Health inspection·May 29, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure personal privacy for 2 of 3 residents (Resident #8 and Resident #56) reviewed for privacy while receiving care. Residents Affected - Few 1. The facility failed to ensure the privacy of Resident #56 by not closing the door or pulling the privacy curtain during administration of enteral formula through a PEG tube. 2. The facility failed to ensure the privacy of Resident #8 by not closing the blinds on the window or pulling the privacy curtain during wound care. This failure could place residents at risk of loss of privacy and dignity. Findings included: 1. Record review of Resident #56's admission record, dated 05/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #56 had diagnoses which included: thrombocytopenia (a condition characterized by a low platelet count and may cause easy bruising and/or prolonged bleeding), aphasia (a language disorder that affects communication), dysphagia (difficulty with swallowing), post traumatic seizures (a seizure disorder that occurs when the brain experiences damage from physical trauma), personal history of traumatic brain injury (a sudden injury that causes damage to the brain), and major depressive disorder (A period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had a majority of specified symptoms, such as problems with sleep, eating, energy, concentration, or self-worth). Record review of Resident #56's Quarterly MDS, dated [DATE], reflected a BIMS score 99, which indicated resident was unable to complete the assessment. Section C- Cognitive Patterns reflected resident had memory problems for both short-term and long-term memory. Record review of Resident #56's care plan, dated 04/11/2025, reflected: Focus: [Resident #56] and his Responsible Party will be educated on their Resident Right's as residents of a Long-Term Care Facility with Interventions that included: Resident and/or the Legal Guardian/Responsible Party is given a copy of the Resident's Rights upon admission. Observation on 05/29/2025 at 08:48 AM, revealed Resident #56 sitting up in specialized wheelchair. LVN H approached resident and explained procedure for administering enteral formula through the PEG tube to Resident #56. LVN H left door open and privacy curtain open when she exposed Resident #56's abdomen to assess PEG tube placement and administer formula through PEG tube. During the assessment Page 1 of 14 675923 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and administration of formula, Resident #56's roommate remained in the room and one unknown female resident sat in a wheelchair at the doorway to Resident #56's room. In an interview on 05/29/2025 at 08:54 AM, LVN H stated privacy, such as closing the door and pulling the curtain, should be provided to residents when assessing and administering anything through a PEG tube. She stated she forgot to provide privacy while providing care to Resident #56. LVN H stated that all staff monitored to ensure residents were receiving appropriate privacy when needed. She stated if [Resident #56] was more alert, then it might embarrass him if privacy was not provided appropriately. 2. Record review of Resident #8's admission record, dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #8 had diagnoses which included: hyperlipidemia (high cholesterol), essential hypertension (high blood pressure), major depressive disorder (persistent feeling of sadness and loss of interest), moderate intellectual disabilities (a condition where someone has an average mental age of 6 to 9 years), peripheral vascular disease (decreased blood circulation to the legs), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). Record review of Resident #8's Quarterly MDS, dated [DATE], reflected a BIMS score 02, which indicated severe cognitive impairment. Record review of Resident #8's care plan, dated 04/17/2025, reflected: Focus: [Resident #8] and her Responsible Party will be educated on their Resident Right's as residents of a Long-Term Care Facility with Interventions that included: Resident and/or the Legal Guardian/Responsible Party is given a copy of the Resident's Rights upon admission. Observation on 05/29/2025 at 10:49 AM, revealed Resident #8 lying in bed covered with a blanket. LVN I uncovered Resident #8's legs to provide wound care to the right calf without closing the blinds to the window that led to the front circle drive or pulling the privacy curtain closed. In an interview on 05/29/2025 at 11:08 AM, LVN I stated she should have pulled the privacy curtain at the foot of the bed and closed the blinds to ensure privacy and dignity to Resident #8. She stated she was not sure how ensuring privacy for the residents was monitored. She stated by not ensuring privacy was provided it could affect the self-esteem of the resident. In an interview on 05/29/2025 at 11:30 AM, MA F stated she had been trained on resident rights in 04/2025. She stated the policy was to close the door and pull the curtain closed when providing patient care in a resident's room. MA F stated it was the responsibility of the person providing care to provide privacy to the resident. She stated not providing privacy to a