Health inspection·January 30, 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, the facility failed to ensure residents have a right to personal privacy for 1 of 3 resident (Resident #11) reviewed for privacy, in that: Residents Affected - Few CNA A did not close Resident #11's window blinds while providing incontinent care for the resident. This deficient practice could place residents who received perineal care at risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #11's admission record dated 01/30/25 indicated she was admitted to the facility on [DATE] with diagnoses of overactive bladder and muscle weakness. She was [AGE] years of age. Record review of Resident #11's significant change MDS assessment dated [DATE] indicated her BIMS score was 06 indicating the resident's mental status was severely impaired. The resident's bladder and bowel status was coded as frequently incontinent. Record review of Resident #11's care plan dated 12/13/2024 indicated in part: Focus: Resident is incontinent of bladder related to physical/mental decline. Goal: Will have decline in incontinent episodes and be free of UTI next 90 days. Interventions: Provide care in a nonjudgmental manner, maintaining the resident's privacy and dignity. During an observation on 01/30/25 at 09:30 AM, CNA A was seen performing incontinent care to Resident #11. The observation was made from the outside of the facility. The state surveyor drove up to the front parking lot, and when he had parked, he saw the CNA performing care through the open blinds of the resident's room. This area of the parking lot was a high trafficked area, and several people walked through that sidewalk. The state surveyor then got out of the vehicle and continued to observe the CNA take some wet wipes and wipe the resident's private areas, apply some skin cream to her buttocks, and then fasten the new brief on the resident. Resident #11 was seen standing up and holding onto to her walker while CNA A performed the incontinent care. CNA A then assisted the resident to sit back down on her recliner and was done with the care, but never closed the blinds. During an interview on 01/30/25 at 09:48 AM, Resident #11 said the staff were good about providing privacy during personal care. The resident said she was not aware that the staff had left the blinds Page 1 of 6 676348 676348 01/30/2025 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few open during incontinent care on 01/30/25. Resident #11 said if the blinds were left open, then that would make her feel very embarrassed as she did not want to be exposed to the people passing by. Resident #11 said CNA A had indeed just changed her brief and had her stand up so that she could remove her brief, wipe her with some wet wipes and then fasten the new brief. During an interview on 01/30/25 at 10:08 AM, CNA A said that whenever she performed incontinent care on a resident she would close the door, pull the privacy curtain, and close the window blinds. CNA A was made aware of the observation this surveyor had of her performing incontinent care for Resident #11 and having the blinds open. CNA A said that she usually closed the blinds, but that obviously she had made an error and forgotten to close them that morning. CNA A said she felt bad that she had done that and understood her leaving the blinds open could expose the resident to the outside especially since she had performed personal care on the resident. CNA A said she had not done that on purpose and from now on would make sure that she would close the blinds during incontinent care. During an interview on 01/30/25 at 04:47 PM, the DON and the Administrator were asked what their expectations when nursing staff provided incontinent care as far as privacy. The DON said that the staff were expected to close the door, pull the privacy curtain, and close the window blinds, if on bed B which is close to the window. The Administrator said the CNA should have closed the blind before she performed the incontinent care. The Administrator said if the blinds were left opened then that could lead to the resident being exposed. Record review of the facility's undated policy titled Perineal care indicated in part: .Procedure: Knock at door, enter room, explain what you are going to do. Provide for privacy (Close door, pull curtain, close blinds) . 676348 Page 2 of 6 676348 01/30/2025 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

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 that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Residents #61 and #253) of 4 residents observed for oxygen management. Residents Affected - Few The facility failed to ensure Oxygen (O2) in use signage was on the doorways of Resident #61 and Resident #253. This failure could place residents at risk of not receiving appropriate respiratory care . The findings were: 1. Record review of Resident #61's admission record dated 01/31/2025 revealed Resident #61 was a [AGE] year-old male with an admission date to the facility of 11/21/2024. admission record revealed Resident #61 had diagnoses that included diabetes mellitus, dementia, peripheral vascular disease (condition that reduces blood flow to the limbs), muscle weakness, and pleural effusion (buildup of flood between the linings of the lungs and chest). Record review of Resident #61's MDS assessment revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Record review of Resident #61's Care plan dated 12/05/2024 revealed a focus of Use of oxygen therapy, has shortness of breath, and has respiratory symptoms. Record review of Resident #61's order summary dated 01/31/2025 revealed an order of Oxygen at 2-4 L/PM via nasal canula OR 5-8 L/PM via mask as needed for SOB (SHORTNESS OF BREATH). 