Health inspection·May 16, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 of 5 residents (Resident's #1, #2, and #3) reviewed for indwelling urinary catheters. 1. The facility failed to have a physician's order for Resident #2's urinary catheter. 2. The facility failed to ensure Resident #1, Resident #2, and Resident #3's urinary catheter bags were inside a privacy cover while inside and outside of their rooms. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of increased UTI's, discomfort, and decreased quality of life. The findings included: Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included stroke (poor blood flow to part of the brain causing cell death), high blood pressure, diabetes, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. In an observation on 05/16/2025 at 9:37 AM, Resident #1 was wheeling down the hallway with her urinary catheter bag clipped to the side of her wheelchair and approximately ¼ of the way full of bright yellow urine. In an interview on 05/16/2025 at 9:45 AM with Resident #1, she stated that she almost never had a privacy cover on her catheter bag, and that it just hung off the side of her wheelchair for anyone to see. In an interview on 05/16/2025 at 10:52 AM with Resident #1's FM, they stated that Resident #1's catheter bag was not usually covered with a privacy bag when they visited the resident. The FM stated that they visited almost daily and that on (5/16/25) was the first time a CNA went in and put a privacy bag over the Resident's catheter bag. Review of Resident #2's closed record comprehensive MDS assessment dated [DATE] reflected an-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, high blood pressure, obstructive uropathy (a blockage that prevents urine from flowing naturally through Page 1 of 5 676197 676197 05/16/2025 Ridgeview Rehabilitation and Skilled Nursing 206 Walls Dr Cleburne, TX 76033

F 0557 Level of Harm - Minimal harm or potential for actual harm the urinary system), hyperlipidemia (high levels of fats in the blood), osteoporosis (bones disease), aphasia (impairment in speech production, comprehension, reading and/or writing), non-Alzheimer's dementia (memory impairment), depression (sadness), and encounter for surgical aftercare following surgery on the digestive system. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Residents Affected - Some Review of Resident #2's care plan dated closed on 05/09/2025 due to discharge reflected no indication the resident had an indwelling catheter. Review of Resident #2's physician's orders dated active as of 4/11/2025 reflected no orders for an indwelling urinary catheter. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included heart failure, high blood pressure, urinary tract infection, diabetes, depression, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In an observation and interview on 05/16/2025 at 3:00 PM of Resident #3 in her room revealed she thought her catheter was coming out and that the bag needed to be changed because it felt full. Observation of her bag hanging on the side furthest from the door revealed an almost full plastic container in front of an almost empty catheter bag that was not inside of a privacy bag. In an interview on 05/16/2025 at 10:33 AM with CNA B she stated that the importance of having a privacy cover on the catheter bag is so other residents don't see the urine. In an interview on 05/16/2025 at 11:30 AM with the DON, she confirmed that the orders for Resident #2's Foley catheter could not be located in the EHR. Additionally, it was confirmed that she was not care planned for a Foley catheter. She stated that she could not understand why the orders were not showing up nor why the care plan would not be showing catheter care, because 'How else would MDS know to mark it?' Regarding catheters having a privacy bag, she stated that those were just there for residents' dignity and that any of the direct care staff can put a privacy cover over a catheter bag. Review of the facility's Catheter Care policy last reviewed December 2023 reflected, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 676197 Page 2 of 5 676197 05/16/2025 Ridgeview Rehabilitation and Skilled Nursing 206 Walls Dr Cleburne, TX 76033