resident in their room while providing care to them could make the resident feel bad or embarrassed. She stated the ADON monitored about every 3 months to ensure residents were provided privacy. In an interview on 05/29/2025 at 11:58 AM, MA K stated she had been trained on resident rights. MA K stated the training covered providing privacy for residents during pericare, wound care, or any care when the body is exposed. She stated when providing patient care in a resident's room, the door should be closed, and the curtain should be pulled to provide privacy. MA K stated, the staff member providing resident care was responsible for ensuring residents had privacy and the nurse that worked 675923 Page 2 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that hall was monitoring to ensure privacy was provided daily. She stated the resident could feel bad, exposed, or embarrassed if they did not have privacy when care was provided. In an interview on 05/29/2025 at 01:11 PM, the DON stated she had been trained on resident rights within the last 6 months. She stated it was her expectation that privacy, like closing the door and blinds and pulling the privacy curtain closed, was provided to all residents when care was provided. The DON stated the staff member providing the care to the resident was responsible for ensuring privacy was provided. She stated that the floor nurses were responsible for monitoring this every day when they perform their walking rounds. The DON stated a resident could become fearful or anxious if privacy was not provided. In an interview on 05/29/2025 at 01:41 PM, the ADM stated he had received training on resident rights. He stated his expectations for providing privacy to residents was to pull the curtain closed and close the door when providing care to the resident in their room. He stated he was ultimately responsible for everything in the building, but he defers that to the DON. He stated he was unsure how it was monitored. The ADM stated it might cause some embarrassment to the resident if privacy was not provided. He stated it was a dignity thing. Record review of facility policy titled Resident Rights, dated 2001 and last revised 02/2021, reflected: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . t. privacy and confidentiality; . 675923 Page 3 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 (D/E Hall) medication room reviewed for pharmacy services. The facility failed to ensure expired medication and medical supplies were removed from D/E-halls medication storage room. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, inaccurate results, and/or contamination from expired supplies. Findings included: During an observation on 05/29/2025 at 07:58 AM, with the ADON revealed a bottle of omeprazole 20mg with an expiration date of 01/2025, a bottle of omeprazole 20mg with an expiration date of 03/2025, 10 BioSign Flu A+B tests with an expiration date of 07/31/2024, a sterile CleanWipe foam swab with an expiration date of 11/2023, a gray top vacutainer (blood collection device for labs) with an expiration date of 05/31/2024, and a gray top vacutainer with an expiration date of 08/31/2024. In an interview on 05/29/2025 at 08:25 AM, the ADON stated the medication and supplies found were expired. She stated if an expired medication was given to a resident, the medication may not be as effective or may cause an unintended adverse reaction. She stated she was not sure who was responsible for checking the medication room for expired medications and supplies. In an interview on 05/29/2025 at 11:58 AM, with MA K stated she had worked at the facility for 13 years. She stated medication aides was responsible for checking the medication room on Hall D/E for expired medications and supplies, but she did not know how often. She stated that nursing management should be following up once a month to ensure there are no expired medications or supplies. She stated that tests could be inaccurate if supplies were expired, and the resident might not receive the correct dosage of medication or not achieve the desired effect if the medication was expired. In an interview on 05/29/2025 at 12:46 PM, MA G stated she had worked at the facility for 10 years. She stated the medication aide that is assigned to the hall is responsible for checking for expired medications and supplies in the respective medication rooms once a month. MA G stated she thought nursing management followed up behind the medication aids to ensure all expired medications and supplies were removed from inventory. She stated if expired medications or supplies were used on the residents then it could be dangerous by causing an adverse reaction to the medication or an infection could occur due to contamination, or even false results could occur. In an interview on 05/29/2025 at 01:11 PM, the DON stated she had worked at the facility for 6 years. She stated the central supply person stocked the medication rooms weekly with over-the-counter medications and was responsible for ensuring the over-the-counter medications were not expired. She stated a medication technician consultant performed an audit every 3 months to ensure all expired medications were removed from inventory. The DON stated the nurse managers were responsible for performing a quick survey of the medication rooms weekly. She stated if expired medications or supplies were used for residents then they might have an adverse effect. 