Health inspection·October 27, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, recognizing each resident's individuality and protect and promoted the rights of the resident for 2 of 15 residents (Resident #7 and #64) reviewed for dignity, in that: Residents #7, and #64 urinary drainage bags were not covered or in a dignity bag for privacy. This deficient practice could place residents at risk of embarrassment, lack of privacy, and loss of dignity. The findings were: Record review of resident #7's face sheet undated revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included [Parkinson's disease], a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement. [Benign prostatic hyperplasia] causes your prostate to increase in size, leading to decreased urine flow, and [Depression] is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities. Record review of Resident's # 7 Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 12, which indicated Resident # 7 is moderately impaired. During observation and interview on 10/26/23 at 910 a.m., resident # 7 was observed in the room watching television, sitting in his wheelchair with a urinary bag hanging under the chair; straw-colored urine was noted. Resident # 7 stated, they usually put a cover on the urinary bag, but they must have forgotten it. During an Interview with RN E on 10/26/23 at 920 a.m., she stated she was the assigned nurse for resident #7, and she did not know where the urinary bag covers [NAME] but would locate one and put it on the urine bag. RN E stated that the resident risked possible embarrassment by not having the urinary bag covered. Record review of Resident #64's profile dated 10/27/23 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with readmission on [DATE] with diagnoses that included other specified myopathies (group of disorders primarily affecting the skeletal muscle structure, metabolism, or channel function), irritant contact dermatitis due to fecal, urinary, or dual incontinence Page 1 of 27 676274 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (nonallergic skin reaction that occurs when an irritant damages your skin's outer protective layer), personal history of malignant neoplasm unspecified (cancerous tumor), Morbid (severe) obesity due to excess calories, and repeated falls. Record review of Resident #64's quarterly MDS assessment dated [DATE] indicated the resident had a BIMS score 15/15 indicating the resident was cognitively intact. The resident was dependent on staff for bed mobility. The resident had a foley catheter for urine and was frequently incontinent of bowel. Section F for preferences was blank. In an observation on 10/24/23 at 9:58 a.m. Resident #64 was in bed watching TV (television), Foley catheter drainage bag was on bed frame, and could be seen from the hallway draining clear yellow urine, no dignity or privacy cover was observed. Observation and interview on 10/24/23 beginning at 2:02 p.m. Resident #64 was in bed watching TV (television), Foley catheter drainage bag was on bed frame, and could be seen from the hallway draining clear yellow urine, no dignity or privacy cover was observed. The resident stated she was doing fine and preferred to stay in her room but was invited to activities by staff. During an interview with the DON on 10/26/2023 at 12:33 p.m., the DON stated that Resident #7's urinary bag should have been covered. She did not know why it was not covered, but he would In-service staff. The DON noted that by having Resident's # 7 urinary bag not covered the resident risked possible embarrassment. Record review of facility policy titled Quality of life - Dignity 2001, revised October 2009 revealed. Resident shall be treated with dignity and respect at all times . 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered; . 676274 Page 2 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to promote and facilitate the residents right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care for 1 of 4 residents (Resident #6) reviewed for self-determination in that: Resident #6 was taken to his room during a behavior and put in bed despite the resident protesting by yelling and hitting staff during transfer. This failure could place residents at risk of feeling like they have no rights, no choice, and no control, and could result in increased aggression, anger, and a decreased quality of life. The findings included: Record review of Resident #6's profile dated 10/27/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Cerebral infarction (stroke), profound intellectual disabilities (profound limitations in cognitive functioning and skills, including conceptual, social and practical skills, such as language, social and self-care skills), unspecified behavioral syndromes associated with physiological disturbances and physical factors, adjustment disorder with anxiety (excessive reactions to stress, feeling worried, anxious and overwhelmed, trouble concentrating), Impulse disorder (behavioral conditions that involve an inability to control impulses and behaviors), anxiety disorder, and Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves and can include a combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning). Record review of Resident #6's annual MDS assessment dated [DATE] indicated the resident had slurred speech, was sometimes understood, and sometimes understands and the resident responded to simple, direct communication only. The resident had a BIMS score of 99 indicating the resident was not able to complete assessment and the resident had impaired short- and long-term memory. Assessment of cognitive skills for decision making indicated the resident was moderately impaired, made poor decisions, required cues and supervision. Physical and verbal behaviors occurred 1-3 days but did not put others at risk for physical injury or significantly intrude on others privacy or activity. The resident rejected care 1-3 days and was dependent on staff for getting in and out of bed and was substantial assistance for rolling left or right. The resident was always incontinent of bowel and bladder. of 11/11/23 indicated a focuses for impaired cognitive function and thought processes, physical and verbal behaviors and the interventions included to remove the resident from the area if in a public or common area and to stop and return later if he was agitated. There were no interventions for putting the resident to bed if agitated. Record review of Resident #6's nurses notes revealed a note dated 9/25/23 at 8:49 p.m. by an unknown nurse the resident hit another resident who was leaving the dining room unprovoked, and the residents were separated, and Resident #6 was taken to his room where he was assisted to bed. While being assisted to bed, (Resident #6) became physical with the staff and began spitting and hitting them . 