Health inspection·May 13, 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, interview, and record review; it was determined the facility failed to ensure each resident was provided privacy during personal care, for 1 of 3 residents reviewed for Resident rights (Resident #2). Residents Affected - Few Facility failed to provide dignity and respect for Resident #2 by providing privacy during incontinent care. The facility's failure could place residents at risk of not being treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents. Findings include: Resident #2 Record review of Resident #2's clinical record, dated 05/13/2025, revealed Resident #2 was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications (a condition where the body either doesn't make enough insulin or the body's cells don't respond properly to insulin, leading to elevated blood sugar levels (hyperglycemia)), atherosclerotic heart disease of native coronary artery without angina pectoris (a heart condition where atherosclerosis (buildup of plaque) in the heart's blood vessels (coronary arteries) is present, but the individual doesn't experience chest pain (angina)), history of transient ischemic attack (TIA) (a past episode of temporary neurological dysfunction caused by brief, localized blockage of blood flow to the brain), and cerebral infarctions without residual deficits (a past episode of a stroke (cerebral infarction) where the damage to the brain tissue resulted in permanent neurological deficits, but the individual has recovered from these deficits, leaving no lasting impairment), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), epilepsy (a chronic neurological condition characterized by recurrent, unprovoked seizures). Record review of Resident #2's most recent MDS assessment, dated 03/01/2025, indicated Resident #2 had a BIMS of 14, indicating no cognitive impairment and a functionality of total dependency or maximal assistance was required in all care areas except moderate assistance needed with upper body dressing. Resident required touch assistance with eating and oral hygiene. During an observation on 05/13/2025 at 11:29 AM SNA C and SNA D did not shut Resident #2's blinds to her room or shut the door to Resident #2's room to provide privacy during incontinent care. During the time incontinent care was being provided to Resident #2, unidentified person walked by Resident #2's bedroom window twice. Page 1 of 7 676347 676347 05/13/2025 Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/13/2025 at 11:41 AM SNA D stated Resident #2 did not like for her window blinds to be closed during the day even during patient care. SNA D stated this is how I was trained. SNA D could not give a negative outcome for the resident by not providing privacy to the resident. During an interview on 05/13/2025 at 11:46 AM SNA C stated she had not been trained on how to perform incontinent care for a resident. SNA C could not give a negative outcome for the resident by not providing privacy to the resident. During an interview on 05/13/2025 at 11:50 AM Resident #2 stated the staff are supposed to close the blinds and door during resident cares. Resident #2 stated she did not want someone to walk by and see her naked. The trash and dirty laundry are taken out of those doors right there (Resident #2 pointed out the window to a door across the open area), and most of the time it is men who are doing that. I don't want them seeing me. During an interview on 05/13/2025 at 5:41 PM DON stated a negative outcome for not providing privacy to the residents could lead to embarrassment and there is a lack of dignity for the resident. Record review of the facility's policy titled Residents Rights, revised 11/28/2016, revealed: .The resident has a right to be treated with respect and dignity, . .The resident has a right to personal privacy . Record review of the facility provided policy titled, Perineal Care dated 05/11/2022, revealed: .7) Provide privacy and modesty by closing the door and/or curtain . 