675923 Page 4 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 05/29/2025 at 01:41 PM, the ADM stated he had worked at the facility for almost 10 years. He stated he was ultimately responsible for everything that occurs in the building, but the DON was responsible for ensuring all expired supplies and medications were removed from inventory in the medication rooms, but he was unsure how often it was reviewed. He stated if expired medications and supplies were used for residents then it could cause an adverse reaction to the medication or false readings in supplies. Record review of facility policy titled Medication Labeling and Storage, dated 2001 and revised last 02/2023, reflected Policy Statement The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . 675923 Page 5 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

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, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure CK A and DM were holding cold foods below the danger zone temperature of 41 degrees Fahrenheit and below. The facility failed to ensure CK A checked food temperatures and recorded temperatures correctly. The facility failed to ensure CK A and DM periodically monitored throughout the meal service to ensure proper cold holding temperatures are maintained for the macaroni salad. The facility failed to ensure functioning of reach in refrigerator and temperature at 41 degrees Fahrenheit and below. This failure could place residents who were served from the kitchen at risk for consuming contaminated food, and/or developing foodborne illnesses. Findings included: Observation on 05/28/2025 at 10:54 AM, revealed CK A preparing lunch and placing deep stainless steel steam table pans of food on the warming table and checking temperatures of cooked food. Observation on 05/28/2025 at 10:57 AM, revealed the reach in refrigerator temperature was reading 55 degrees. Observation and interview on 05/28/2025 at 10:57 AM, revealed CK A checking temperatures for the cold macaroni salad he pulled out of the reach in refrigerator. The level 4 - pureed macaroni salad temperature read 48 degrees, the level 5 - minced & moist macaroni salad temperature read 55 degrees, and the level 7 - regular macaroni salad temperature read 48 degrees. He stated the cold food temperatures should be under 40 degrees and he was going to bring down the temperatures of the 3 deep steam table pans of macaroni salad by placing in an ice bath and returning to the reach in refrigerator. Observation and interview on 05/28/2025 at 11:37 AM, revealed CK A began plating lunch trays. To the right side of CK A was a large deep container filled with ice and (3) deep dish containers of macaroni salad. Surveyor requested for CK A to recheck the macaroni salad temperatures before serving. The level 4 pureed macaroni salad temperature read 38 degrees, the level 5 - minced & moist macaroni salad temperature read 48 degrees, and the level 7 - regular macaroni salad temperature read 38 degrees. He stated he did not understand why the level 5 - minced & moist macaroni salad temperature had not dropped under 40 degrees and placed it back on ice. Observation and interview on 05/28/2025 at 11:46 AM, revealed CK A returning to food plating. Surveyor again asked that the macaroni salad temperatures be checked, specifically the level 5 - minced & moist macaroni salad. The temperature was checked for a 3rd time and the level 5 - minced & moist macaroni salad now was reading 42.06 degrees, which remained in the danger zone. CK A stated the 675923 Page 6 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature went down and surveyor asked what he was going to do with the macaroni salad. CK A stopped food plating and left the line and went to the back area to discuss the issue with his manager. CK A returned to the tray line and began food plating and serving the level 5 - minced & moist macaroni salad that was above the appropriate cold temperature. In an interview on 5/28/2025 at 3:27 PM, CK A stated he prepares breakfast and lunch for the facility. He stated he's been employed one year at this facility. He secured his food safe certification roughly 2 years back. He stated he last received in-person training this past December 2024 and topics included hand hygiene practices and wearing hairnets. He stated proper hygiene is necessary to avoid cross contamination as this could cause the residents to become ill. He stated the food temperatures should also be followed. He stated chicken temperatures should be 165 degrees and above, fish should be 145 degrees and above, steak should be 160 degrees and above, boiling vegetables should reach 180 degrees and above, the steam table and holding temperatures for cooked food should be between 140 to 160 degrees and holding at 160 degrees. He stated if any foods are under 160 degrees and in the danger zone, he would put them back in the oven or stove to cook longer and reach