Health inspection·September 4, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #2) reviewed for parenteral fluids The facility failed to ensure Resident #2's PICC line dressing was changed per physician orders. This failure could place residents with PICC line dressing at risk for potential infections.Findings included: Review of Resident #2's face sheet dated 09/04/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Staphylococcal arthritis, left knee, (infection of knee joint) sepsis (occurs when your immune system has a dangerous reaction to an infection) and methicillin susceptible staphylococcus aureus infection. Review of Resident #2's admission MDS dated [DATE] reflected she was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed to have the administration of IV medications. Review of Resident #2's comprehensive care plan reflected a focus area dated 08/15/2025 for Resident is receiving intravenous (IV) medication for acute treatment. Interventions included .monitor IV site every shift for signs of infiltration (leaking into the skin) . Review of Resident #2's consolidated physician orders dated 09/04/2025 reflected an order dated 08/15/2025 to change PICC line dressing every week and PRN. Review of Resident #2's TAR dated 08/2025 reflected an entry to change Resident #2's PICC line dressing every week. The dressing change was due 08/31/2025 and it was signed off as done by LVN B. Observation and interview on 09/04/2025 at 2:00 pm revealed Resident #2 in room in bed. Observation of PICC line dressing revealed it was dated 08/24/2025, with no signs of infection. Resident #2 stated the site did not hurt, and she stated she did not know when the dressing was changed last. In an interview on 09/04/2025 at 3:30 PM the DON stated after review of Resident #2's TAR that Resident #2's PICC line dressing change was signed off as completed on 08/31/2025 by LVN B. The DON stated LVN B obviously did not change the dressing if the dressing was dated 08/24/2025. The DON stated it was not appropriate to sign off on doing a treatment and not completing the task and it was her expectation that PICC line dressing be changed per MD orders to prevent infections. The DON provided LVN B's phone number and stated she would probably not answer because she was out of the country. Attempt to contact LVN B on 09/04/2025 at 3:45 PM revealed no answer and no voicemail on phone number provided. Review of the facility policy peripheral and midline IV dressing change dated 03/2022 reflected This purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised Maintain sterile dressing (transparent semi-permeable membrane dressing or sterile gauze) for all peripheral catheter sites. Change the dressing if it becomes damp, loosened or visibly soiled and: at least every 7 days. Residents Affected - Few Page 1 of 5 675887 675887 09/04/2025 St. Joseph Manor 2333 Manor Dr Bryan, TX 77802

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts reviewed (station 1 medication cart). The facility failed to ensure on 09/04/2025 that expired medications (one bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025) were removed from the station one medication cart once expired. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications.Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025. In an interview on 09/04/2025 at 2:35 pm, LVN A stated it was the medication aide's responsibility to ensure expired medication are not on the cart, but they currently did not have one and since he was passing medications on the cart it was his responsibility to ensure the expired drugs were removed to ensure the residents do not get expired medications which could be less effective. In an interview on 09/04/2025 at 3:00 PM the DON stated both medications were expired and were removed from the medication carts. The DON stated the staff should check the medication prior to administration to ensure the medications are not expired. Review of the facility's policy medication labeling, and storage dated 02/2023 reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 675887 Page 2 of 5 675887 09/04/2025 St. Joseph Manor 2333 Manor Dr Bryan, TX 77802

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure storage of drugs and biologicals used in the facility for 1 of 4 medication carts reviewed (station 1 medication cart). The facility failed to ensure medications were stored and used in an orderly manner to ensure the liquid did not run down the sides of the bottle causing it to be sticky on the sides of the bottle and the bottle was stuck to the bottom of the medication cart drawer. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications. Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of lactulose in the medication cart drawer which was sticky on the sides of the bottle and the bottle was stuck to bottom of cart. In an interview on 09/04/2025 at 2:35 pm, LVN A stated the lactulose bottle was sticky and should have been cleaned. In an interview on 09/04/2025 at 3:00 PM the DON stated that staff should check the medication prior to administration to ensure the medications are stored properly. Review of the facility's policy medication labeling, and storage dated 02/2023 reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 675887 Page 3 of 5 675887 09/04/2025 St. Joseph Manor 2333 Manor Dr Bryan, TX 77802

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #1) residents reviewed for infection control practices. The facility failed to ensure LVN A followed standard precautions during wound care on 09/04/2025 for Resident #1's RLE stasis ulcer, when he failed to perform hand hygiene prior to wound care, and between glove changes and failed to use gloves that were not contaminated. This failure could place residents at risk for developing wound infections and risk for healthcare associated cross-contamination and infections.Findings included: Review of Resident #1's face sheet dated 09/04/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: alcohol dependence, major depression and muscle wasting. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Resident #1 was further assessed to have applications of ointment/medications to other than feet. Review of Resident #1's comprehensive care plan reflected a focus area dated 03/23/2025 for Potential for impaired skin integrity. Interventions included .evaluate skin integrity, provide skin care per facility guidelines . Review of Resident #1's consolidated physician orders dated 09/04/2025 reflected an order dated 08/29/2025 for non-pressure wound RLE cleanse with normal saline or wound cleanser, pat dry with gauze, cover wound bed with xeroform and cover with boarder gauze (dressing) one time day every Monday, Wednesday and Friday. Observation on 09/04/2025 at 1:30 pm revealed LVN A outside of Resident #1's room to prepare for wound care. LVN A gathered his supplies and placed them on a piece of wax paper. LVN A took a hand full of gloves and placed them in the right leg pocket of his scrubs. LVN A then took the wax paper with his treatment supplies into Resident #1's room and placed them on an overbed table. LVN A did not clean the table prior to placing the treatment supplies. Without washing his hands LVN A pulled a pair of gloves from the leg pocket of his scrubs and donned the gloves. LVN A removed the dressing from Resident #1's RLE and placed the dirty dressing in the trash. LVN A removed his gloves and without hand hygiene donned another pair of gloves that he pulled out of his scrub pocket. LVN A cleaned the wound with normal saline and changed his gloves again with gloves from his pocket without hand hygiene. LVN A then applied the clean dressing with the same gloves. In an interview on 09/04/2025 at 1:40 pm LVN A stated he did not wash his hands and should have washed his hands prior to the treatment and during glove changes. He stated he did not clean the table in Resident #1's room prior to bringing in his treatment supplies and stated, they were on wax paper. LVN A stated he was not sure if he had Santi-wipes on the cart. He stated failure to perform hand hygiene could cause cross contamination and possible infection. In an interview on 09/04/2025 at 3:30 pm the DON stated LVN A should have washed his hand prior to wound care and between glove changes. The DON stated the pocket of his scrub pants was not an appropriate place to put clean gloves because they become contaminated and should not be used. She stated she expected staff to follow infection control procedures during wound care. Review of the facility policy handwashing/hand hygiene dated 10/2023 reflected This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. indications for Hand Hygiene. Hand hygiene is indicated: immediately before touching a resident; before performing an aseptic Residents Affected - Few 675887 Page 4 of 5 675887 09/04/2025 St. Joseph Manor 2333 Manor Dr Bryan, TX 77802

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few task (for example, placing an indwelling device or handling an invasive medical device); after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. Review of the facility's policy wound care dated 10/2020 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 675887 Page 5 of 5