676274 Page 3 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0561 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #6's nurses notes revealed a note dated 9/28/23 at 12:09 p.m. by an unknown nurse the resident grabbed at another resident who was wheeling by him and pinched the medication aide that was trying to pull him away. Resident #6 had a pen in his hand and attempted stabbing at staff with it. The resident taken to his room to be changed and laid down. He continued to hit and curse at staff throughout incontinent care. And a message was left for the NP. Residents Affected - Few Record review of Resident #6's nurses notes revealed a note dated 10/9/23 at 9:13 a.m. by RN E while leaving the dining room the resident had kicked the back of another resident's chair. Residents were separated and Resident #6 was brought to the nursing station where he began displaying his middle finger and yelling obscenities to everyone who approached him. He was then taken to his room while continuing to yell obscenities. The CNA attempted to put him to bed and he was aggressively yelling and coming at her as if to hit her. We separated ourselves from the resident and gave him cool-down time. Later another CNA attempted to put him to bed. While she was putting him to bed, he continued to become aggressive and punched her right arm until it became bruised . Record review of Resident #6's physician orders revealed an order with a start date of 11/17/22 and a revision date of 12/11/22 for behavior monitoring and documenting interventions each shift . Record review of Resident #6's EMAR for October 2023 indicated the resident had 0 behaviors from 10/1/23 to the first shift on 10/26/23. Available codes for interventions were 1-1 to 1, 2-activity, 3-adjust room temperature, 4-backrub, 5-change position, 6-give fluids, 7-give food, 7-redirect. There were no interventions documented. Observation on 10/24/23 at 11:58 a.m. Resident #6 was in the dining room sitting at a table next to his brother (roommate) eating lunch. No aggression observed. Observation and interview on 10/25/23 beginning at 10:25 a.m. Resident #6 was sitting inside the nurses station coloring. The resident was calm and quiet and agreed to be interviewed. The resident stopped coloring, put down the crayon and backed away from the counter and turned to face surveyor. The resident was slow in his responses and his speech was slurred but able to understand the resident. The resident was able to answer simple yes or no questions and stated staff were nice and good when asked how the staff treated him. When asked if he was able to make choices about when to go to bed the resident stared at surveyor and did not respond to the question. The resident continued answering other questions after and no aggression or behavior was observed. In an interview on 10/26/23 at 10:18 a.m. CNA I stated if a resident was hitting her or being combative with care, showers, or going to bed she would tell the nurse and try again later once the resident had calmed down but would not continue with attempting care at that time. In an interview on 10/26/23 at 10:20 a.m. CNA J stated if a resident were combative, she would let the nurse know, and come back later and try again but would not continue with attempted care despite aggression. In an interview on 10/26/23 at 2:45 p.m. CNA K stated she works with Resident #6 and when he becomes aggressive, she attempts to find out what was causing the aggression. CNA K further stated staff sometimes offer snacks to the resident and she will have the resident sit next to her while she was documenting when he was in a bad mood or yelling and cussing at people, and he usually calms down, but she tells him that he needs to be nice, and he will sit next to her and color. 676274 Page 4 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 10/27/23 at 4:10 p.m. RN E stated she had worked at the facility for 6 months and Resident #6 was having more behaviors recently and she was unsure what was causing the behaviors. RN E stated Resident #6 becomes aggressive at different times, but she attempts to talk to him because he likes 1 to 1 attention, and he will sit behind the nurses station and color. RN E further stated on 10/6/23 when the resident became aggressive RN E and the other staff left the room so the resident could calm down and later (unsure of the length of time) the CNA notified RN E the resident had punched her arm multiple times leaving a bruise. RN E stated she checked on the resident and he was in bed calm and quiet. RN E stated she was unsure of the time the CNA had put the resident to bed because she was not present. RN E further stated the resident does get tired and will sometimes state lay down when he wants to go to bed or I'm wet when he needs incontinent care and was usually cooperative during those times. In an anonymous interview it was stated staff (no names given) will often times just go in and start doing stuff and not explaining what they are going to do and Resident #6 will start yelling and become aggressive. It was further stated Resident #6 was often taken to his room and put to bed during a behavior but trying to put him to bed only makes the Resident's behavior worse because he does not want to go to bed and he does not like to be isolated or secluded and or feel like he's in trouble for the behaviors. It was further stated the resident will yell, cuss, and hit staff but they continue to put him to bed instead of giving him time sitting in his room to calm down and the resident responded favorably when offered snacks that he likes and positive 1 on 1 attention. It was further stated they felt putting the resident to bed was a trigger for the Resident's behavior and only made him angrier and more aggressive. In an interview on 10/27/23 at 1:50 p.m. the DON stated during behaviors Resident #6 was agitated, yelling, and screaming prior to being taken to his room and was brought to his room to decrease stimulation and let the resident relax but he continued the behavior and was not yelling and being aggressive towards staff about going to bed. The DON further stated a lot of times the resident will relax and calm down once he was in bed. Review of facility policy titled Resident Rights revealed . 