appropriate cooked temperatures. He stated that cold foods should be below 40 degrees and if above this temperature it is in the danger zone. He stated that if the temperature is above 40 degrees for more than 45 - 60 minutes this would make the food no good to serve and it would have to be tossed out and remade or substituted for something similar. He stated he began preparing the macaroni salad at 7:00 AM. He stated the truck made a delivery today between 6 AM and 7 AM and the macaroni salad was already cold. He stated the macaroni salad is premade and he does not need to do anything to it but prepare puree and mince & moist levels and serve. He stated he began the puree and minced & moist process at 7:00 AM and returned the deep dish filled with macaroni salad back to the refrigerator about 20 minutes later. When asked about serving the macaroni salad that had produced (3) temperature checks above the danger zone to the residents during lunch service he stated he should not have served the macaroni salad. He stated residents could become ill and die if they were to become sick from this practice. He stated he understands he did not do the right thing and he sees this now. He stated one of the dietary aids cleaned out the refrigerator this morning and the temperature rose, and stated he was not sure how long she kept the doors open while she cleaned it but believes this is what may have caused the temperature of the cold foods to rise. In an observation and interview on 05/28/2025 at 3:45 PM, revealed CK B was checking temperatures for dinner foods: meats, vegetables, and starch, which were all within appropriate temperatures. She stated she had been employed one year at this facility. She was knowledgeable of hand hygiene, cooking temperatures, and serving portions. She stated she had received kitchen training from her manager and the dietitian over the last year. She stated that cold food holding temperature is 40 degrees and below and anything above this temperature is considered the danger zone and would get placed in a cold ice bucket to bring down to an appropriate temperature for safety. She stated if holding temperatures of a food are in the danger zone for long period of time, she would not serve it and ask her manager to switch out for something similar. She stated that if temperatures are in the danger zone bacteria can form and residents could get sick. She stated the best practice is to notify her manager and toss it in the trash and substitute the food with something similar. In an interview on 05/28/2025 at 4:14 PM, the DSM stated she had been employed at this facility one year. She stated she recently obtained her dietician certification and is now transitioning to the clinical side for the facility. She stated there is a full-time dedicated kitchen manager who focuses on the operations side of the kitchen and provides the dietary aides and cooks one-on-one training, staff meetings, ordering, and scheduling. She stated she has provided staff training on cooking 675923 Page 7 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperatures, temperature logs, holding temperatures, and the danger zone for food items not in appropriate temperatures. She stated the cooking temperatures are 155-165 degrees for meats, 140 degrees and above is the holding temperature on the warmer for serving, and the cold food items should be below 41 degrees. She stated that food items above 41 degrees for more than one hour is considered the danger zone. She stated she would toss the food item out and substitute it with something similar and document the substitute log. She stated the holding time is up to 4 hours on the warmer. She stated that temperature logs are maintained by the cook and foods are checked in the morning, noon, and evening meals. She stated that if this practice is not followed it can cause bacteria and this can cause harm and be detrimental to a resident's health. She stated the cleaning schedules are followed by dietary staff on a regular basis and equipment and refrigerators require less time to clean. She stated the cleaning time for the refrigerator would have been no more than 15-20 minutes. She stated that if she would have known all the facts of the macaroni salad that was shared with her during the interview she would have thrown out the product and replaced it with something similar. She then stated the hold temperatures are 4 hours or less if above the danger zone and stated this information was in her training and should be in the manual. In an interview on 05/28/2025 at 4:14 PM, the RDLD a third-party consultant stated she provided consultation services to the dietary staff 2-3 times per month if needed; however, her focus is more on the clinical side. She stated she had provided dietary staff training on cooking temperatures, temperature logs, holding temperatures, and the danger zone for food items. She stated the cooking temperatures are 155-165 degrees for meats, 140 degrees and above is the holding temperature on the warmer for serving, and the cold food items should be below 41 degrees. She stated that if this practice is not followed it can cause bacteria and this can cause harm and be detrimental