Health inspection·March 19, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #15, Resident #50, and Resident #52) of 15 resident reviewed for dignity. The facility failed to ensure Resident #52 received their meal with other residents at their table. The facility failed to ensure that Resident #15 and Resident # 50 received their meal during the dining room meal pass while other dining room residents were receiving their lunch meals. This failure could place residents at risk of diminished dignity and affect their quality of life. Findings included: Record review of Resident #15's admission face sheet dated 3/18/25 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident # 15 had diagnoses of respiratory failure, sepsis (a life threatening infection), pneumonitis due to inhalation of food and vomit (lung inflammation, swelling, and irritation), protein calorie malnutrition (a condition that occurs when a person does not consume enough protein and calories to meet their body's needs), Alzheimer's disease, need for assistance with personal care, lack of coordination, abnormalities of gait and mobility, bronchitis (inflammation of the lining of the bronchial tubes which carry air to the lungs), benign prostatic hyperplasia (prostate gland enlargement), hyperlipidemia (increased fat particles in the blood), and atherosclerotic heart disease (damage or disease to the hearts major blood vessels). Review of Resident # 15's quarterly MDS dated [DATE] reflected a BIMS score of 3 indicating severe cognitive impairment. Further review indicated Resident # 15 required supervision or touching assistance for eating. Review of Resident # 15's care plan dated 1/11/25 reflected an ADL self-care performance deficit related to dementia with intervention of eating requires staff x1. Record review of Resident #50's admission face sheet 3/19/25 revealed a [AGE] year-old female admitted on [DATE]. Resident # 50 had diagnoses of hypertension (elevated blood pressure), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), hyperlipidemia (increased fat particles in the blood), chronic atrial fibrillation (irregular rapid heart rate), intellectual disabilities, need for assistance with personal care, mild cognitive Page 1 of 35 675913 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0550 Level of Harm - Minimal harm or potential for actual harm impairment, lack of coordination, abnormalities of gait and mobility, morbid obesity, and speech disturbances. Review of Resident # 50's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Further review indicated Resident # 50 required set up or clean up assistance for eating. Residents Affected - Few Review of Resident # 50's care plan dated 4/28/24 reflected an ADL self-care performance deficit related to impaired cognition and morbid obesity. Interventions include eating supervision as needed. Chooses and prefers to eat meals in bed with HOB elevated encouraged and meal tray on abdomen, not on bedside table. Record review of Resident # 52's admission face sheet dated 3/19/25 reflected an [AGE] year-old female admitted on [DATE]. Resident # 52 had diagnoses of senile degeneration of brain (a group of conditions that cause a progressive decline in cognitive function also called dementia), type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar levels), chronic pain syndrome, hypothyroidism (underactive thyroid), hyperlipidemia (increased fat particles in the blood), lack of coordination, need for assistance with personal care, major depressive disorder (clinical depression), anxiety disorder, hypertension (elevated blood pressure), dementia (a group of conditions that cause a progressive decline in cognitive function), and polyneuropathy in disease (a peripheral nerve disorder that cause multiple nerves throughout the body to malfunction simultaneously). Review of Resident # 52's comprehensive MDS dated [DATE] reflected a BIMS score of 5 indicating severe cognition impairment. Further review revealed partial to moderate assistance required for eating. Review of Resident # 52's care plan dated 1/9/24 reflected a n ADL self-care performance deficit related to Alzheimer's, confusion, and dementia. Interventions include for eating supervision as needed. Observation of dining room lunch meal service on 3/18/25 at 12:00 PM revealed that Resident # 15 was served his meal tray off the hall tray meal cart at 12:00 PM. Resident # 15 was sitting at a table with his family member. Resident # 50 was served her meal tray off the hall tray meal cart at 12:23 PM. Resident # 50 was sitting at a table alone. Resident # 52 was served her meal tray off the hall tray meal cart at 12:37 PM. Resident # 52 was sitting at a table with 3 other residents. No other dining room residents were served until the dining room meal service began at 12:50 PM. Interview with Resident # 50 on 3/18/25 at 12:50 PM, she stated she normally eats in her room but decided to come to the dining room today. Resident stated her lunch was very good today and she planned to ask for another helping of the vegetable. Interviews with Resident # 15 and Resident # 52 was attempted on 3/18/25 at 1:00 PM but was unsuccessful due to cognition status. Interview on 3/19/25 at 3:31 PM with the DON revealed it was best practice that all residents are served meals at the same time. The DON stated sometimes that just does not happen if the resident chooses to eat in the dining room but usually eats in their room. The DON stated she needs to work with her ADM and the DM for better communication when this happens. The DON stated she was unsure if this could be a dignity issue. The DON stated it was everyone's responsibility since everyone helps 675913 Page 2 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0550 with meal service. Level of Harm - Minimal harm or potential for actual harm Interview on 3/19/25 at 5:11 PM with the ADM revealed it was his expectation that each table be completely served before moving to the next table. The ADM stated nursing and dietary were supposed to be communicating which residents were coming to the dining room for their meals. The ADM stated it was the responsibility of nursing staff and the DM to ensure communication occurred. Residents Affected - Few Review of the Dining room etiquette policy undated reflected: 4. Please make sure that a nurse checks the trays before they are served to the resident, having a second set of eyes to verify tray accuracy helps to avoid errors. Please serve all residents at one table before moving to another table. Review of Resident Rights undated reflected: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. 675913 Page 3 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #239) reviewed for comprehensive care plans. The facility failed to implement Resident # 239's care plan instructions of having fall mat in place beside bed. This failure could place residents at risk for not receiving proper care and services due to care plans instructions not being implemented. Findings included: Record review of Resident # 239's admission face sheet dated 3/18/25 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of toxic encephalopathy (a neurological disorder that occurs when someone is exposed to toxic substances), malignant neoplasm of temporal lobe (cancer of the temporal lobe of the brain), major depressive disorder (clinical depression), parkinsonism (a disorder of the central nervous system that affects movement often including tremors), hypertension (elevated blood pressure), GERD (a digestive disease in which stomach acid or bile irritates the food pipe lining), and cerebral edema (buildup of fluid in the brain causing increased pressure ). Review of Resident # 239's admission MDS reflected a BIMS score and functional abilities data had not been recorded. The comprehensive MDS was in progress at time of survey. Review of Resident # 239's care plan dated 3/17/25 reflected resident was at risk for falls related to unsteady gait, combative with staff when trying to redirect. Interventions of bed in lowest position with fall mat in place. Anticipate and meet resident's needs. Observation on 3/17/25 at 1:33 PM revealed Resident # 239 in bed neatly groomed. Resident room appeared neat and clean. Resident was very sleepy and hard to arouse. The resident was unable to answer any of the surveyor's questions. The Fall mat was folded up by the head of the bed. Bed in lowest position. Observation on 3/18/25 at 11:28 AM revealed Resident # 239 asleep in bed. The Fall mat was pushed up under the bed. The mattress inclined so resident was sleeping in a reclining position. Bed was not in the lowest position. Observation on 3/18/25 at 2:38 PM revealed Resident # 239 in bed napping. Resident mouthed he was ok when asked if he was ok. Resident shook head no when asked if he needed anything. The Fall mat was folded up beside the bed between the bedside table and wheelchair. The mattress inclined so resident was sitting in a reclining position. Bed was not in the lowest position. Observation on 3/19/25 at 9:45 AM revealed Resident # 239 in bed asleep. Resident's family member was sitting in a chair in the resident's room reading a paper. The Fall mat was folded up by the 675913 Page 4 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0656 bedside table. Level of Harm - Minimal harm or potential for actual harm Interview on 3/19/25 at 3:20 PM CNA I stated Resident # 239 has a fall mat beside the bed and the bed was kept in low position. CNA I stated the resident never gets out of bed as he was terminal. Residents Affected - Few Interview on 3/19/25 at 3:31 PM with the DON revealed that hospice brought the blue fall mat, and the facility prefers the brown mats that have a suction to keep them in place. The DON stated fall mats were supposed to remain on the floor beside the resident's bed when a resident is in bed. The DON could not provide answer as to why Resident # 239's fall mat kept getting moved. The DON stated residents need orders for fall mats. The DON stated if a fall mat was not on the floor beside the bed and resident fell it could cause an injury or make an injury more significant. Interview on 3/19/25 at 5:11 PM with ADM revealed if fall mats were not in place then that defeats the purpose of the fall mat. The ADM stated that his expectation was that fall mats should be in place on the floor beside the bed if the resident was in bed. The ADM stated it could negatively affect residents in that a resident could sustain a more significant injury from a fall if the fall mat was not in place. The ADM stated that the CNA's and the charge nurses were responsible for making sure fall mats were in place. Review of the Comprehensive Care Planning policy undated reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident [NAME] records, baseline care plans, and task listings. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. 675913 Page 5 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 (Resident #47, Resident #59, and Resident #70) of 8 residents reviewed for care plans. The facility failed to ensure Resident #47's, #59's, and #70's care plan was revised to reflect the change of activity level. This failure placed residents at risk of not having their needs reviewed and revised when needed to ensure appropriate care is being provided. Findings include: Resident #47 Review of Resident #47's face sheet, dated, 03/19/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #47 had diagnoses which included cerebral palsy, unspecified (caused by changes in the developing brain that disrupt its ability to control movement and maintain posture and balance), severe intellectual disabilities ( major delays in development- average mental age of between 3 and 6 years, and individuals have limited communication skills), and autistic disorder ( a condition characterized by difficulties in social interaction and communication, along with restricted behaviors and interests). Review of Resident #47's Annual MDS, dated [DATE], reflected Resident #47was unable to complete the BIMS. Resident #47 had poor short- and long-term memory recall. She had unclear speech. Resident #47 had disorganized thinking (rambling or irrelevant conversation) and was easily distracted. Resident #47's activity preference was bed bath, snacks between meals, staying up past 8:00 PM and family involved in care decisions. Review of Resident #47's Quarterly MDS, dated [DATE], Resident #47 was unable to complete the BIMS. Resident #47 had poor short- and long-term memory recall. She did not speak. Resident #47 declined to respond to concern of social isolation. Resident #47 had impaired cognitive function and impaired thought process related to intellectual disabilities. Resident #47 had nonverbal communication. Interventions: (initiated on 10/10/2024)- Engage Resident #47 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Resident #47 had a communication impairment related to intellectual disabilities. Interventions: (initiated on 10/10/2024) Provide a program of activities that accommodates Resident #47's communication abilities. Review of Resident #47's One-On-One Activity Participation Record from January 2025 to March 2025, reflected Resident #47 was to receive one-on-one activities three times per week. Resident #47 would fall asleep when assisted out of her room . Resident #47 was assessed by the activity department on the one-on one Activity Participation Record from January 2025 to March 2025; she needed one-on-one activities . Her activity preference was watching cartoons and, listening to music (did not specify 675913 Page 6 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0657 what type of music). Level of Harm - Minimal harm or potential for actual harm In an interview on 03/19/2025 at 4:15 PM the Activity Director stated Resident #47's care plan was not revised to reflect she needed one-on-one activities. She stated anytime a residents activity level changed and it was not time for their care plan to be updated, the staff was expected to revise the care plan to show the current activity needs of a resident. The Activity Director stated she was expected to revise Resident #47's care plan. She stated if the staff viewed Resident #47's care plan the staff would not know Resident #47 needed one-on-one activities and this may affect their quality of life such as feeling isolated or become depressed . Residents Affected - Some Resident #59 Review of Resident #59's face sheet, dated, 03/19/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #59 had diagnoses which included senile degeneration of brain, not elsewhere classified (decline in memory and thinking skills, often associated with aging, though it was not a normal part of aging), Alzheimer's disease (affects memory, thinking and behavior), adjustment insomnia (a temporary sleep problem that arises due to stressful life events or life changes) and chronic pain (persistent pain that lasts for three months or longer, or beyond the expected healing time, and can significantly impact daily life. Review of Resident #59's admission MDS, dated [DATE], reflected the resident was rarely or never understood. Resident #59 had poor short- and long-term memory recall. She was unable to complete the BIMS on the MDS. Her decision-making ability was moderately impaired (decisions were poor; Resident #59 required cues and supervision). She had difficulty focusing and was easily distracted. Resident #59 had ramble (lack of a clear point or focus) conversation. Resident #59 had mood symptoms such as the following: 1. Feeling or appearing depressed or hopeless ( experiencing persistent sadness, a lack of motivation, and a sense that things will never improve or that there's no way to improve your situation). 2. Trouble falling or staying asleep or sleeping too much. 3. Feeling tired or having little energy. Resident #59 was unable to respond if she felt lonely or isolated. Resident #59's activity preferences was the following: 1. Activities somewhat important a. Listening to music 675913 Page 7 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0657 b. Going outside to get fresh air when the weather was good. Level of Harm - Minimal harm or potential for actual harm c. Do things in group of people d. Do your favorite activities. Residents Affected - Some 2. Activities not very important a. Have books, newspapers, and magazines to read. b. Keep up with the news. c. Being around animals. d. Participate in religious services or practices. Resident #59's Quarterly MDS, dated [DATE], reflected Resident #59 had poor short- and long-term memory recall. She is able to recall staff names and faces. Resident #70's decision making ability was severely impaired. She had difficulty focusing and was easily distracted. Resident #59 had ramble (lack of a clear point or focus) conversation. Resident #59 had the following mood symptoms: 1. Trouble falling asleep or sleeping too much. 2. Trouble concentrating on things, such as reading the newspaper or watching television. 3. Poor appetite or overeating. reflected Resident #59 had impaired cognitive function and impaired thought processes related to dementia and senile degeneration of the brain. Intervention: Engage Resident #59 in simple, structured activities, that avoid overly demanding tasks. Provide activities programs to accommodate Resident #59's abilities. Intervention: Use task segmentation to support Resident #59's short term memory deficits. Resident #59 had a communication problem related to speaks Korean and confusion. Family member stated Korean was mostly nonsensical. Use the Korean communication chart. Intervention: Provide a program of activities that accommodates Resident #59's communication abilities. Record review of Resident #59's One-on-One Activity participation record reflected Resident #59 was to receive one-on-one interaction 5 days a week. In an interview on 03/19/2025 at 4:15 PM the Activity Director stated Resident #59's one-on- one activities began 03/05/2025. The Activity Director stated she did not know why her care plan was not 675913 Page 8 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revised to reflect Resident #59 being on one-on-one activity program. She stated anytime there was a change in a resident's physical, mental or even activity level, the change was to be documented on the care plan. The Activity Director stated Resident #59's interventions did not match what was documented on the one-on one activity participation record. She stated Resident #59's care plan needed to be revised on 02/28/2025 to reflect her activity level of needing one-on-one activities . She stated the staff viewed the care plan would not know Resident #59 needed one-on-one activity visits. She stated she was responsible for the activity care plans. Resident #70 Review of Resident #70's face sheet, dated, 03/19/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #70 had diagnoses which included vascular dementia, unspecified severity (problems with reasoning, planning, judgement , memory, and other thought processes caused by brain damage from impaired blood flow to your brain where the severity was not specified), adjustment insomnia (a temporary sleep problem that arises due to stressful life events or life changes), and polyosteoarthritis, unspecified (multiple joints had pain, stiffness, and loss of function). Review of Resident #70's admission MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #70 had disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) and was easily distracted. Resident #70 had difficulty keeping track of what was being said. Resident #70's activity preference reflected the following: 1. Activities somewhat important a. Listening to music b. Being around animals c. Do things in group of people 2. Activities not very important a. Have books, newspapers, and magazines to read. b. Keep up with the news c. Go outside to get fresh air when weather was good. d. Participate in religious services or practices 3. Important, but can't do or no choice 675913 Page 9 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0657 a. Level of Harm - Minimal harm or potential for actual harm How important was it to you to do your favorite activities. Residents Affected - Some Review of Resident #70's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #70 felt depressed or hopeless 7-11 days prior to the MDS being completed. Resident #70 had the following concerns: 1. Trouble falling or staying asleep or sleeping too much. 2. Feeling tired or having little energy. 