676347 Page 2 of 7 676347 05/13/2025 Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 4 of 6 staff (SNA A, SNA B, SNA C, SNA D) reviewed for nursing services. The facility failed to ensure the following: -SNA A failed to perform hand hygiene before, during, or after incontinent care for Resident #1. -SNA B failed to perform hand hygiene before assisting with incontinent care for Resident #1. -SNA C failed to perform hand hygiene before or after assisting with incontinent care for Resident #2. -SNA D failed to perform hand hygiene before, during, or after incontinent care for Resident #2. -SNA D wiped back to front during incontinent care for Resident #2 This failure placed residents at risk of receiving care that is performed by untrained staff which could result in increased risk of infection or skin breakdown. Findings included: During an observation on 05/13/2025 at 9:44 AM SNA A and SNA B started to perform incontinent care for Resident #1, but failed to perform hand hygiene before care was started. SNA A performed perineal care and cleaned Resident #1. No glove change or hand hygiene was performed after cleaning the dirty areas of Resident #1, before picking up a clean brief to put on Resident #1. SNA A proceeded to touch Resident #1 and her clothing, bedding, and items on night stand. During an interview on 05/13/2025 at 9:56 AM SNA A stated the negative outcome for not performing hand hygiene would be that the resident did not receive the correct care. During an interview on 05/13/2025 at 9:59 AM SNA B stated the negative outcome for not performing hand hygiene would be that we could spread germs from one resident to another. During an observation on 05/13/2025 at 11:29 AM 05/13/2025 at 11:29 AM SNA C and SNA D performed incontinent care on Resident #2. Neither SNA's performed hand hygiene before starting incontinent care for Resident #2. SNA D used one wipe more than once and wiped back to front and not front to back when performing perineal care. SNA D then proceeded to place a clean brief on Resident #2 while the dirty brief was still in place, the dirty brief touched the clean brief. No glove change or hand hygiene were performed at any time during the incontinent care of Resident #2. SNA C took soiled wipes from SNA D and would throw them in the trash for SNA D and then return to holding the resident on her side so that SNA D could perform incontinent care on the back side or Resident #2. SNA C then touch the clean brief, residents clothing, and the blankets of Resident #2 with no glove change or hand hygiene was performed. Neither SNA performed hand hygiene after care was completed. 676347 Page 3 of 7 676347 05/13/2025 Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 05/13/2025 at 11:41am SNA D stated that she used multiple wipes during incontinent care and that is how I was taught how to do it, that is how I was trained. SNA D could not provide a negative outcome for the resident. During an interview on 05/13/2025 at 11:46 AM SNA C stated she had not been taught how to perform perineal care for residents. SNA C was unable to provide a negative outcome for not performing hand hygiene during incontinent care. During an interview on 05/13/2025 at 4:28 PM with CO-RN stated that the previous ADON whose last day was last Friday was supposed to have trained 3 of the SNAs and has their documentation. The documentation cannot be found for SNA B, SNA C, and SNA D due to previous ADON having their documentation. During an interview on 05/13/2025 at 5:41 PM DON stated the negative outcome for having staff who do not have the appropriate qualifications could lead to abuse, neglect, and increased infections for the residents. DON stated the SNAs come in for orientation, and further training, which will include training on the floor in the facility. Then they will get clinical training on top of that which will equal 40 hours over a 6-8-week time frame with clinical educators. Record review of Texas Nurse Aide Performance Record for SNA A, training start date: 03/18/2025, training end date: 05/02/2025, revealed the following: .6. Hand washing was completed on 03/18/2025 with a satisfactory for her clinical check-off. . 21. Perineal care/incontinent care-Female (with or Without catheter) (l, P) was completed on 04/23/2025 with a satisfactory for her clinical check-off. No trainings were found for SNA C or SNA D Record review of the facility provided policy titled, Student Nurse Aide dated 2010, revealed: .Only perform patient care areas that the student has received training for . .Ability to comply with the patient [NAME] of Rights and the employee responsibilities. .Ability to comply with Company and departmental safety policies and procedures. .Accountable for personal care (i.e., grooming, bathing, catheter care, pericare, and dressing), and observation of residents within patient care policy guidelines. 