to a resident's health. She stated that cooks are knowledgeable of checking food temperatures and stated had she had additional information regarding the temperature checks with temperatures above the danger zone, knowledge of food being taken out of the refrigerator with above danger zone temperatures she would have directed the cook to toss out and make something similar. In an interview on 05/28/2025 at 4:20 PM, the DM interrupted the interview in progress with surveyor and RDLD and stated that the macaroni salad was already delivered the prior week and was already cold. She stated it was not delivered today and cook was mistaken with information. The product should have maintained an appropriate temperature and there would be no reason as to it being above 41 degrees. In an interview on 5/29/2025 at 1:56 PM, the DM stated she had been employed for three years at this facility. She stated all staff are responsible for checking refrigerator temperatures, cooks are responsible for checking food temperatures and documenting on the specific logs. She was knowledgeable of food temperatures and holding temperatures. She stated the expectation is for the cooks to check each item to be served and to document the temperature on the log before line service. She stated each level of a food item is to be documented on the log to keep an accurate account of temperatures. She stated she provides the monthly training during monthly meetings, and additional in-services take place during Monday morning meetings; however, these are not documented. She stated these Monday meetings also include any feedback from staff, residents, changes to ingredients, if anything needs to be worked on in the kitchen. She stated the cooks have been trained that if a food item is not hot enough and at the appropriate temperature before meal service to take it off the line and put it in the oven. She stated if the food item is not cold enough the expectation is for the cook to place in an ice bath and put back in the refrigerator to hold temp even if on the service line. She stated that if the temperature is not coming down to the appropriate temperatures, she would direct the cooks to toss it in the trash and replace it with another similar food 675923 Page 8 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some item. She stated the impact to residents can be food borne illness and can give residents stomach problems, diarrhea, and vomiting. When asked about the macaroni salad that remained in the danger zone during yesterday's lunch service, she stated that the cook notified her and she instructed him to put the macaroni salads into 2 separate deep warming pans and into an ice bath to help cool faster, to continue monitoring the food on the line, and temping the service. She stated that she gave the cook the directions to serve the food as she did not believe it was in the danger zone for more than 4 hours. She stated that the cook continued to check the temperatures while monitoring and the diced & moist macaroni salad was cooling down but stated that he did not document this in the log. She stated that the cook made an error, and he notified her at the end of his shift that he did not document the correct temperatures for the foods that were above the danger zone and only documented once prior to meal service and he documented that the macaroni salad was at an appropriate temperature. She stated the cook did not document on the log as to what occurred with the macaroni salad, and he did not correctly notate the temperature he observed, and he was counseled on this. She stated that she did advise him not to do this in the future and that she would be training her dietary staff to document each item being temped from each level. Record review of Diet Type Report, dated 5/29/2025 revealed 20 residents are on level 5 minced & moist, diet texture and would have been served the macaroni salad with temperatures above the danger zone of 41 degrees. Record review of written statement by DSM, dated 5/28/2025 reflected, upon internal review, we acknowledge that this specific instance may have reflected a brief, isolated deviation from standard protocol. Per this policy corrective action was initiated by kitchen manager and was cooled i.e. ice bath consistently stirring to improve circulation of temperature .The remaining item trended down but remained at approximately 42 degrees. Record review of Policy and Procedure Manual, dated 2023 revealed: 7. Food Temperatures for Meal Service a. Check to be sure the staff takes food temperatures correctly and records temperatures. b. Teach staff what to do if temperatures are in the Temperature Danger Zone. Be sure temperatures are taken again, halfway through tray line to assure safety. Record review of Staff Meeting, dated 12/28/2024 revealed cooks were in-serviced on temp logs, timeline, and preparing minced & moist and puree foods. Record review of food temperature log dated 5/28/2025 revealed CKA documented lunch food items as one single food item. CKA documented the macaroni salad end preparation temperature of 36 degrees and tray line temperature of 40 degrees noting it was below the temperature danger zone. There was no entry for the corrective action column of the temperature log. Record review of [NAME] Timeline, not dated revealed: cooks are directed to, 6:40 AM temp logs; 11:05 AM temp logs. 675923 Page 9 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 residents (Resident #8, Resident #27, Resident #53, and Resident #57) reviewed for infection control. Residents Affected - Some 1. During pericare, CNA J folded and reused a disposable wipe when cleaning the groin and penis for Resident #27. 