3. Trouble concentrating on things, such as reading the newspaper or watching television. Resident #70 had impaired cognitive function and impaired thought process related to dementia. Interventions: Engage Resident #70 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Resident #70 had a communication impairment related to language barrier (unable to speak the same language and impaired cognition (difficulties with thinking, learning, remembering, using judgement, and making decisions). Resident #70 speaks Spanish, however, understand some English. Interventions: Provide a program of activities that accommodates Resident #70's communication abilities. Intervention : Refer to Speech Therapy. Validate Resident #70's message by repeating aloud. Provide Resident #70 translation as needed to communicate with the resident or call family member to assist with translation as needed. Resident #70 had little or no activity involvement related to decreased vision; will participate in activities that don't require vision. Intervention: Modify the resident's daily schedule, treatment plan as needed to accommodate activity participation. Provide monthly activities calendar. Invite/encourage the resident's family members to attend activities with resident in order to support participation. Resident #70 had impaired visual function related to glaucoma (an eye condition that damages the optic nerve - the nerve that carries messages from the retina to the brain) and macular degeneration (a condition that damages the central part of retina responsible for sharp, central vision, leading to vision loss, particularly for tasks like reading and recognizing faces). Record review of Resident #70s One-on-One Participation Record for the year 2025 reflected Resident #70 required one-on-one activities three time per week. Resident #70 is blind and speaks only Spanish. Resident #70 loved to visit with activity staff. In an interview on 03/19/2025 at 4:15 PM The Activity Director stated Resident #70 had been receiving one-on-one visits since 01/01/2025. She stated Resident #70 loved to visit in her room. The Activity Director stated Resident #70's care plan was expected to be revised to meet Resident #70's preference of having visits in her room at least three times per week beginning on 01/22/2025. She stated with her activity preference not documented on her care plan the staff would not know Resident #70's current activity plan and her activity preference. She stated Resident #70 may be encouraged by 675913 Page 10 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0657 other staff to do an activity she may not prefer to do and it may affect her mood and behavior. Level of Harm - Minimal harm or potential for actual harm Interview on 03/19/2025 at 11:30 The MDS Coordinator stated any time there was a change in a resident physical condition, mental condition or activity level, the residents care plan was expected to be revised to reflect the change with the resident. She stated if a resident was changed to receive one-on-one activities this was expected to be revised on the care plan of residents new activity program. She stated if staff was reviewing the care plan the staff would not know the resident did not want to attend group activities they were on the one-on-one activities in their room. She stated this may affect resident's mood if staff assisted a resident to an activity that did not meet the residents needs or preference. Residents Affected - Some Interview on 03/19/2025 at 9:36 AM The Director of Nurses stated all care plans are to be revised any time when there is a change of condition with a resident's care, mental status, and activity needs. She stated the information on the care plans would be on the [NAME] ( the tool CNAs uses to know what type of care and needs for each resident). She stated if a resident care plan was not revised when their activity level changed the CNAs would not have that information on the [NAME] and would not know the resident's activity preference. She stated the resident's mood or behavior may change if the CNAs attempted to assist resident out of their room to attend a group activity and the resident's preference was to do activities in their room. Record review of the Facility's Comprehensive Care Planning, not dated, reflected the resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 675913 Page 11 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three of eight residents (Resident#20, Resident #77, and Resident #56 ) reviewed for ADL care. Residents Affected - Some 1. The facility failed to ensure Resident #20's and Resident # 77's nails were cleaned, trimmed, and did not have any rough edges. 2. The facility failed to ensure Resident # 56 was free of facial hair on 3/17/25-3/19/25. These failures could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: 1.Review of Resident #20's face sheet, dated, 03/19/2025, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. Resident #20 had diagnoses which included need for assistance with personal care ( helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), unspecified sequelae of cerebral infarction (the long-term consequences or complications that arise following a stroke. Not enough blood was getting through certain blood vessels in the brain), muscle weakness ( lack of muscle strength- muscles did not move very easily), lack of coordination ( inability to control muscle movements) , and type 2 diabetes mellitus with hyperglycemia (a chronic condition- when you have persistently high blood sugar levels). Review of Resident #20's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 1, which indicated his cognition was severely impaired. Resident #20 required partial/moderate assistance ( helper does less than half the effort) with personal hygiene, upper body dressing, showers, oral hygiene, and toileting hygiene. He required substantial/maximal assistance (helper does more than half the effort) with lower body dressing. Resident #20 had an ADL Self Care Performance Deficit related to decreased activity tolerance (inability to perform or endure regular activities due to factors like pain or underlying health conditions), decreased mobility ( loss or difficulty in the ability to move around independent), and impaired cognition ( a decline in mental abilities that affects a person's thinking, memory, and decision-making processes). Interventions: Assist with personal hygiene. Assist with bathing: check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Observation and interview on 3/17/2025 at 11:20 AM, revealed Resident # 20 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle ring and fore fingernails on her right hand. Resident #20's ring and middle fingernail on her right hand were uneven around the edges. Resident #20 was not interview able. Resident #77 675913 Page 12 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0677 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #77's face sheet, dated 03/19/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #77 had diagnoses which included Alzheimer's disease ( affects memory, thinking and behavior), need assistance with personal care (helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), lack of coordination ( affects the ability to control and execute smooth, purposeful movements). Residents Affected - Some Record review of Resident #77's Quarterly MDS Assessment, dated 12/17/2024, reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #77 required partial/moderate assistance ( helper does less than half the effort) with personal hygiene, showers, and toileting hygiene. Resident #77 Required supervision or touching assistance ( helper sets up or cleans up. Helper assists only prior to or following the activity) with the following: upper and lower dressing, eating, and oral hygiene. reflected Resident # 77 had an ADL Self Care Performance Deficit related to Alzheimer's disease. Intervention: Personal Hygiene- Resident #77 required one staff to assist with personal hygiene. BathingCheck nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Review of Resident #77's Nurses Notes, dated 03/03/2025 to 03/19/2025 reflected Resident #77 did not refuse nail care. She was aggressive during mouth care on 03/16/2025. Observation and interview on 02/04/2025 at 10:37 AM, revealed Resident #77 was sitting in her wheelchair on the secure unit toward middle of the hall. Her nails on her right hand were not smooth around the edges. She had a blackish brownish substance underneath her middle and ring fingernails on her right hand. Resident #77 was not interview able. Interview on 03/17/2025 at 12:50 PM LVN B stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. LVN B stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems nausea and vomiting. LVN B stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. She stated Resident #20 did not refuse care. LVN B stated Resident #77 refuses care such as showers and changing her clothes. She stated no one had reported to her Resident #77 refused nail care. LVN B stated she had worked with Resident #20 and Resident #77 for several weeks. She stated she had been in- serviced on nail care, however, she did not recall the date. In an interview on 03/17/2025 at 1:30 PM, CNA E stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA E stated the residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. She stated a resident may cause a skin tear if their fingernails were not smooth. CNA E stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 20 and Resident #77, and she was not aware of Resident #20 refusing care, however, Resident #77 s ometimes refused showers. CNA E stated she did not know the last time these residents nails were trimmed or cleaned. She stated if any resident 675913 Page 13 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. She stated she was in-serviced on nail care. CNA E stated she did not recall the date of the nail care in-service. Interview on 03/19/25 at 10:30 AM, RN A stated the nurses, and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs responsibility to clean and trim all other residents' nails during showers or as needed. She stated if there was a blackish substance underneath the resident's nails, there was a possibility the substance had bacteria. RN A stated if a resident swallowed the bacteria there was a possibility a resident may become ill with stomach problems such as vomiting. RN A stated if a resident refused nail care the nurses would document the refusal in nurses' notes. RN A stated she was in-serviced on nail care; however, she did not recall the date. Interview on 03/19/25 at 09:36 AM, the Director of Nurses stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become sick if ingested the blackish/ brownish substance. The Director of Nurses did not elaborate of what type of sickness a resident may endure if ingested a blackish/brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes (a disease that occurs when your blood sugar, is too high). She stated any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. She stated she would need to refer to nurses notes to determine if Resident #20 and Resident #77 refused nail care. The Director of Nurses did not provide this information prior to exit. 2. Record review of Resident # 56 admission face sheet reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident # 56 had diagnosis of diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar levels), hypertension (elevated blood pressure), anxiety disorder, hyperlipidemia (increased fat particles in the blood), hypothyroidism (underactive thyroid), cerebral infarction (stroke), schizoaffective disorder bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder), major depressive disorder (clinical depression), dementia (a group of conditions that cause a progressive decline in cognitive function), abnormalities of gait and mobility, and muscle weakness. Review of Resident # 56's quarterly MDS dated [DATE] reflected a BIMS score of 5 indicating severe cognition impairment. Further review indicated Resident # 56 required partial to moderate assistance with personal hygiene (combing hair, shaving, applying makeup, washing/drying face, and hands). Review of Resident # 56's care plan dated 4/6/24 reflected an ADL self-care performance deficit related to dementia and schizoaffective disorder. Interventions include bathing Mon, wed, Fri 6-2 pm. Encourage the resident to participate to the fullest extent possible with each interaction. Review of Resident # 56's POC personal hygiene ADL task log revealed limited assistance provided on 3/15/25-3/19/25. Review of Resident # 56's nursing progress notes dated 3/19/25 10:04 AM reflected no documented refusal of ADL care or personal hygiene care. Observation and Interview on 3/17/25 at 1:57 PM revealed Resident # 56 in bed resting. Resident was 675913 Page 14 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some neatly dressed. Resident was observed with facial hair. Resident stated the food was good, and she likes playing bingo. Resident unable to answer any other questions. Resident was not able to be further interviewed due to cognition status. Observation and Interview on 3/19/25 at 9:29 AM revealed Resident up ambulating around the room going through a box of beads. Resident was dressed in clean clothes with her hair pulled back in a ponytail. Resident was observed still to have facial hair. When asked about the facial hair, the resident stated she lets the nurses shave her face during showers. Interview on 3/19/25 at 9:37 AM CNA J stated Resident # 56 helps with her showers and with toileting as she can. CNA J stated resident will help put water on herself and try to wash her hair and that she washes her peri area. CNA J stated resident gets showers in the evening. CNA J stated that the staff shave the residents face. Interview on 3/19/25 at 9:45 Am with CNA K st ated Resident # 56 helps with her showers and with toileting as much as she can. CNA K stated the resident will wash her own hair and mainly just needs help with her peri area. CNA K stated when she showers resident if resident has facial hair, she will shave her face. CNA K stated resident was always very receptive to care and does not refuse care. Interview on 3/19/25 at 3:31 PM the DON stated it was her expectation that female resident with facial hair were shaved on their scheduled shower day when they receive their showers. Unless the resident has documentation that they prefer to have the facial hair. The DON stated it was the responsibility of the CNA to complete the residents ADLs as scheduled. The DON stated that Resident # 56 refused her shower on Monday 3/17/25 and staff did not document the refusal until 3/19/25. The DON stated staff were supposed to document in the resident chart of the ADL completion or refusal on the day the instance occurred. The DON could not give reason as to why documentation had not occurred on Monday of Resident # 56 refusal. Interview on 3/19/25 at 5:11 PM with the ADM stated he expected that facial hair on women to be shaven when ADL care was performed. The ADM stated if the resident refused or it to keep the hair was a preference then he expected that to be documented. The ADM stated if female residents were not shaved and had facial hair it can negatively affect their mood and make them feel not as feminine. The ADM stated the CNA, charge nurse, and ADON were responsible for ensuring ADL care was being performed. Review of the Facility's Policy on Nail Care, dated 2003, reflected Nail management is the regular care of toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker. Goals: 1. Nail care will be performed regularly and safely. 2. 675913 Page 15 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0677 The resident will be free from abnormal nail conditions. Level of Harm - Minimal harm or potential for actual harm 3. The resident will be free from infection. Residents Affected - Some . 675913 Page 16 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 Provide activities to meet all resident's needs. 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 to provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 3 of 8 residents ( Resident #47, Resident #59, and Resident # 70) reviewed for activities. Residents Affected - Few 1. The facility failed to provide Residents #47 and #70 one-on-one activities three times per week during the months of January, February, and March of 2025. 2. The facility failed to provide Resident #59 one -on- one during the month of January, February and March of 2025. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. Findings include: 1. Review of Resident #47's face sheet, dated, 03/19/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #47 had diagnoses which included cerebral palsy, unspecified (caused by changes in the developing brain that disrupt its ability to control movement and maintain posture and balance), severe intellectual disabilities ( major delays in development- average mental age of between 3 and 6 years, and individuals have limited communication skills), and autistic disorder ( a condition characterized by difficulties in social interaction and communication, along with restricted behaviors and interests). Review of Resident #47's Annual MDS, dated [DATE], reflected Resident #47was unable to complete the BIMS. Resident #47 had poor short- and long-term memory recall. She had unclear speech. Resident #47 had disorganized thinking (rambling or irrelevant conversation) and was easily distracted. Resident #47's activity preference was bed bath, snacks between meals, staying up past 8:00 PM and family involved in care decisions. Review of Resident #47's Quarterly MDS, dated [DATE], Resident #47 was unable to complete the BIMS. Resident #47 had poor short- and long-term memory recall. She did not speak. Resident #47 declined to respond to concern of social isolation. Resident #47 had impaired cognitive function and impaired thought process related to intellectual disabilities. Resident #47 had nonverbal communication. Interventions: (initiated on 10/10/2024- Engage Resident #47 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Resident #47 had a communication impairment related to intellectual disabilities. Interventions: (initiated on 10/10/2024) Provide a program of activities that accommodates Resident #47's communication abilities. Review of Resident #47's One-On-One Activity Participation Record dated, for January 2025 to March 2025 reflected Resident #47 was to receive one-on-one activities three times per week. Resident #47 675913 Page 17 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 Level of Harm - Minimal harm or potential for actual harm would fall asleep when assisted out of her room . She was assessed by activity department Resident #47 required one-on-one activities. Her activity preference was watching cartoons and, listening to music (did not specify what type of music). During the months of January 2025 to March 2025 of 2025 Resident #47 received one-on-one activities on the following dates: Residents Affected - Few 1. 01/28/2025 2. 