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Residents #1, #2, #3, and #4) of 7 residents reviewed for comprehensive care plans. The facility failed to care plan the use of Residents #1, #2, #3, and #4's urinary catheters. This failure placed residents that had urinary catheters at risk of not having their need for assistance met and increased susceptibility to UTI's. The findings included: Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included stroke (poor blood flow to part of the brain causing cell death), high blood pressure, diabetes, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #1's initial care plan dated 04/23/2025 reflected no indication the resident had an indwelling catheter. In an observation on 05/16/2025 at 9:37 AM, Resident #1 was wheeling down the hallway with her urinary catheter bag clipped to the side of her wheelchair and approximately ¼ of the way full of bright yellow urine. In an interview on 05/16/2025 at 9:45 AM with Resident #1, she stated that she almost never had a privacy cover on her catheter bag, and that it just hung off the side of her wheelchair for anyone to see. Review of Resident #2's closed record comprehensive MDS assessment dated [DATE] reflected an-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, high blood pressure, obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system), hyperlipidemia (high levels of fats in the blood), osteoporosis (bones disease), aphasia (impairment in speech production, comprehension, reading and/or writing), non-Alzheimer's dementia (memory impairment), depression (sadness), and encounter for surgical aftercare following surgery on the digestive system. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #2's care plan date closed on 05/09/2025 due to discharge reflected no indication the resident had an indwelling catheter. Review of Resident #2's physician's orders revealed no orders for a Foley catheter or catheter care. 676197 Page 3 of 5 676197 05/16/2025 Ridgeview Rehabilitation and Skilled Nursing 206 Walls Dr Cleburne, TX 76033

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #2's hospital record dated 04/07/2025 reflected, Patient placed on Foley catheter by urology, plan to DC with Foley catheter and follow-up with urology. Hydronephrosis (a condition where a kidney swells due to urine buildup caused by an obstruction) significant improvement of right hydronephrosis after manual reduction. -Foley catheter. Renal Function okay. Follow-up with urology. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included heart failure, high blood pressure, urinary tract infection, diabetes, depression, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having none of the above when asked if the resident had an indwelling catheter, external catheter, ostomy, or intermittent catheterization. Review of Resident #3's care plan last revised 05/14/2025 reflected no indication that the resident had an indwelling catheter or intermittent catheterization. Review of Resident #3's physician's orders revealed an order for Foley Catheter Care every shift, ordered 3/19/25. An order for Indwelling Foley catheter (16F 30cc) to continuous drainage, ordered 3/19/25. An order for Secure catheter tubing with anchor every shift, ordered 3/19/25. An order for Change the Foley catheter every 30 days, ordered 3/19/25. In an observation and interview on 05/16/2025 at 3:00PM of Resident #3 in her room revealed she thought her catheter was coming out and that the bag needed to be changed because it felt full. Observation of her bag hanging on the side furthest from the door revealed an almost full plastic container in front of an almost empty catheter bag that was not inside of a privacy bag. Review of Resident #4's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included high blood pressure, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #4's care plan last revised 04/29/2025 reflected no indication that the resident had an indwelling catheter. In an interview on 05/16/2025 at 10:33 AM with CNA B she stated that she recalled Resident #2 often yanking on her catheter, asking why she had it, and demanding it be removed from her body. She stated that the importance of having a privacy cover on the catheter bag is so other residents don't see the urine. In an interview on 05/16/2025 at 2:00 PM with the MDSC, she stated that Resident #3's MDS assessment would be updated to reflect a catheter during her next assessment unless she had a significant change before then, and that becoming catheterized did not call for an SCSA. She stated that the resident previously had a catheter, had it removed, had it replaced at another time, and it was failed to be care planned during the most recent insertion. As for the other residents, she stated that she could not provide an answer as she maintained the long-term residents' assessments, and the short term 676197 Page 4 of 5 676197 05/16/2025 Ridgeview Rehabilitation and Skilled Nursing 206 Walls Dr Cleburne, TX 76033

F 0656 MDSC was out of office for an extended period. Level of Harm - Minimal harm or potential for actual harm In an interview on 05/16/2025 at 3:46 PM with LVN A, she stated that she knew to provide catheter care to Resident #2 because she could see the resident had a catheter. She recalled that the resident would frequently ask for the catheter to be removed and asked the staff why she had it. She stated that she knew what hygienic care to provide because with any resident that has a Foley, they are to provide a standard practice of cleanliness and hygiene when providing incontinent care, including cleaning the pubic area and the tubing surrounding the outside of the pubic area. She stated that she can recall multiple times providing incontinent care to Resident #2 and they also began the toileting program with her. Residents Affected - Some Review of the facility's Care Plans, Comprehensive Person-Centered dated last revised 03/2022 reflected, . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 676197 Page 5 of 5