2. MA G did not conduct hand hygiene after preparing medications and prior to administering the medications for Resident #53 and Resident #57. 3. LVN I failed to ensure supplies that were to be used on multiple residents was not placed on a dirty surface in a resident's room for Resident #8. These failures could place residents at risk of transmission of disease and infection. Findings included: 1. Record review of Resident #27's admission record, dated 05/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #27 had diagnoses which included: dysphagia (difficulty swallowing), moderate intellectual disabilities (a condition where someone has an average mental age of 6 to 9 years), spastic quadriplegic cerebral palsy (a conditions that affects movement and posture caused by brain damage before birth), thrombocytopenia (a condition characterized by a low platelet count and may cause easy bruising and/or prolonged bleeding), and malignant neoplasm of descended right testis (testicular cancer). Record review of Resident #27's Quarterly MDS, dated [DATE], reflected a BIMS score 04, which indicated severe cognitive impairment. Record review of Resident #27's care plan, dated 05/22/2025, reflected: Focus: Incontinence of Bowel & Bladder: r/t impaired mobility, cognitive deficit, physical limitations with Goals that included: No infection and Interventions that included: Provide good perineal care . Observation on 05/28/2025 at 03:16 PM, revealed CNA J performing pericare on Resident #27. CNA J used a disposable wipe to wipe the left groin from front to back, then folded the wipe and wiped the penis. CNA J then threw the wipe away, obtained a new wipe and cleaned the right groin from front to back then folded the wipe and used it to clean the pubic mound (area above the base of the penis), then tossed the wipe in the trash. 2. Record review of Resident #53's admission record, dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #53 had diagnoses which included: unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), other impulse disorders (a group of behavioral conditions that involve an inability to control impulses and behaviors), and generalized anxiety disorder (a 675923 Page 10 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 condition characterized by persistent and excessive worry about everyday issues). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #53's Quarterly MDS, dated [DATE], reflected a BIMS score 04, which indicated severe cognitive impairment. Residents Affected - Some Record review of Resident #53's care plan, dated 05/08/2025, reflected: Focus: Medication Administration: Medications whole with water with Goals: will have no complications from medication administration throughout the 90 days. Observation on 05/29/2025 at 07:03 AM, revealed MA G performed hand sanitization, prepared medications appropriately, then locked the cart, grabbed the cup of medication and a cup of water, approached Resident #53, and administered the medication as ordered without performing hand hygiene after touching the surfaces of the medication cart and prior to administering the medication to Resident #53. 3. Record review of Resident #57's admission record, dated 05/29/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: personal history of pneumonia (a history of an infection in the lungs), hypertensive heart disease without heart failure (a heart condition caused by long-term high blood pressure, which can lead to changes in the heart's structure and function), thrombophilia (a condition that makes your blood more likely to for clots), dysphagia (difficulty swallowing), generalized anxiety disorder (a condition characterized by persistent and excessive worry about everyday issues), and chronic kidney disease stage 2 (a condition that mildly affects the kidneys ability to filter out toxins). Record review of Resident #57's Comprehensive MDS, dated [DATE], reflected a BIMS score 04, which indicated severe cognitive impairment. Record review of Resident #57's care plan, dated 03/21/2025, reflected: Focus included: Medication Administration: Medications whole with pudding/applesauce with Goal: will have no complications from medication administration throughout the 90 days. Observation on 05/29/2025 at 07:09 AM, revealed MA G performed hand sanitization, prepared medications, while attempting to place a Vitamin D3 tab in a medication cup, it fell on the top of the medication cart. MA G used a glove to pick up the tablet and used ungloved hand to lift trash can lid while using gloved hand to place tablet in trash can. MA G then place a Vitamin D3 tablet in medication cup, returned bottle to cart, then locked the cart, grabbed the cup of medication and a cup of water, approached Resident #57, and administered the medication as ordered without performing hand hygiene after touching the surfaces of the medication cart and trash can and prior to administering the medication to Resident #57. 