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Review of facility policy titled Quality of life - Dignity, 2001, revised October 2009 revealed under treatment for cognitively impaired residents .12. Staff shall treat cognitively impaired residents with dignity and sensitivity; for example: a. Addressing the underlying motives or root causes for behavior; and b. Not challenging or contradicting the resident's beliefs or statements. 676274 Page 5 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #16) of 18 residents reviewed for advance directives, in that: Resident #16 was able to make her wishes known and her OOH-DNR was executed by her daughter. This deficient practice put residents at risk of not having their rights honored and of receiving CPR against their will. The findings were: Record review of Resident #16's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses including: Type 2 Diabetes Mellitus with Hyperglycemia, Hypertensive Heart Disease with Heart Failure, and Bilateral Primary Osteoporosis of Knee. Record review of Resident #16's comprehensive MDS, dated [DATE], revealed a BIMS of 12 which indicated moderately impaired cognition. Record review of Resident #16's quarterly MDS, dated [DATE], revealed a BIMS of 11 which indicated moderately impaired cognition. Record review of Resident #16's care plan, as of [DATE], revealed, My code status is DNR. Record review of Resident #16's physician orders as of [DATE], revealed an order dated [DATE], DNR. Record review of Resident #16's clinical record did not reveal findings of incompetence from a psychiatric practitioner and did not reveal letters of guardianship from a judge. Record review of Resident #16's OOH-DNR form revealed it was executed by the resident's family member. During an interview with Resident #16 on [DATE] at 4:45 p.m., Resident #16 stated she was aware of the OOH-DNR and agreed with it, but had not been given the opportunity to execute the document for herself. During an interview with the DON on [DATE] at 4:52 p.m., the DON confirmed Resident #16 had not been deemed mentally incompetent and should have been given the opportunity to execute an OOH-DNR for herself. Program, updated [DATE], revealed, Frequently Asked Questions for DNR: --What happens if the form is not filled out correctly or EMS has doubts about any of the information? 676274 Page 6 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Resuscitate Program, updated [DATE], revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form: Declaration A. This box is for patients who are competent . B. This box is used when the order is being completed by a legal guardian, the person with medical power of attorney for the patient or a proxy in a directive to physician for a person who is incompetent or otherwise mentally or physically incapable of communication. Record review of the facility policy, Advance Directives, revised [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy. 676274 Page 7 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an assessment within 14 days after the resident experienced a significant change in status for 1 (Resident #53) of 18 residents reviewed for resident assessment, in that: Residents Affected - Few A feeding tube was placed for Resident #53 and the facility failed to re-assess the resident. This deficient practice could lead to improper care and diminished quality of life for residents whose needs are not fully assessed. The findings were: Record review of Resident #53's face sheet, dated 10/27/2023, revealed an admission date of 07/12/2023 with diagnoses including: Critical Illness Myopathy, Unspecified Severe Protein Calorie Malnutrition, and Adult Failure to Thrive. Record review of Resident #53's comprehensive MDS dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #53's care plan, as of 10/27/2023, revealed [Resident #53] require tube feeding [related to] weight loss. Record review of Resident #53's clinical record as of 10/27/2023 revealed the resident was hospitalized from [DATE] 10/09/2023 and a feeding tube was placed during her hospital stay. Record review of Resident #53's clinical record as of 10/27/2023 revealed a significant change MDS assessment had not been completed following the resident's hospitalization and placement of the feeding tube. During an interview with the MDS/Care Plan Coordinator on 10/27/2023 at 4:24 p.m., the MDS/Care Plan Coordinator confirmed the significant change MDS assessment had not been completed and should have been. The MDS/Care Plan Coordinator stated she was responsible for completing MDS assessments and stated she was new to the position and had not yet completed a review of past work. The MDS/Care Plan Coordinator stated the potential harm to the resident of not having a complete and correct assessment was receiving care from staff who are unaware of the resident's needs. Record review of the facility policy, Resident Assessment Instrument, revised April 2010, revealed, 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: b. When there has been a significant change in the resident's condition . 676274 Page 8 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 1 (Resident #68) of 18 residents reviewed for comprehensive care plans, in that: Resident # 68's therapeutic diet was not listed on his care plan. This deficient practice could result in resident's receiving improper care and improper diets due to a lack of communication. The findings were: Record review of Resident #68's face sheet, dated 10/27/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Metabolic Encephalopathy, Muscle Wasting and Atrophy, and Chronic Obstructive Pulmonary Disease. Record review of Resident #68's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #68's care plan, as of 10/27/2023, revealed it did not include the resident's therapeutic diet order. Record review of Resident #68's clinical record revealed a physician order dated 09/18/2023, [No added salt], no fried or high fat foods, mechanical soft texture, nectar consistency. During an interview with the MDS/Care Plan Coordinator on 10/27/2023 at 4:24 p.m., the MDS/Care Plan Coordinator confirmed Resident #68's therapeutic diet should have been included in his care plan. The MDS/Care Plan Coordinator stated she was responsible for completing MDS assessments and stated she was new to the position and had not yet completed a review of past work. The MDS/Care Plan Coordinator stated the potential harm to the resident of not having a complete and correct assessment was receiving care from staff who are unaware of the resident's needs. Record review of the facility policy, Care Plan-Comprehensive revised April 2010, revealed, An individualized comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs is developed for each resident. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. 676274 Page 9 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 (Resident #53) of 4 residents with pressure ulcers reviewed, in that: Residents Affected - Few Resident #53 did not receive treatment for her pressure ulcer for 10 days and the pressure ulcer worsened. This deficient practice could place residents with pressure ulcers at risk of pain and diminished quality of life due to wounds. The findings were: Record review of Resident #53's face sheet, dated 10/27/2023, revealed an admission date of 07/12/2023 with diagnoses including: Critical Illness Myopathy, Unspecified Severe Protein Calorie Malnutrition, and Adult Failure to Thrive. Record review of Resident #53's comprehensive MDS dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #53's care plan, as of 10/27/2023, revealed [Resident #53] have actual impairment to skin integrity. Record review of Resident #53's clinical record as of 10/27/2023 revealed the resident was hospitalized from [DATE] 10/09/2023 and developed a pressure ulcer while in the hospital. Record review of Resident #53's Admit/Readmit Screener, dated 10/09/2023, revealed the resident had a pressure ulcer on her sacrum which measured 0.4 cm long x 0.3 cm wide x 0.1 cm deep. Record review of Resident #53's Weekly Skin Assessment, dated 10/18/2023, revealed a wound is present to the sacrum measuring 1.0 cm long x 0.4 wide x 0.1 cm deep. Record review of Resident #53's clinical record revealed an order dated 10/19/2023 for daily wound care. Record review of Resident #53's clinical record revealed no treatments were conducted between 10/09/2023 and 10/19/2023. During an interview with Resident #53 on 10/24/2023 at 12:15 p.m., Resident #53 stated she experienced pain in her sacral area. During an interview with the DON on 10/27/2023 at 4:52 p.m., the DON confirmed Resident #53 did not receive wound care for her sacral pressure ulcer between 10/09/2023 and 10/19/2023 and that the resident should have received treatment. The DON stated she was responsible for nursing care and the deficient practice was an oversight. The DON confirmed the harm to the resident was that her wound worsened and added the resident had received daily treatments since 10/19/2023. 676274 Page 10 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility policy, Pressure Ulcer Treatment, revised September 2016, revealed, The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s); b. Managing tissue loads; c. Pressure ulcer care; d. Managing bacterial colonization and infection; e. Operative repair of the pressure ulcers(s). 676274 Page 11 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 (Hall 400) 8 halls reviewed for accident hazards, in that: A container of liquid disinfectant was stored in an unlocked room in Hall 400. This deficient practice could place residents at risk of harm by coming into contact with hazardous materials. The findings were: Observation on 10/24/2023 at 12:30 p.m. revealed a container of liquid disinfectant mixture in an unlocked room in Hall 400. During an interview with the Maintenance Director on 10/27/2023 at 4:20 p.m., the Maintenance Director stated the disinfectant was made up of peroxide disinfectant or bleach disinfectant, of which both containers were labeled, Danger and Keep Out of Reach of Children. The Maintenance Director confirmed the disinfectant mixture had been stored in an unlocked room on Hall 400 following its use during an outbreak of Covid-19. The Maintenance Director confirmed a resident could be harmed if he or she came into contact with the disinfectant mixture. Record review of the facility's policy titled, Accidents, undated, revealed, Purpose: The facility must ensure the resident's environment remains as free from accident hazards as is possible . 'Avoidable Accident' means that an accident occurred because the facility failed to: identify environmental hazards and/or individual resident risk of an accident . 'Hazards' refer to elements of the resident environment that have the potential to cause injury . 676274 Page 12 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **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 appropriate treatment and services to prevent urinary tract infections for 1 of 15 residents (Resident #7) who were reviewed for indwelling urinary catheter care, in that; a. Residents # 7's Condom catheter was not removed on 10/25/23 and 10/26/23 as per physician orders These deficient practices could affect residents with indwelling urinary catheters and place them at risk of urinary tract infections. The findings included: Record review of resident #7's face sheet undated revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included [Parkinson's disease], a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement. [Benign prostatic hyperplasia] causes your prostate to increase in size, leading to decreased urine flow, and [Depression] is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities. Record review of Resident's # 7 Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 12, which indicated Resident # 7 was moderately impaired. Record review of Resident #7's physician order, dated 03/05/2023, revealed the order Remove condom catheter, first thing in the a.m. Record review of Resident # 7's care plan, undated, revealed: Resident uses condom catheter at night. a. Observation on 10/25/23 at 10:45 a.m. revealed Resident # 7 in his wheelchair, propelling himself to the dining room with the urinary bag attached to his wheelchair. b. Observation on 10/26/23 at 11:34 a.m. revealed Resident #7 in his room, sitting in his wheelchair, watching television with the urinary bag attached to his wheelchair. During an interview with Resident # 7 on 10/26/23 at 11:50 a.m., resident #7 stated, They (Nurses) sometimes forget to remove my condom catheter in the morning, but I don't mind it on . During an interview with CNA G on 10/26/23/2023 at 11:55 AM, CNA G confirmed that Resident #7's condom catheter was present on Resident #7, as she was the assigned CNA today, and on 10/25/23, CNA G did not know why resident # 7 was wearing a Condom catheter on 10/25/23 and today, but she directed the surveyor to speak to the Nurse. 