2. Record review of Resident #253's admission record dated 01/31/2025 revealed Resident #253 was a [AGE] year-old female with an admission date to the facility of 01/27/2025. admission record revealed Resident #253 had diagnoses that included diabetes mellitus, pulmonary edema (condition caused by excess fluid in the lungs), respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and end stage renal disease (loss of kidney function that requires ongoing medical treatment to maintain life). Record review of Resident #253's MDS dated [DATE] revealed the MDS had not been completed due to her recent admission. Record review of Resident #253's Care plan dated 01/28/2025 revealed a focus of Use of oxygen therapy and has altered respiratory status/difficulty breathing. Record review of Resident #253's order summary dated 01/31/2025 revealed the following orders: OXYGEN - CONTINUOUSLY = Oxygen at _2-4_L/PM via nasal cannula continuously. OXYGEN as needed = Oxygen at 2-4 L/PM via nasal canula OR 5-8 L/PM via mask as needed for SOB Observation on 01/28/2025 at 7:58 AM revealed that there was no oxygen in use sign on Resident 676348 Page 3 of 6 676348 01/30/2025 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0695 #61's door. Level of Harm - Minimal harm or potential for actual harm Observation on 01/29/2025 at 10:38 AM revealed that there was no oxygen in use sign on Resident #61's door. Residents Affected - Few Observation on 01/28/2025 at 7:32 AM revealed that there was no oxygen in use sign on Resident #253's door. Observation on 01/29/2025 at 10:56 AM revealed that there was no oxygen in use sign on Resident #253's door. Observation on 01/30/2025 at 10:00 AM revealed that there was no oxygen in use sign on Resident #253's door. In an interview on 01/30/2025 at 3:10 PM, the DON stated that the ADONs and all staff members (including management) were responsible for ensuring that oxygen in use signs were posted on the doors of residents receiving oxygen therapy. For monitoring the oxygen in use signs, the CNAs made rounds every 2 hours and the ADONs made rounds daily. The DON stated she did not think any adverse outcomes or harm could occur to the residents in relation to the signs not being posted. Regarding training/in-services provided to staff, the DON stated the facility had not conducted any. Record review of the undated facility policy titled Regular Oxygen Storage and Handling indicated in part .Oxygen in Use-No Smoking signs will be posted at doors leading to rooms where oxygen is in use. 676348 Page 4 of 6 676348 01/30/2025 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #55, Resident #207) of 6 residents reviewed for incontinent care and transfers in that Residents Affected - Some 1. CNA D and CNA E failed to comply with enhanced barrier precaution regulations during incontinent care for Resident #55. 2. CNA B and CNA C failed to comply with enhanced barrier precaution regulations during a transfer for Resident #207. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Record review of Resident #55's admission record revealed resident was a [AGE] year-old female admitted to the facility 11/14/2024. Resident #55 had diagnosis that included muscle weakness, hypertension (high blood pressure), and pneumonia (infection of the lungs). Record review of Resident #55's Significant change minimum data set assessment indicated the resident had an indwelling catheter and was always incontinent of stool. Resident was considered to need substantial/maximal assistance for transferring and positioning. Record review of Resident #55's care plan revealed special instructions of assist x2 transfer *full weight bearing left leg* Enhanced Barrier Precaution . Record review of Resident #207's admission record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that include acute kidney failure, urinary tract infection, weakness, and dementia. Record review of Resident #207's Significant change minimum data set indicated the resident had an indwelling catheter and is always incontinent of stool. Resident is considered to need substantial/maximal assistance for transferring and positioning. Record review of Resident #207's care plan revealed focus of The resident has UNSTAGABLE TO COCCYX. With interventions of STAFF TO MAINTAIN ENHANCED BARRIER PRECAUTIONS D/T PRESSURE WOUND. The focus of Resident utilizing indwelling F/C (foley catheter) placing resident at risk for UTI (urinary tract infection). And Interventions of STAFF TO MAINTAIN ENHANCED BARRIER PRECAUTIONS D/T (due to) F/C. Observation of incontinent care on 01/29/25 at 10:30 AM for Resident #55 with CNA E and CNA D. Neither CNA's donned Enhanced Barrier Precaution (EBP) prior to performing incontinent care. In an interview on 01/29/25 at 11:34 AM, CNA D stated that for incontinent care they should introduce themselves, wash hands, put on their EBP , that included gown and gloves, and set up supplies. CNA D stated EBP was in place when residents have catheters or open wounds. CNA D stated he was in a rush and was nervous and forgot to use EBP. CNA D stated if they do not use EBP it could be a concern 676348 Page 5 of 6 676348 01/30/2025 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0880 for cross contamination. Level of Harm - Minimal harm or potential for actual harm In an interview on 01/29/25 at 11:37 AM, CNA E stated residents who has wounds, or catheters staff need EBP on when caring for those residents. CNA E stated they just forgot to put it on. CNA E stated, if we don't wear them, we could get stuff on our clothes and contaminate others. Residents Affected - Some Observation of a mechanical lift transfer from bed to chair on 01/30/25 at 10:10 AM for Resident #207 with CNA B and CNA C. Neither staff member donned Enhanced Barrier Precaution (EBP) prior to performing Hoyer transfer. In an interview with CNA B and CNA C on 01/30/25 at 10:28 AM , they both stated they were informed they did not need to wear EBP for transfers. [NAME] interview with the DON on 01/30/25 at 01:51 PM revealed that EPB should be used on anyone who has a line, catheter, wounds and should be worn when providing patient care, incontinent care, but not transfers because they are not in contact with the reason the residents are on precautions. The DON stated she understood now how not wearing EBP during transfers could be a concern of cross contamination. Record review of facility policy titled ENHANCED BARRIER PREECAUTIONS (EBP) with a signed date of 1/23/25 stated in part EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provides opportunities for transfer of MDRO's (Multi-drug resistant organisms) to staff hands and clothing. 676348 Page 6 of 6