nursing Policy and Procedure Manual, undated revealed Procedure . 14. Hold catheter tubing . 19. Remove gloves. 675779 Page 12 of 12