676274 Page 13 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0690 Level of Harm - Minimal harm or potential for actual harm During an interview with RN E on 10/26/2023 at 12:05 a.m., RN E stated she was the assigned nurse for resident #7 on 10/25/23, and on 10/26/23, RN E stated she did not remove the condom catheter on both days because the resident requested to keep it on, and she had forgotten to call the doctor and change the condom catheter orders. RN E stated that Resident #7 risked a possible urinary tract infection by keeping the condom catheter past physicians' orders. Residents Affected - Few During an interview with the DON on 10/26/2023 at 12:33 p.m., the DON stated that Resident #7's condom catheter should have been removed by RN E as directed by physician's orders. The DON stated nursing staff had been in-serviced on following physician orders. DON stated she did not know this deficient practice occurred. The DON noted the possible risk to the resident wearing a condom catheter longer than ordered by the physician, which could possibly affect the resident negatively. Record review of facility policy Catheter Insertion , dated 2001, revised 2016, revealed, Verify there is a physician's order. 676274 Page 14 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was provided necessary respiratory care consistent with professional standards of practice for 3 of 6 residents (Residents #34, and #11, and #30) reviewed for respiratory care in that: Residents Affected - Some 1. Resident #34's nebulizer tubing was outdated, and on the floor. The resident's nebulizer mask was disconnected from the tubing and on the floor on 4 of 4 days (10/24/23, 10/25/23, 10/26/23. and 10/27/23) of observations. 2. Resident #11's humidification water bottle was not connected. 3. Resident # 30 did not have physician orders for oxygen and oxygen was in use. This failure could place residents at risk of delays in receiving necessary respiratory care, and illness. The findings included: 1. Record review of Resident #34's profile dated 10/26/23 revealed the resident was a [AGE] year-old male admitted on [DATE] with readmission on [DATE] with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease - lung disease restricting airways, making breathing difficult), dependence on supplemental oxygen, unspecified diastolic (congestive) heart failure ( The heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), and Morbid (severe) obesity with alveolar hypoventilation (Overweight with insufficient ventilation leading to elevated carbon dioxide blood levels). Record review of Resident #34's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS of 15/15 indicating the resident was cognitively intact. Further review revealed the resident was frequently incontinent of urine and always incontinent of bowel. Section O revealed oxygen therapy was blank. 11/30/23 indicated the resident was on oxygen therapy for COPD and a history of respiratory failure with interventions to monitor vital signs, position changes, notify the doctor as needed, and administer oxygen as ordered. Record review of Resident #34's physician orders revealed an active order with a start date of 2/12/23 to change oxygen tubing every Sunday night, change tubing and masks and cover with a plastic safeguard. Record review of Resident #34's physician orders revealed an active order with a start date of 2/8/23 for Ipratropium/Albuterol solution 0.5-2.5 (3) mg/ml, inhale every 4 hours as needed for shortness of breath or wheezing via nebulizer. Record review on 10/25/23 at 4:44 p.m. of Resident #34's Electronic Medical Record for October 2023 revealed the resident had no documentation of the ordered nebulizer treatment being administered for October 2023. 676274 Page 15 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #34's Electronic Medical Record for October 2023 revealed the oxygen tubing was documented as changed on 10/15/23, and 10/22/23. In an observation on 10/24/23 at 10:42 a.m., in Resident #34's room, a nebulizer machine was observed on the nightstand with tubing attached and dated 10/15/23, and a clear plastic bag with a small coil of the nebulizer tubing in the bag and the opposite end of the tubing that connects to the nebulizer mask was on the floor next to the resident's electric wheelchair and also observed the nebulizer mask on the floor approximately 1 foot away from the tubing behind the wheelchair. Neither the end of the tubing nor the mask was connected. In an interview on 10/24/23 2:41 p.m. Resident #34 stated he receives nebulizer treatments as needed and had received one earlier today but had not needed one for weeks probably months prior to today. The resident was sitting in bed with HOB (Head Of Bed) elevated. The nebulizer tubing dated 10/15/23 and mask remained in the same positions as previously observed on the floor. In an observation on 10/25/23 at 11:45am in Resident #34's room, the nebulizer tubing dated 10/15/23 and mask remained in the same positions as previously observed on the floor. In an observation on 10/26/23 at 2:30 p.m. in Resident #34's room, the nebulizer tubing dated 10/15/23 and mask remained in the same positions as previously observed on the floor. In an observation and interview on 10/27/23 at 11:32 a.m., in Resident #34's room with the DON, the nebulizer tubing dated 10/15/23 and mask remained in the same positions as previously observed on the floor. The DON disconnected the tubing from the nebulizer machine and picked up the tubing and mask from the floor and threw them in the trash. The DON stated staff would be in-serviced on proper storage and dating of respiratory equipment. 2. Record review of Resident's # 11 face sheet dated 10/26/23 revealed a [AGE] year old female was admitted on [DATE] with diagnosis that included [Chronic Resspiratory Failer ] a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body. [Chronic Pain] pain that lasts for over three months and [Atrial fibrillation ] is an irregular and often very rapid heart rhythm. Record review of Residents # 11's quarterly MDS assessment dated [DATE] revealed a BIMS of 15 indicating the resident was cognitively intact . Further review of Quartlerly MDS dated [DATE] revealed Section O was selected indicating use of oxygen in the last 14 days . 