03/04/2025 Observation on 3/17/2025 at 3:15 PM Resident #47 was lying in bed in her room. Her roommate was viewing her phone and there was not any stimulation in Resident #47 room. She was not interview able. In an interview on 03/19/2025 at 4:15 PM the Activity Director stated Resident #47 was on the one-on-one activity program. She stated the one-on- one activity program was when residents needed individual activities with the activity staff. She stated Resident #47 had been on the one-on-one activity program since January 2025 . The Activity Director stated Resident #47 was not physically able to participate in group activities. She stated she benefited from one-on-one activities. She stated she could not answer the question about what activities she did with Resident #47 to accommodate communication needs. The Activity Director stated if this was on the care plan she would need to review the care plan and determine what activities Resident #47 would need to accommodate communication. She stated simple structured activities that avoid over demanding tasks was activities such as talking to the resident. She stated Resident #47 would benefit from one-on-one activities due to being unable to do the majority of group activities. The activity director stated if Resident #47 was not receiving one-on-one activities on a consistent basis there was a possibility she may feel lonely and may affect her overall quality of life. She stated there was a lot to do in the facility with census in the 80's and she did have a full-time assistant. The activity director did not elaborate in her response if it was difficult to ensure all residents was receiving the activities they needed and preferred. Review of Resident #70's face sheet, dated, 03/19/2025, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #70 had diagnoses which included vascular dementia, unspecified severity (problems with reasoning, planning, judgement , memory, and other thought processes caused by brain damage from impaired blood flow to your brain where the severity was not specified), adjustment insomnia (a temporary sleep problem that arises due to stressful life events or life changes), and polyosteoarthritis, unspecified (multiple joints had pain, stiffness, and loss of function). Review of Resident #70's admission MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #70 had disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) and was easily distracted. Resident #70 had difficulty keeping track of what was being said. Resident #70's activity preference reflected the following: 4. Activities somewhat important 675913 Page 18 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 a. Listening to music Level of Harm - Minimal harm or potential for actual harm b. Being around animals c. Do things in group of people Residents Affected - Few 5. Activities not very important a. Have books, newspapers, and magazines to read. b. Keep up with the news c. Go outside to get fresh air when weather was good. d. Participate in religious services or practices 6. Important, but can't do or no choice b. How important was it to you to do your favorite activities. Review of Resident #70's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #70 felt depressed or hopeless 7-11 days prior to the MDS being completed. Resident #70 had the following concerns: 4. Trouble falling or staying asleep or sleeping too much. 5. Feeling tired or having little energy. 6. Trouble concentrating on things, such as reading the newspaper or watching television. Resident #70 had impaired cognitive function and impaired thought process related to dementia. Interventions: Engage Resident #70 in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Resident #70 had a communication impairment related to language barrier (unable to speak the same language and impaired cognition (difficulties with thinking, learning, remembering, using judgement, and making decisions). Resident #70 speaks Spanish, however, understand some English. Interventions: Provide a program of 675913 Page 19 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activities that accommodates Resident #70's communication abilities. Intervention : Refer to Speech Therapy. Validate Resident #70's message by repeating aloud. Provide Resident #70 translation as needed to communicate with the resident or call daughter to assist with translation as needed. Resident #70 had little or no activity involvement related to decreased vision; will participate in activities that don't require vision. Intervention: Modify the resident's daily schedule, treatment plan as needed to accommodate activity participation. Provide monthly activities calendar. Invite/encourage the resident's family members to attend activities with resident in order to support participation. Resident #70 had impaired visual function related to glaucoma (an eye condition that damages the optic nerve - the nerve that carries messages from the retina to the brain) and macular degeneration (a condition that damages the central part of retina responsible for sharp, central vision, leading to vision loss, particularly for tasks like reading and recognizing faces). Record review of Resident #70s One-on-One Participation Record for the year 2025 reflected Resident #70 required one-on-one activities three time per week. Resident #70 is blind and speaks only Spanish. Activity staff will bring her out to activities of interest. Resident #70 loved to visit. Resident #70 received one-on-one activities the following dates during the months of January, February, and March of 2025: 1. January- 01/27/2025 and 01/28/2025 2. February - 02/03/2025, 02/04/2025, 02/10/2025 , and 02/11/2025 3. March - No visits. Observation on 3/17/2025 at 4:15 PM Resident #70 was sitting in her wheelchair in her room. There was not any stimulation in her room. Resident was not interview able. In an interview on 03/19/2025 at 4:15 PM The Activity Director stated Resident #70 had been receiving one-on-one visits since January 2025 . She stated Resident #70 loved to visit in her room. The activity director stated Resident #70 understood some English and used a voice Spanish translator. She stated Resident #70 had poor vision and was legally blind. The activity director stated when she did simple structured activities it was using Spanish translator and playing Spanish music. She stated Resident #70 was expected to receive one-on-one activities three times per week. The activity director stated sometimes it was difficult in a facility with about 80 residents in the facility to do all the activities . She did not have any excuse of why Resident #70 did not receive one-on-one activities. The activity director stated what was documented on the one-on-one participation record was Resident #70 activity plan. She stated if a resident needed one-on-one activities and the resident was not receiving these activities as planned, there was a potential Resident #70 may become lonely, depressed or feel isolated. 2. Review of Resident #59's face sheet, dated, 03/19/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #59 had diagnoses which included senile degeneration of brain, not elsewhere classified (decline in memory and thinking skills, often associated with aging, though it 675913 Page 20 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 Level of Harm - Minimal harm or potential for actual harm was not a normal part of aging), Alzheimer's disease (affects memory, thinking and behavior), adjustment insomnia (a temporary sleep problem that arises due to stressful life events or life changes) and chronic pain (persistent pain that lasts for three months or longer, or beyond the expected healing time, and can significantly impact daily life. Residents Affected - Few Review of Resident #59's admission MDS, dated [DATE], reflected the resident was rarely or never understood. Resident #59 had poor short- and long-term memory recall. She was unable to complete the BIMS on the MDS. Her decision-making ability was moderately impaired (decisions were poor; Resident #59 required cues and supervision). She had difficulty focusing and was easily distracted. Resident #59 had ramble (lack of a clear point or focus) conversation. Resident #59 had mood symptoms such as the following: 4. Feeling or appearing depressed or hopeless ( experiencing persistent sadness, a lack of motivation, and a sense that things will never improve or that there's no way to improve your situation). 5. Trouble falling or staying asleep or sleeping too much. 6. Feeling tired or having little energy. Resident #59 was unable to respond if she felt lonely or isolated. Resident #59's activity preferences was the following: 3. Activities somewhat important a. Listening to music b. Going outside to get fresh air when the weather was good. c. Do things in group of people d. Do your favorite activities. 4. Activities not very important a. Have books, newspapers, and magazines to read. b. Keep up with the news. 675913 Page 21 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 c. Being around animals. Level of Harm - Minimal harm or potential for actual harm d. Participate in religious services or practices. Residents Affected - Few Record review of Resident #59's Quarterly MDS, dated [DATE], reflected Resident #59 had poor short- and long-term memory recall. She is able to recall staff names and faces. Resident #70's decision making ability was severely impaired. She had difficulty focusing and was easily distracted. Resident #59 had ramble (lack of a clear point or focus) conversation. Resident #59 had the following mood symptoms: 4. Trouble falling asleep or sleeping too much. 5. Trouble concentrating on things, such as reading the newspaper or watching television. 