3. Record review of Resident #8's admission record, dated 05/29/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #8 had diagnoses which included: hyperlipidemia (high cholesterol), essential hypertension (high blood pressure), major depressive disorder (persistent feeling of sadness and loss of interest), moderate intellectual disabilities (a condition where someone has an average mental age of 6 to 9 years), peripheral vascular disease (decreased blood circulation to the legs), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar). Record review of Resident #8's Quarterly MDS, dated [DATE], reflected a BIMS score 02, which 675923 Page 11 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 indicated severe cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #8's care plan, dated 04/17/2025, reflected: Focus: Enhanced Barrier Precautions: r/t wound with Interventions that included: Maintain enhanced barrier precautions as outline in nursing home policy. Residents Affected - Some Observation on 05/29/2025 at 10:49 AM, revealed LVN I gathered supplies for wound care for Resident #8 into a basket. She proceeded to take all gathered supplies, including a roll of paper tape, into the room. LVN I performed hand hygiene and put on gown and gloves for enhanced barrier precautions. She then set the basket on the bed next to Resident #8's leg and proceeded to perform wound care. After cleaning and applying new dressing to the wound on Resident #8's right calf, LVN I took the roll of paper tape out of the basket, tore a piece of tape off the roll, and set the roll of tape on the bed next to Resident #8. After securing the wrapped gauze around Resident #8's right calf, LVN I gathered the roll of tape off the bed and placed in the basket and placed basket on counter in room. She then took off her gown and gloves and washed her hands, retrieved basket, and returned to nurses' medication cart. In an interview and observation on 05/29/2025 at 11:08 AM, LVN I stated the roll of paper tape should not have been taken into the room with the Resident #8 and set it on the bed. She stated they are supposed to tear a piece of tape off the roll and leave the roll of tape in the medication cart. She stated she was going to throw the roll of tape away and observation revealed LVN I threw the roll of paper tape in the trashcan attached to LVN I's medication cart. LVN I stated using the roll of paper tape on a different resident since it had been on Resident #8's bed could cause transfer of bacteria from one resident to another and could cause an infection. In an interview on 05/29/2025 at 11:30 AM, MA F stated she had worked for the facility for about 30 years. She stated that she had been trained on infection control, that included hand hygiene and how to use the proper personal protective equipment, in April 2025. MA F stated it was policy to wash or sanitize hands before and after providing direct care to a resident. She stated hands should be sanitized before dispensing medications and after administering them to the resident. MA F stated she didn't think hands needed to be sanitized after dispensing the medication and before administering the medication. She stated the ADON monitored hand hygiene about every 3 months. MA F stated by not performing some form of hand hygiene at the appropriate times then the residents could get sick by spreading germs from one resident to another resident. In an interview on 05/29/2025 at 11:39 AM, CNA J stated she had been trained on infection control about a month ago. She stated the training discussed the personal protective equipment needed for residents with enhanced barrier precautions. CNA J stated she had not received training on the proper use of disposable wipes. She stated that in her training they used wash basins and wash cloths, and it was appropriate to fold the washcloths and use them again to clean. CNA J stated that by using a disposable wipe and folding it to use again it could possibly cause an increased risk of infection. In an interview on 05/29/2025 at 11:58 AM, MA K stated she had worked at the facility for 13 years. She was trained on infection control in 2024 and the training covered hand hygiene, how to use personal protective equipment to avoid cross contamination, and enhanced barrier precautions. She stated that hand hygiene needed to be done before and after entering a resident's room to provide care to a resident. MA K stated hand hygiene needed to be performed before dispensing medication and after giving the medication to the resident. She stated it did not need to be performed after gathering medication and before administering the medication to the resident. MA K stated all staff were 675923 Page 12 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responsible for monitoring hand hygiene and the ADON and DON were often on the floor walking around the halls monitoring for proper hand hygiene. MA K stated not