11/30/23 indicated the resident was on oxygen therapy for Respiratory Failer with interventions to monitor vital signs, position changes, notify the doctor as needed, and administer oxygen as ordered. Record review of Resident #11's physician orders revealed an active order with a start date of 10/20/22 to change oxygen tubing, humidifer bottle every Sunday night, Record review of Resident #11's Electronic Medical Record for October 2023 revealed the oxygen tubing, humidifer bottle was documented as changed on 10/15/23, and 10/22/23. In an observation on 10/23/23 at 9:42 a.m , in Resident #11's room, O2 concentrator was noted next 676274 Page 16 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0695 to residents bed with tubing dated 10/22/23 , however 02 humidification was not noted . Level of Harm - Minimal harm or potential for actual harm In an observation and interview on 10/23/23 10:41 a.m. Resident #11 stated she is on 02 all the time and does not like the 02 conected to the humidification . Residents Affected - Some In an observation and interview on 10/24/23 at 12:32 p.m., in Resident #11's room with RN A , the 02 tubing with noted with date of 10/22/23 and no humidification . RN A stated she did not now why the 02 hummidifacation was not connected but she would verify orders . In an interview with the DON on 10/24/23 at 1:30 p.m the DON stated that she had not had a chance to review orders , The DON stated she would inservice licensed staff regarding physicans orders matching treatment adminstration record . 3. Record review of Resident # 30's face sheet, dated 10/27/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: [Acute Respiratory Failure] the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient. [Hypertension] is when the pressure in your blood vessels is too high. [Restless legs syndrome] is a condition that causes an uncontrollable urge to move the legs. Record review of Resident # 30's Quarterly MDS dated [DATE] revealed Resident # 30 had a BIMS score 15, indicating intact cognition. Record review of Resident #30's Treatment Physican Orders February 2023 - October 2023 did not reveal an order for O2. Record review of Residents # 30's Physicans orders for January 2023 revealed 02 was discontinued on 1/19/23. Record review of quarterly MDS dated [DATE] revealed section O left blank, indicating 02 was not in use . Record review of the care plan dated 8/16/23 revealed a care plan I require oxygen at times, with interventions administered medication as ordered. Observation and interview with resident # 30 on 10/25/23 at 9:25 a.m. observed resident using oxygen at two liters per nasal cannula. Resident # 30 states she uses it whenever she feels she needs it. Further observation noted oxygen tubing with the date of 10/8/2023 unbagged. During an Interview with CNA C on 10/25/23 at 10:15 a.m. She states she is the assigned CNA for resident # 30, and to her knowledge, Resident # 30 has used oxygen as far as she can recall, but the surveyor to speak to the assigned nurse to make sure. During an Interview with RN E on 10/25/23 at 10:30 a.m., she stated she is the nurse assigned to Resident # 30. She stated that resident # 30 is currently on 02 without order; she does not know why this occurred and for the surveyor to speak to the DON for clarification. During an interview with the DON on 10/25/23 at 1120 a.m., the DON stated that the resident had been admitted to the hospital sometime in January of 2023. When resident # 30 returned to the facility, the admitting nurse did not add the oxygen to the treatment administration record. She stated 676274 Page 17 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0695 Level of Harm - Minimal harm or potential for actual harm resident # 30 risked possible respiratory illness exacerbation if no orders for 02 were on the treatment administration record; she stated he would Inservice all nursing staff regarding this issue. Review of the policy provided by the facility did not address oxygen or nebulizer tubing being outdated, undated, unbagged, or on the floor. Residents Affected - Some 676274 Page 18 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0759 Ensure medication error rates are not 5 percent or greater. 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 a medication error rate was not 5% or greater. The facility had a medication error rate of 32%, based on 7 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #40, Resident # 13) and 1 of 4 staff (CMA D) reviewed for medication administration. Residents Affected - Few The facility failed to ensure CMA D administered medications according to the physician's orders and per professional standards which resulted in a 32% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions. The findings are: 1. Record Review of Resident # 40's face sheet dated 10/25/23 revealed an [AGE] year-old female with an admission date of 02/27/2023 with a diagnosis that included: [Dementia] loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life. [Anxiety] feelings of unease, such as worry or fear, that can be mild or severe, and [Mood Disorder] marked disruptions in emotions. Record review of Resident # 40's quarterly MDS assessment, dated 8/18/23, revealed a BIMS score of 03, indicating severe cognitive impairment. Record review of Resident #40's order summary report for October 2023 revealed the following orders at 900 am : -Claritin 10 mg, give one tab by mouth daily for allergies. -Losartan 50 mg, give one tablet by mouth daily for hypertension. -Evista 60 mg, give one tab by mouth daily for diabetes. - Aspirin chews 81mg, give one tablet by mouth daily for heart health. -Colace 100 mg capsule, give one capsule by mouth daily for constipation. -Pepcid 20 mg tablet, give one tablet by mouth daily for indigestion. -Mag Ox 400 mg tablet, give one tablet by mouth daily for hypomagnesemia - Meloxicam 7.5 mg tablet, give one tablet by mouth daily for arthritis. - Zoloft 50 mg tablet, give one tablet by mouth daily for depression. - Calcium 600 mg tablet, give one tablet by mouth daily for osteoporosis. - Sodium Chloride (no dose), give one tablet by mouth daily for hyponatremia ( low sodium ) 676274 Page 19 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview during the medication pass on 10/26/23 at 9:31 a.m., CMA D, prepared Resident #40's medications. When CMA D pulled the medication Sodium Chloride, she noted that she did not have a strength listed on her Maedicaion Adminstration Record CMA D stated that the resident risked possible medication error if this is not corrected. CMA D referred the surveyor to RN E for clarification. During an interview on 10/26/23 at 9:35 a.m., RN A stated, that she did not know why the medication Sodium Chloride did not list strength on the Medication Adminstration Record , but she would call Dr. and have the order clarified. RN E noted that the resident risked a possible medication error if this was not corrected. 