6. Poor appetite or overeating. reflected Resident #59 will be in social settings during the day. Interventions: Staff will only utilize Resident #59's room for personal care and return the resident to the highly populated area once task is completed. Resident #59 will not be in her room during AM hours to avoid isolation per R/P request. Resident #59 had impaired cognitive function and impaired thought processes related to dementia and senile degeneration of the brain. Intervention: Engage Resident #59 in simple, structured activities, that avoid overly demanding tasks. Provide activities programs to accommodate Resident #59's abilities. Intervention: Use task segmentation to support Resident #59's short term memory deficits. Resident #59 had a communication problem related to speaks Korean and confusion. Son stated Korean was mostly nonsensical. Use the Korean communication chart. Intervention: Provide a program of activities that accommodates Resident #59's communication abilities. Record review of Resident #59's One-on-One Activity participation record for the year 2025 reflected Resident #59 was to receive interaction 5 days a week. There was not any documentation of Resident #59 received one-on-one activity visits. Observation on 03/17/2025 at 3:45 PM Resident #59 was sitting in her wheelchair in her room. There was not any stimulation in the room. Resident #59 was not interview able. In an interview on 03/19/2025 at 4:15 PM The Activity Director stated Resident #59 began one-on-one activities during the month of February 2025. She stated Resident #59 was not coming out of room due to decline in physical condition. The activity director stated she came out of room on 3/18/2025 for a short time and sat in the dining room. She stated her family was wanting her to come out of room in the morning. She stated Resident #59 was on the one-on-one activities related to it was difficult for her to do activities without assistance. The activity director stated she would need to review Resident #59's care plan to determine what type of task segmentation activities was needed for Resident #59. She stated Resident #59 would benefit in having one-on-one activities related to her 675913 Page 22 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 Level of Harm - Minimal harm or potential for actual harm language barrier and unable to participate in the majority of group activities. The activity director did not respond why Resident #59 did not receive any one-on-one activities during the month of February 2025 and March 2025. She stated if a resident needed one-on-one activities and they did not receive one-on-one activities there was a possibility the resident may become depressed and have a decline in their overall quality of life. Residents Affected - Few Interview on 03/19/2025 at 9:36 AM The Director of Nurses stated all departments including activities was expected to document on their appropriate forms of any task the staff completed. She stated if any task including any type of activity was not documented it indicated the staff did not complete the task or do the activity. The Director of Nurses stated if a resident was not receiving the activity programs designed from the activity director there was a possibility a resident may become bored, have a decline in cognition, become lonely, or depressed. She stated this may affect their quality of life. Interview on 03/19/2025 at 10:50 AM CNA L stated she had been working at the facility over a year. She stated she had been assigned to Resident #47, Resident #59 and Resident #70 throughout their stay at the facility. She stated she may not be assigned to them every week but was assigned to give care to them 3 times per in a month. CNA L stated she had not witnessed Activity staff do any type of one-on-one activity with Resident 347, Resident #59 or Resident #70. She stated these residents really needed someone to sit with them and do some type of activity related to their culture and their mental abilities. She stated it would be difficult for these three residents ( Resident #47, Resident #59, and Resident #70) to do the group activities offered at this facility due to speaking different language, poor vision, their physical abilities, and mental condition. She stated Resident #59's family does visit during the week but did not assist Resident #59 with activities. Interview on 03/19/2025 at 2:45 PM The Administrator stated his expected activity documentation to be accurate and when the activity staff completes an activity they are required to document the activity immediately after the activity is finished. He stated activities should reflect the residents' preferences and their abilities to complete an activity. He stated if a resident was not receiving one-on-one activities there was a possibility a resident may become bored, decline in cognition, and affect their mood. The Administrator stated he was the activity director supervisor. Record review on 03/19/2025 at 8:15 AM of the Activity Director personnel record reflected the Activity Director was certified Activity Professional through NCCAP ( National Council Certification Activity Professional). She was in compliance with her certificate. She signed her job description when she was hired on 04/15/2024. Record review on 03/19/2025 at 8:25 AM of the Activity Director Job Description signed by the Activity Director on 04/15/2024 reflected the following: 1. Ability to develop, organize and implement a program of activities for the social, emotional, physical, and other therapeutic needs of the residents within specified budget. 2. Maintain detailed records of activity programs and participation of individual residents, identifying progress toward established care plan goals. 675913 Page 23 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0679 Level of Harm - Minimal harm or potential for actual harm Record review on 03/19/2025 at 8:30 AM the Facility's Activity Program Variety Policy, dated 2011, reflected The Activity Director and staff will provide a variety of programs to meet the needs and interests of the residents. Practice Guidelines: Residents Affected - Few The Activity Director assists the resident in maintaining, improving, or stimulating his/her physical capabilities, cognitive capabilities, creative ability, social abilities, spiritual/cultural interests, and hobby interests, self-esteem, and community participation. 675913 Page 24 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #63) of 5 residents reviewed for quality of care. Residents Affected - Few The facility failed to obtain Resident # 63's meal preferences. The facility failed to implement and monitor RD recommendations of snacks with protein and Med Pass 2.0 2 oz. BID for Resident # 63. These failures could place residents at risk of weight loss and decreased health status. Findings included: Record review of Resident # 63's admission face sheet dated 3/19/25 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of alcohol dependence with alcohol induced dementia (a group of conditions that cause a progressive decline in cognitive function caused by alcohol abuse), anemia (lack of blood), hypertension (elevated blood pressure), hyperlipidemia (increased fat particles in the blood), muscle wasting and atrophy, need for assistance with personal care, lack of coordination, abnormalities of gait and mobility, chronic kidney disease stage 4, and alcohol abuse. 12/18/24 reflected a BIMS score of 9 indicating moderate cognitive impairment. Further review revealed resident required supervision for eating. Nutritional coding was listed as 0 or unknown. Review of Resident # 63's care plan dated 3/20/24 reflected resident has a potential nutritional problem related to dementia, hypertension, and history of alcohol abuse. Interventions of monitor weight as ordered and notify MD/RD if significant change occurs. Monitor/document/report signs and symptoms of dysphagia and malnutrition. Provide and serve diet as ordered. Monitor intake and record at each meal. RD to evaluate and make diet changes and recommendations PRN. Review of Resident # 63's RD assessment dated [DATE] reflected current weight of 143 pounds resident continues to be IBWR. Resident IBW 178 pounds. Recommendations of continue current plan of care for diet ordered. Recommend snacks with protein. Recommend Med Pass 2.0 20z BID will continue to monitor monthly weights and assess annually unless problems arise. Review of Resident # 63's clinical physician orders reflected Resident # 63's diet order of fortified /enhanced diet mechanical soft texture with thin liquid consistency ordered on 12/29/23. RD recommendations of snacks with protein and Med Pass 2.0 2 oz BID ordered on 1/6/25 and discontinued on 1/30/25. Observation and Interview of Resident # 63 on 3/17/25 at 12:55 PM revealed the Resident was in his room ambulating with a walker. Resident appeared clean. Resident #63 stated food was cold and tastes terrible. Resident #63 stated that was his only concern. Resident stated he has never talked with anyone from dietary about his meal preferences. Resident also stated that he prefers to eat his meals in his room. Resident stated he has never received any snacks between meals and that would be nice as he frequently gets hungry between meals since often the meals consist of food he does not like. 675913 Page 25 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the DM on 3/19/25 at 12:35 PM revealed that the RD sends an email with her recommendations, and she documents in their electronic record keeping system with her assessments. The DM stated after receiving the email with the resident recommendations that he updates the electronic meal system that the facility uses to print meal tickets and snack labels. The DM stated that nursing updated the electronic record keeping system with new orders and recommendations as he does not have order writing privileges. The DM stated he obtains the dietary profile for each resident including preferences upon admit and then quarterly thereafter. The DM could not provide answer as to why Resident # 63 did not have a dietary profile with preferences on record. The DM stated if resident preferences were not obtained then it could negatively affect the resident by decreased intake or possibly receiving a food item, they are allergic to. The DM stated it was his responsibility to obtain