using proper hand hygiene could make residents sick by spreading germs and cross contamination. She stated that when providing pericare on a resident, she did not think wet wipes could be folded and used again. MA K stated it's a one and done and to throw away the wipe once used and get a new wipe, but she did not provide pericare often. She said she thought the DON would be the person responsible for monitoring pericare to ensure it was done correctly but did not know how often. In an interview on 05/29/2025 at 12:46 PM, MA G stated she had worked at the facility for about 10 years. She stated she was trained on infection control last month and it covered hand hygiene. MA G stated hand hygiene should be performed before dispensing medication and after administering medication to the resident. She stated she didn't think it was necessary to performed between dispensing the medication and administering the medication to the resident. She stated hand hygiene was monitored by all manager as they performed their walking rounds. She stated by not performing hand hygiene at the appropriate times then germs could be passed from one resident to another and make the residents sick. In an interview on 05/29/2025 at 01:11 PM, the DON stated she had received training on infection control. She stated she received specialized training on infection control in residents with disabilities. The DON stated it was her expectations for staff to perform some sort of hand hygiene, whether it be hand washing or hand sanitizing, before entering a resident's room, after leaving a resident's room, before and after performing any type of direct care to a resident, and when moving from a dirty to a clean field when performing direct patient care. The DON stated that hands are to be sanitized before dispensing medications, before administering medication and after administering medication during medication pass. She stated it was the responsibility of the person providing any care to the resident to ensure they are performing hand hygiene at the appropriate times. The DON stated the weekend RN supervisor was responsible for performing random weekly hand hygiene audits. She stated if hand hygiene is not performed at the appropriate time, then staff could spread infections from one resident to another. The DON stated when performing pericare on a resident it is her expectation for staff to use the disposable wipe one time then throw the wipe away and obtain a new wipe. She stated by using a disposable wipe, folding it, and using it again it increased the risk of a urinary tract infection in the resident. The DON stated staff were required to perform check offs twice prior to working independently then staff had to perform the skill check off again annually to ensure competency. The DON stated that any resident who had a need for wound care that required tape should have their own roll of tape that was kept in a bag with the resident's name labeled on it. She stated if a roll of tape was placed on a dirty surface in a resident's room, then placed back in the nurses' medication cart, it could spread germs to other things in the cart. In an interview on 05/29/2025 at 01:41 PM, the ADM state he had received training on infection control in January 2024. He stated he expected staff to perform hand hygiene before providing personal care to the residents, with glove changes, before serving meal trays. He stated he thought hands should be sanitized before, after and maybe in the middle of a medication pass though that was more of a clinical question and he wasn't sure. He stated he was responsible for everything in the building but deferred the monitoring of hand hygiene to the DON and the ADON. The ADM stated the DON and ADON performed checkoffs regularly though it was unsure of the exact timeframe. He stated by not performing hand hygiene at the appropriate times, the residents could be at a higher risk of infection. The ADM stated disposable wipes should be used only one time then thrown away. He stated he relied on the DON and the ADON to monitor skills checkoffs for pericare performed by the staff. He stated there was not a policy related to the use of disposable wipes when 675923 Page 13 of 14 675923 05/29/2025 Marbridge Villa 2504 Bliss Spillar Road Manchaca, TX 78652

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some performing pericare. The ADM stated he was unsure of the process for using paper tape on residents, but the roll of tape shouldn't be placed on a resident's bed then placed back in the nurses' medication cart. He stated if tape was set on a resident's bed, then used on a different resident that could be an infection control issue. Record review of the facility's policy titled Handwashing/Hand Hygiene, dated 2001 and revised 10/2023, reflected, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretations and Implementation 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident; . Record review of the facility's policy title Wound care, dated 2001 and revised 10/2010, reflected, Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Steps in the Procedure . 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart . 675923 Page 14 of 14