2. Record review of Resident's # 13 face sheet dated 10/25/23 revealed a [AGE] year-old male admitted to the facility on [DATE] , with diagnosis that included :[ Benign prostatic hyperplasia] is when the prostate and surrounding tissue expand.[COPD] is a chronic inflammatory lung disease that causes obstructed airflow from the lungs, and [Depression] is a common and serious medical illness that negatively affects how you feel, the way you think, and how you act. Record review of Resident # 13's quarterly MDS assessment, dated 7/15/23, revealed a BIMS score of 15, indicating intact cognition. Record review of Resident #13's order summary report for October 2023 revealed the following orders at 7:00 am: - Aspirin chews 81mg; give one tablet by mouth daily for heart health. -Finasteride 5 mg tablet, give one tablet by mouth daily for Benign prostatic hyperplasia -Folic acid 5 mg tablet, give one tablet by mouth daily for red blood cell production - Gabapentin 800 mg, give one tablet by mouth three times a day for neuropathy pain -Hydroquinone 200 mg, give one tablet by mouth daily for rheumatoid arthritis -Senna 8.6 mg, give one tablet by mouth daily for constipation. -B-12 vitamin /25mcg, give one tablet by mouth daily for vitamin supplementation. Observation and Interview During the medication pass on 10/26/23 at 9:40 a.m., CMA D prepared Resident #13's medications. When CMA D pulled the medication, she noted that they were scheduled at 0700 and were now late; she continued to pull the medications and give them to Resident # 13. CMA D stated that she would request the charge nurse change the medication times, so they don't show late. CMA D referred the surveyor to LVN F for further questioning. During an interview on 10/26/23 at 9:45 a.m., LVN F stated she was the assigned nurse for Resident # 13. She did not know why the medications were scheduled at 700 a.m. and administered at 9:40 a.m. but she would call the Dr. and get the order clarified. LVN F stated that the resident risked possible drug interactions by administering the medications late. During an interview on 10/26/23 at 10:28 a.m., the DON stated that the medication administered 676274 Page 20 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without dosage on MAR was a medication error and that Medication administered at a time different from Dr. Orders was a medication error. The DON stated that Resident # 40 and 13 risked possible medication interactions by medications administered late and without a proper medication dose on MAR. Record Review of Facility policy titled, Medication Orders, 2001, revised April 2010 revealed Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency, and strength of the medication ordered. 676274 Page 21 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0812 Level of Harm - Minimal harm or potential for actual harm 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, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Residents Affected - Many 1. The top of the dish machine was soiled with a sand-like substance. 2. The door of the freezer near the dish room was soiled. 3. Three containers of ground meat wrapped in plastic were thawing on a countertop. 4. Powdered milk container in the pantry was labeled milk and also labeled rice. 5. The containers of loose sugar and flour had lids that were not secure. 6. The large walk-in refrigerator had debris in the floor and contained: -two thermometers with different temperature readings -a container of heads of lettuce with multiple brown spots. -a container of breadsticks labeled keep frozen -a container of heavy whipping cream with a best by date of 09/27/2023 -a container of individual servings of sour cream with a best by date of 09/18/2023 -a container of scrambled egg blend labeled keep frozen -an open container of teriyaki sauce with no date -a container of bacon strips labeled keep frozen that was unsealed with a tray sitting on top of it -a container of raisin bread labeled keep frozen -a container with sliced turkey labeled use or freeze by 10/13 and a handwritten note do not use -containers of individual servings of cranberry, apple, and orange juice cups labeled keep frozen and a cranberry juice cup that had leaked and stained the container and other cranberry juice cups with sticky residue -the fan in the refrigerator was soiled with a substance that appeared to be dust. 7. The walk-in freezer contained: -a container of loose sliced carrots that was unsealed 676274 Page 22 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0812 -a container of burritos that was unsealed Level of Harm - Minimal harm or potential for actual harm -a container of meat patties that was unsealed -a container of frozen strawberries that was undated Residents Affected - Many -a bag of frozen vegetables closed with a binder clip for papers. 8. The refrigerator near the kitchen workstation had a container of pimento cheese that was undated. 9. The fryer contained crumbs and had grease on the side. 10. The food heater had debris on the top and grease on the sides. 11. The hood over the stove and oven had grease on the sides. 12. A wet floor hazard sign was stored on a shelf above dishes. 13. A serving cart had sticky residue and spilled syrup. 14. The iced tea dispenser was soiled with drips from the machine. 15. The coffee pot was opaque due to residue. 16. The coffee cart was soiled with spilled sugar. 17. Coffee and tea were spilled on the drinks station. 18. The juice dispenser was soiled on top. 19. The toaster had crumbs. 20. A container under the workstation held several loaves of bread which were undated. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: During observations on 10/24/2023 between 10:20 a.m. and 11:40 a.m. in the facility kitchen: 1. The top of the dish machine was soiled with a sand-like substance. 2. The door of the freezer near the dish room was soiled. 