676347 Page 4 of 7 676347 05/13/2025 Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 resident care areas (Resident #1, #2 and Resident #3) and 5 of 6 facility staff (SNA A, SNA B, SNA C, SNA D, and SNA F) reviewed for infection control. Residents Affected - Some The facility failed to ensure that facility staff performed hand hygiene appropriately during incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. Findings included: During an observation on 05/13/2025 at 9:44 AM SNA A and SNA B started to perform incontinent care for Resident #1, but failed to perform hand hygiene before care was started. SNA A performed perineal care and cleaned Resident #1. No glove change or hand hygiene was performed after cleaning the dirty areas of Resident #1, and before picking up a clean brief to put on Resident #1. SNA A proceeded to touch Resident #1 and her clothing, bedding, and items on night stand. Neither SNA A nor SNA B performed hand hygiene after the conclusion of incontinent care of Resident #1. During an interview on 05/13/2025 at 9:56 AM SNA A stated the negative outcome for not performing hand hygiene would be that the resident did not receive the correct care. During an interview on 05/13/2025 at 9:59 AM SNA B stated the negative outcome for not performing hand hygiene would be that we could spread germs from one resident to another. During an observation on 05/13/2025 at 11:29 AM SNA C and SNA D performed incontinent care on Resident #2. Neither SNA's performed hand hygiene before starting incontinent care for Resident #2. SNA D used one wipe more than once and wiped back to front and not front to back when performing perineal care. NA D then proceeded to place a clean brief on Resident #2 while the dirty brief was still in place, the dirty brief touched the clean brief. No glove change or hand hygiene were performed at any time during the incontinent care of Resident #2. SNA C took soiled wipes from SNA D and would throw them in the trash for SNA D and then return to holding the resident on her side so that SNA D could perform incontinent care on the back side or Resident #2. SNA C then touch the clean brief, residents clothing, and the blankets of Resident #2 with no glove change or hand hygiene performed. Neither SNA performed hand hygiene after care was completed. During an interview on 05/13/2025 at 11:41am SNA D stated she used multiple wipes during incontinent care and that is how I was taught how to do it, that is how I was trained. SNA D could not provide a negative outcome for the resident for not performing hand hygiene during incontinent care. During an interview on 05/13/2025 at 11:46 AM SNA C stated she had not been taught how to perform perineal care for residents. SNA C was unable to provide a negative outcome for not performing hand hygiene during incontinent care. 676347 Page 5 of 7 676347 05/13/2025 Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 05/13/2025 at 2:34 PM SNA E and SNA F performed incontinent care for Resident #3. SNA F was complete with cleaning Resident #3 and doffed gloves but failed to perform hand hygiene before placing clean gloves on to place clean brief on Resident #3. During an interview on 05/13/2025 at 2:50 PM with SNA F stated that the negative outcome for residents would be cross contamination and an increased chance of infection. During an interview on 05/13/2025 at 5:41 PM DON stated the negative outcome for staff not performing hand hygiene during incontinent care for residents could lead to an increase of infections for the residents. Record review of the facility provided policy titled, Fundamentals of Infection Control Precautions undated, revealed: .1. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. . Before and after entering isolation precaution settings; . .Before and after assisting a resident with personal care (e.g., oral cre, bathing); . .After contact with a resident's mucous membranes and body fluids or excretions; . .After removing gloves or aprons; . Record review of the facility provided policy titled, Hand Washing dated 2012, revealed: We will ensure proper hand washing procedures are utilized. Record review of the facility provided policy titled, Perineal Care dated 05/11/2022, revealed: . Procedure content . .Start . .10) Perform hand hygiene . .17)Gently perform perineal care, wiping from clean, urethral area, to dirty rectal area to avoid contamination the urethral area - CLEAN to DIRTY!' Female resident: Working from front to back, . .BACK . . 21) Gently perform care to the buttocks and anal area, working form front to back without contamination the perineal area . .24) Doff gloves . 676347 Page 6 of 7 676347 05/13/2025 Amarillo Center for Skilled Care 6641 W Amarillo Blvd Amarillo, TX 79106

F 0880 .25) perform hand hygiene. Level of Harm - Minimal harm or potential for actual harm .CONCLUDE . 26) provide resident comfort . Residents Affected - Some .31) perform hand hygiene . 676347 Page 7 of 7