resident meal preferences. The DM stated the resident received super cereal at breakfast and super pudding at dinner, so he felt like that counted for the snacks with protein. Interview on 3/19/25 at 3:31 PM with the DON revealed for RD recommendations that the process was the recommendations were communicated to the physician and if he agrees then the recommendations were implemented. The DON could not explain why recommendations were implemented on 1/6/25 and then discontinued on 1/30/25. The DON acknowledged that no communication to discontinue orders had been received from the RD or physician. The DON acknowledged that Resident # 63 was under his IBW. The DON stated she would be looking into this matter and communicating with the RD and physician. Interview on 3/19/25 at 5:11 PM with the ADM revealed it was his expectation that food preferences were obtained upon admit and then quarterly after that. The ADM stated if preferences were not obtained or updated that it could negatively affect residents with decreased intake and possible weight loss. The ADM stated it was the DM's responsibility for obtaining meal preferences. The ADM stated it was his expectation that the DON, ADON, and DM input the RD recommendations into each of their respective electronic systems. The ADM stated it could negatively affect the resident if RD recommendations were not implemented by the resident losing weight. The ADM stated it was the responsibility of the DON, ADON, and the DM to ensure RD recommendations were implemented. Interview on 3/19/25 at 5:30 PM with the DON showed surveyor in the MAR where the resident had refused the Med Pass that had been recommended by the RD 7 out of 24 times it was administered. The DON stated that was why the orders were discontinued. DON stated she discontinued the orders. The DON acknowledged that no communication had been attempted with the RD or physician to change the supplement ordered to see if the resident would be acceptable of something different. Review of Resident Meal Service and HS snack policy undated reflected: We strive to provide meals and HS snacks to all residents in a timely manner. A bedtime snack is offered to all residents. Each facility can customize their menu based on regional or resident preferences, after the approval of the RD. Under heading procedure: 1. Upon admission and periodically thereafter the resident will be interviewed by the DM to determine individual food preference, dislikes, and allergies. These will be recorded on their tray card and honored at mealtimes. 675913 Page 26 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0684 Level of Harm - Minimal harm or potential for actual harm 7. The dietary department shall prepare HS snacks for all residents. These will be served in bulk and offered to all residents following the constraints of their specific diet order by nursing personnel. 8. If the resident has a physician ordered snack or one that is part of his/her nutritional plan of care it will be individually prepared and labeled with resident name. Residents Affected - Few 675913 Page 27 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

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 the facility failed to ensure medications and biologicals were stored in the medication refrigerator located in 1 of 1 medication room. The over-the-counter medication of Probiotics was stored in the locked refrigerator on the secure unit where food and open drink containers that belonged to staff were also being stored. This facility failure placed the facility's residents at risk of being administered contaminated medication and or supplements. Findings included: Observation/ Interview on 03/17/2025 at 12:16 PM revealed the refrigerator located in the dining room on the secure unit had three bottles of 100 capsules of Probiotic over the counter medication stored on the shelf located in the door of the refrigerator with staff food and open drinks. LVN B stated the Probiotic medication was stored in the refrigerator on secure unit to be given to the residents resided on the secure unit. She stated she did receive in-service on medication policy but did not recall the date. Interview on 03/17/2025 at 12:20 PM CNA E stated all the staff had access to the refrigerator where the Probiotics were stored. She stated the staff kept their food and drinks in the same refrigerator where medications were stored on secure unit . She stated she did received in-service on medications were to be locked but did not recall the date of the in-service. Observation on 03/17/2025 at 12:24 PM revealed there was not a refrigerator temperature log located on the secure unit. Interview on 03/17/2025 at 12:26 PM LVN B stated they did not keep temperatures of the refrigerator. She stated she never documented the temperature of the refrigerator on any type of paper log or in the computer system. Interview on 03/17/2025 at 12:28 PM CNA E stated she was not aware of any temperature log for the refrigerator on secure unit. She stated all staff on the secure unit had access to the refrigerator in the dining room on the secure unit. She stated the key was usually with the nurse. Interview on 03/17/2025 at 12: 40 PM The Director of Nurses stated the Probiotic over the counter medication was expected to be stored in the medication refrigerator in the medication room. She stated the medication room was not located on the secure unit. The Director of Nurses stated she did not know if all staff had access to the locked refrigerator on the secure unit. She stated all refrigerated medication was not to be stored with staff food and drinks. She stated it was not in best nursing practice to store medication in any refrigerator except the medication refrigerator. She stated nurse administration was responsible for training staff on medication storage facility protocol. Requested the medication storage policy and it was not provided at time of exit. 675913 Page 28 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for one (1) of three (3) residents (Resident #51) reviewed for food allergies. The facility failed to honor Resident #51's food preference of large portions according to his care plan and meal ticket. This failure could place the residents at risk of not having their preference honored and a diminished quality of life. Findings included: Review of Resident # 51's face sheet, dated, 03/18/2025, reflected a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. Resident #51 had diagnoses which included need for assistance with personal care ( helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), gastro-esophageal reflux disease without esophagitis (a condition where stomach contents flow back into the esophagus without causing inflammation or damage to the tube that connects the throat to the stomach), and type 2 diabetes mellitus with hyperglycemia (a chronic conditionwhen you have persistently high blood sugar levels). Review of Resident #51's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 5, which indicated his cognition was severely impaired. Resident #51 did not have a weight loss or a weight gain. Resident #51 was at risk for pressure ulcer. Resident #51 had a potential nutritional problem related to diabetes mellitus. Resident #51 diet was regular texture, thin regular consistency. Resident #51 requested large portions. He also requested no pork in meals. Intervention: Provide and serve diet as ordered. Review of Resident #51's Physician Orders, revised on 03/17/2025, reflected Resident #51 was ordered regular diet, regular texture, and thin regular consistency (did not specify fluids). Resident #51 preferred large portions. Review Resident #51's meal ticket on 03/17/2025 at 12:04 PM reflected Resident #51 was on a regular large portion diet. Resident #51's beverage texture was regular. Resident #51's entrée was one serving meat double portion. His dislikes was pork and pork products. His meal ticket did not specify any other food being large or double portion. Observation and Interview on 03/17/2025 at 12:06 PM Resident #51 meal was not double or large portion. He had normal portion size . Resident did not respond to questions about his meal. Interview on 03/19/2025 at 1:00 PM The Dietary Manager stated all residents' meals was to reflect the physician order and the residents' preferences. He stated Resident #51 did have a preference of double portions. The Dietary Manager stated if it was on Resident #51's care plan and physician order it was expected to be on the meal ticket. He stated the dietary staff was expected to check the 675913 Page 29 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal ticket and compare it to the meal prior to the meal placed on the meal tray cart. The Dietary Manager stated the nurse was required to check the meal ticket and compare it to the Residents meal tray prior to serving the meal to the resident. He stated the dietary staff and the nurse in the dining room was responsible to ensure the meal ticket matched the resident's meal. Interview on 03/19/2025 at 9:36 AM The Director of Nurses stated Resident #51 was expected to receive double portions. She stated the nurse was to check the meal ticket and meal tray to ensure they matched. She stated if the meal ticket did not match the meal tray, the nurse was to request a different meal tray to match the meal ticket. She stated all physician orders was expected to be followed including all residents diet orders. She stated all residents had a right to make preferences related to their diet. She stated Resident #51 did not have a weight loss this was his preference to have double portions. Interview on 03/19/2024 at 10:30 AM RN A stated a nurse was expected to check the meal ticket and compare each residents meal ticket to their meal on the tray. She sated if the meal ticket did not match the meal, the nurse was to inform the dietary staff and request a new plate of food. RN A stated if the nurse noticed the meal ticket was not correct, the dietary manager was informed immediately or someone from dietary staff if dietary manager was not in the facility. She stated the nurse would double check the physician order and ensure the correct diet a resident was expected to receive according to the physician order. She stated if a resident did not receive the correct meal there was a possibility a resident may choke or lose weight. She stated all residents had a right to voice their meal preferences. Record review of the facility's Resident Right Policy , not dated, reflected a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Resident had a right to receive services and /or items included in the plan of care. 675913 Page 30 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure DM wore a beard guard while in the kitchen. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: Observation on 3/17/25 at 12:12 PM-1:00 PM revealed DM with beard guard down under chin with visible facial hair while serving lunch meal trays in dining room. Further observation revealed DM going in and out of kitchen 5 different times without beard guard on facial hair visible. Observation on 3/18/25 at 11:45 AM of DM in kitchen preparing Brussels sprouts with beard guard down under chin facial hair visible. Observation on 3/19/25 at 11:55 AM of DM in kitchen preparing lunch meal trays with beard guard down under chin facial hair visible. Interview on 3/19/25 at 12:35 PM the DM stated hair nets or cap and beard guard on facial hair is present are required for all staff while in the kitchen. The DM stated it could negatively affect a resident if hair restraints are not worn by a resident receiving food with hair in it. The DM states it is his responsibility to ensure hair restraints are worn by all staff in the kitchen. The DM could not provide answer as to why he did not properly wear a beard guard while in the kitchen even though he has facial hair. Interview on 3/19/25 at 3:31 PM DON stated hair restraints are to be worn by everyone in the kitchen. The DON stated a negative of not wearing a hair restraint would be hair in the food. The DON stated the DM was responsible for ensuring hair restraints were worn by everyone in the kitchen. Interview on 3/19/25 at 5:11 PM the ADM stated his expectation was that hair restraints were to be worn by all staff in the kitchen. The ADM stated it could negatively affect residents if hair restraints are not worn by hair getting into the food. The ADM stated all kitchen staff are responsible for wearing hair restraints and that ultimately the DM is responsible for ensuring hair restraints are worn by all staff in the kitchen. Review of facility Dress Code policy undated reflected: 1. Facial hair must be neatly trimmed, and dietary staff must wear hair restraints/nets. 2. Dietary staff must wear hair nets while in the dietary department. Dietary staff with facial hair 675913 Page 31 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0812 must wear beard nets while in the dietary department. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675913 Page 32 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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 6 (Resident # 7, Resident #17, Resident #33, Resident #36, Resident #44, and Resident #51) of 9 residents reviewed for infection control. Residents Affected - Some 1. The facility failed to ensure Student Nurse A sanitized or washed her hands prior to touching contaminated surfaces (her shirt, wheelchair arm rest, and clothes of other residents) prior to touching Resident #33, Resident #44, Resident #7, and Resident #36's food. 2. The facility failed to ensure Student Nursing Aide G sanitized or washed his hands prior to touching contaminated surfaces (his shirt, wheelchair arm rest, and clothes of other residents) prior to touching Resident #17's and Resident #51's food. These failures could place residents at risk of transmission of disease and infection. Findings included: Observation on 03/17/25 at 12:07 PM was conducted on 200 Hall during lunch tray pass. Student Nurse Aide A was observed taking a lunch tray from the cart to Resident #33 and did not conduct handwashing/hand hygiene. She then took a lunch tray from the cart to Resident #44 and did not conduct handwashing/hand hygiene. Student Nurse Aide A then returned to the cart and took another lunch tray to Resident # 36 and did not conduct handwashing/hand hygiene between residents. Student Nurse Aide A then returned to the cart and took a lunch tray to Resident #7 and assisted with positioning and setting up the tray. Student Nurse Aide A did not conduct hand washing or hand hygiene when or after leaving Resident #7's room. Interview on 03/17/2025 at 12:27 PM with Student Nurse A revealed she might have forgotten to wash or sanitize her hands when passing out the residents' trays. Student Nurse A stated she had been in-serviced on hand hygiene and infection control since working at the facility. Observation on 03/17/2025 at 12:10 PM thru 12:25 PM Student Nurse Aide G was delivering trays to the residents in the dining room on the secured unit. He touched the right side of his scrub top with his right hand. Student Nurse Aide G continued to deliver meal trays to residents and did not wash or sanitize his hands. He delivered meal tray to Resident #17. Student Nurse Aide G touched the arm of her wheelchair and touched her left side of her blouse. He began to set up her meal tray. He removed the cellophane off the cake and touched the left side of the cake and the left side top of the cake when he removed the cellophane. Student Nurse Aide G delivered Resident #51's meal tray and touched Resident #51's right side of wheelchair arm rest. Student Nurse Aide G removed cellophane off the cake. He touched the top of the cake and the right side of the cake when removed the cellophane. Interview on 03/17/2025 at 12:40 PM Student Nurse G stated he washed hands before he began to pass out the meal trays. He stated he did touch his scrub top; arm rest of wheelchair and he may have touched Resident #17's blouse. Student Nurse G stated he did not wash or sanitize his hands during passing resident's trays and when he touched contaminated items such as his shirt, other resident clothes, or wheelchair arm rest. He stated he did touch Resident #17's and Resident #51's cake when he removed the cellophane. He stated there was a possibility that bacteria from his hand may transfer to 675913 Page 33 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Residents cake. Student Nurse G stated there was a potential for the resident become ill from cross contamination such as stomach problems. (he did not elaborate on what type of stomach problems). He stated he was trained in CNA school on infection control and hand hygiene. Student Nurse G stated he also went through orientation and training at this facility on infection control and hand hygiene. He stated when he was hired at the facility he went through training and had been given in-services on hand hygiene and infection control since he was hired. Student Nurse G stated he did not recall the exact date when he was hired. Interview on 03/17/2025 at 12:50 PM LVN B stated all staff was expected to wash and sanitize hands after passing each meal tray. She stated if any staff touched any contaminated item the staff was expected to wash or sanitize hands immediately. LVN B stated if staff does not wash or sanitize their hands and touch residents' food there was a possibility the food may become contaminated with bacteria. She stated there was a possibility a resident may become ill with vomiting or diarrhea if ingested certain types of bacteria. She stated she had been in-service on hand hygiene and infection control but did not recall the date. Interview on 03/18/25 at 10:14 AM with the DON revealed hand washing/hand sanitization between each resident was the best practice, and hand hygiene should be conducted by all staff members, between each resident when passing out resident trays. The DON further stated the risk to the residents was cross-contamination and bacteria getting in their food, which could cause gastrointestinal illness. Interview on 03/19/25 at 03:25 PM with the ADM revealed his expectation was that hand hygiene should be conducted between each resident during meal tray pass. The ADM stated it could negatively affect a resident if hand hygiene was not performed by a diminished quality of life and risk of getting an infection. The ADM stated it was everyone's responsibility to perform correct hand hygiene. Record review of Student Aide G's personnel record on 03/19/2025 at 8:30 AM he was hired on 01/31/2025. He received his certificate of completion the course of study prescribed by the Texas health and Human Service Commission for Nurse Aide Training dated on 01/22/2025. He received orientation, training and completed CNA Proficiency Audit on 01/31/2025. During the training, Student Aide G was trained on infection control awareness such as: 1. Proper handwashing 2. Prevent cross contamination 3. Universal precaution 4. Contact precaution 5. Droplet precaution Record review of the facility's Policy on Hand Hygiene, not dated, reflected staff my use alcohol-based hand cleaner or soap/water for the following: before and after assisting a resident with meals Record review of the facility's policy on Infection Control Plan, dated 03/2022 reflected, The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will require staff to wash their hands after each direct resident contact for 675913 Page 34 of 35 675913 03/19/2025 Pflugerville Care Center 521 S Heatherwilde Blvd Pflugerville, TX 78660

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some which hand washing is indicated by accepted professional practice. To assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions by implementing hand hygiene (handwashing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. 675913 Page 35 of 35