3. Three containers of ground meat wrapped in plastic were thawing on a countertop. 4. Powdered milk container in the pantry was labeled milk and also labeled rice. 676274 Page 23 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0812 5. The containers of loose sugar and flour had lids that were not secure. Level of Harm - Minimal harm or potential for actual harm 6. The large walk-in refrigerator had debris in the floor and contained: -two thermometers with different temperature readings Residents Affected - Many -a container of heads of lettuce with multiple brown spots. -a container of breadsticks labeled keep frozen -a container of heavy whipping cream with a best by date of 09/27/2023 -a container of individual servings of sour cream with a best by date of 09/18/2023 -a container of scrambled egg blend labeled keep frozen -an open container of teriyaki sauce with no date -a container of bacon strips labeled keep frozen that was unsealed with a tray sitting on top of it -a container of raisin bread labeled keep frozen -a container with sliced turkey labeled use or freeze by 10/13 and a handwritten note do not use -containers of individual servings of cranberry, apple, and orange juice cups labeled keep frozen and a cranberry juice cup that had leaked and stained the container and other cranberry juice cups with sticky residue -the fan in the refrigerator was soiled with a substance that appeared to be dust. 7. The walk-in freezer contained: -a container of loose sliced carrots that was unsealed -a container of burritos that was unsealed -a container of meat patties that was unsealed -a container of frozen strawberries that was undated -a bag of frozen vegetables closed with a binder clip for papers. 8. The refrigerator near the kitchen workstation had a container of pimento cheese that was undated. 9. The fryer contained crumbs and had grease on the side. 10. The food heater had debris on the top and grease on the sides. 676274 Page 24 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0812 11. The hood over the stove and oven had grease on the sides. Level of Harm - Minimal harm or potential for actual harm 12. A wet floor hazard sign was stored on a shelf above dishes. 13. A serving cart had sticky residue and spilled syrup. Residents Affected - Many 14. The iced tea dispenser was soiled with drips from the machine. 15. The coffee pot was opaque due to residue. 16. The coffee cart was soiled with spilled sugar. 17. Coffee and tea were spilled on the drinks station. 18. The juice dispenser was soiled on top. 19. The toaster had crumbs. 20. A container under the workstation held several loaves of bread which were undated. During an interview with Dietary Aide L on 10/24/2023 at 10:40 a.m., Dietary Aide L stated the ground meat had been removed from the freezer at approximately 6:15 a.m. and had been left to thaw on the kitchen counter. During an interview with the Dietary Manager on 10/24/2023 between 11:40 a.m. and 11:45 a.m., a walk-through of the facility kitchen was performed, and the Dietary Manager confirmed the Surveyor observations and stated the listed items would be corrected. The Dietary Manager confirmed she was responsible for kitchen sanitation and proper storage of food products and that the deficient practices were oversights. Record review of the facility policy, Sanitation, revised December 2008, revealed, The food service area shall be maintained in a clean and sanitary manner. Record review of the facility policy, Food Receiving and Storage, revised December 2008, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. 676274 Page 25 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident # 7) reviewed for accuracy of medical records in that: Resident # 7's order to remove condom cathater in the [NAME] was not done and treatment record signed . This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of resident #7's face sheet undated revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included [Parkinson's disease], a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement. [Benign prostatic hyperplasia] causes your prostate to increase in size, leading to decreased urine flow, and [Depression] is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities. Record review of Resident's # 7 Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 12, which indicated Resident # 7 is moderately impaired. Record review of Resident's # 7 physicans orders for month of October 2023 , reveiled orders for condom catheter to be removed first thign in the morning. Record review of Resident's #7 treatment adminstration record for October 2023 , reveled RN E had signed treatment adminstration record for 10/25/23 , indicating conodm cathater was removed . Observation on 10/25/23 at 10:35 reveiled resident # 7 was wearing condom catheter During an interview with Resident # 7 on 10/25/23 at 10:50 a.m., resident #7 stated, They (Nurses) sometimes forget to remove my condom catheter in the morning, but I don't mind it on. During an interview with CNA G on 10/25/23/2023 at 11:50 AM, CNA G confirmed that Resident #7's condom catheter was present on Resident #7, as she was the assigned CNA today, CNA G did not know why resident # 7 was wearing a Condom catheter today, but she directed the surveyor to speak to the Nurse. During an interview with RN E on 10/25/2023 at 12:05 p.m., RN E stated she was the assigned nurse for resident #7 , RN E stated she did not remove the condom catheter because the resident requested to keep it on, and she had forgotten to call the doctor and change the condom catheter orders. RN E stated that Resident #7 risked a possible urinary tract infection by keeping the condom catheter past physicians' orders. During an interview with the DON on 10/25/2023 at 12:33 p.m., the DON stated that Resident #7's 676274 Page 26 of 27 676274 10/27/2023 River Bend Healthcare 1339 Eastwood Dr Seguin, TX 78155

F 0842 Level of Harm - Minimal harm or potential for actual harm condom catheter should have been removed by RN E as directed by physician's orders. The DON stated nursing staff had been in-serviced on following physician orders. DON stated she did not know this deficient practice occurred. The DON noted the possible risk to the resident wearing a condom catheter longer than ordered by the physician, which could possibly affect the resident negatively. Residents Affected - Few Record review of facility policies revealed none addressed physicians' orders. 676274 Page 27 of 27