Health inspection·March 7, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect for 3 of 7 staff (LVN #1, [NAME] #2,CNA #3, and CNA #4) reviewed for background screenings. Residents Affected - Some The facility failed to ensure that employees were screened for a history of abuse, neglect, exploitation, or misappropriation prior to employment for LVN #1, Cook# 2, and CNA #3, and CNA # 4. Criminal history checks, and checks of the EMR/NAR were not conducted prior to employment. These deficient practices could place residents at risk for abuse and neglect. The findings were: 1.Review of the personnel file for LVN #1 indicated a hire date of 07/2/2024 and the Criminal History background check was verified on 12/3/24, and initial EMR/ NAR verified on 3/4/25. 2. Review of the personnel file for [NAME] # 2 indicated a hire date of 12/02/2024 and the Criminal History background check was verified on 01/13/2025, and initial EMR/NAR verified on 01/21/2025. 3. Review of the personnel file for the CNA # 3 indicated a hire date of 06/28/2024 and the Criminal History background check was verified on 12/03/2024, and the initial NAR/EMR verified on 03/04/2025. 4. Review of the personnel file for CNA # 4 indicated a hire date of 06/28/2024 and the Criminal History Background Check was verified 0on 12/02/2024, and the initial NAR/EMR verified on 03/04/2025. During an interview with the Administrator, on 03/25/2025 at 1:00 PM the administrator stated her expectation is for Criminal History and EMR/NAR searches to be completed prior to hire. She stated conducting these searches was the responsibility of Human Resources, however in mid-January the process changed, and she began to monitor and sign off on audits. She stated around January of 20254, she noticed that searches were not being completed and she requested an audit which was completed on 1011/20/2025 . She stated all DPS, and license checks were completed at that time. However corporate did not audit the EMR/NAR checks but stated they would be back to complete the audit which had not occurred. The administrator stated a negative outcome that could occur by not completing the Criminal background and EMR/NAR searches would be that someone with a criminal background could be hired and put the residents a risk of abuse. During an interview on 03/05/2025 at 2:55 PM, the Human Resource staff (HR) stated the criminal history background checks had not been verified prior to the hiring of the LVN #1, [NAME] #2, CNA #3, Page 1 of 4 676148 676148 03/07/2025 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or CNA #4. She stated the HR stated that all NA's should have background checks within 72 hours of hire. She stated she was responsible, and the administrator and the corporate Human Resources monitored to see that they were in compliance. She stated the negative impact of not performing the background check on staff could have possibly caused harm to residents. She stated by not doing so, the residents could be harmed by abuse or neglected. She stated the failure was the background check verifications did not occur the 72 hours, with her expectations was for every potential employee to have a background check prior to working with any resident going forward. During an interview on 09/06/2024 at 3:10 PM, the ADMN stated all staff needed to have background checks prior to working with residents as it could have resulted with staff working with residents that should not be allowed to work. She stated in doing so could have led to Abuse, Neglect, and Exploitation. The ADMN stated her expectations wasere for the criminal history background checks should to be performed prior to being allowed to work in the facility and around residents. Record review of facility document Criminal Background Checks dated revised 01/31/2017 revealed: It is the policy of this facility to conduct criminal background checks of all applicants within 72 hours of employment according to the State of Texas law. This facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250. All potential employees will be screened for history of abuse, neglect, or mistreating of elderly individuals as defined by the applicable requirements of 483.13 ( c ) (1) (ii) (A) and (B). The facility will check potential employees with the Texas Nurses Aide Registry or Misconduct Registry. The facility will not employ individuals who have been found guilty abusing, neglecting, mistreating residents, or misappropriation, of a resident's property; as determined by the Texas Nurse Aide Registry or Misconduct Registry, or have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property . Employees whose background check reveals convictions or formal action of the type prohibited by law or company policy will not be eligible for employment. An employee who has been discharged due to information revealed from the background check may obtain a copy of the Criminal History Check from the local law enforcement agency. 676148 Page 2 of 4 676148 03/07/2025 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident # 4) of 6 residents reviewed for infection control, in that: Residents Affected - Few The facility failed to implement Enhanced Barrier Precautions for Resident #4 who required feedings via a gastrostomy tube (a surgically created hole with a tube inserted into the stomach to provide an alternative route for nutrition and hydration for the resident). This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #4's electronic face sheet dated 03/05/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Dysphagia (difficulty swallowing), Dementia, and Multiple sclerosis (a disease that affect the nervous system that leads to muscle loss and weakness) The resident had a gastrostomy tube (a surgically created hole with a tube inserted into the stomach to provide an alternative route for breathing). During observation of perineal care on Resident # 4 on 3/5/25 at @ 2:55 p.m, it was observed that CNA A and CNA B did not follow enhanced barrier precautions by donning a gown during incontinent care. There was a sign indicating Resident #4 was on enhanced barrier precautions on the outside of the resident's door. The resident did not respond verbally to the surveyor, but he did follow her movement with his eyes. In an interview with CNA A on 3/5/25 at 3:10 p.m., she reports she identifies when a resident is on enhanced barrier precautions by looking for the sign outside the resident's door. She stated acknowledged that she should have gowned up for perineal care but forgot to do so. She stateds she was provided training from the facility regarding enhanced barrier precautions in the form of an in-service. When asked about any negative outcomes that could occurring if enhanced barrier precautions are not followed, she stateds not really, the g-tube doesn't have an infection. In an interview with CNA B on 3/5/25 at@ 3:11 p.m., she stated she is new, and it was only her second day working in this facility. She reporteds she did not see the sign prompting her to gown up and does not know where to find PPE. She reported she hads not been provided enhanced barrier training at this facility but hads taken trainings in the past at other facilities. She stated that an enhanced barrier precaution sign is typically outside a room and the sign indicateds you should wear PPE which included gowns. When asked what negative outcome could occur by not following enhanced barrier precautions, she stateds, You or the patient could become sick. In an interview on 3/5/25 at 3:30 PM the DON (who is also the Infection Preventionist) said the facility should have implemented Enhanced Barrier Precautions for the rResident # 4's gastrostomy tube. She said a possible negative outcome could be the possible spread of infection. She provided a copy of the policy Enhanced Barrier Precautions. Record review of dated 4/1/2024 Titledthe Enhanced Barrier Precautions policy dated 4/1/2024 which 676148 Page 3 of 4 676148 03/07/2025 Peach Tree Place 315 W Anderson St Weatherford, TX 76086

F 0880 stated [in part] : Level of Harm - Minimal harm or potential for actual harm Multi Drug Resistant Organisms are common in long term care facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROS. Enhance Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employ targeted gown and glove use during high contact resident care activities. Residents Affected - Few Review of website https://www.cdc.gov/preventmdro on 7/20/24, revealed the following: Multi drug resistant organism transmission is common in skilled nursing facilities, contributing to substantial resident, morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP may be indicated when contact precautions do not apply for residents with any of the following: wounds or indwelling medical devices regardless of multidrug resistant organism colonization status 676148 Page 4 of 4