Health inspection·December 23, 2025

F 0551 Give the resident's representative the ability to exercise the resident's rights. 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 the resident's responsible party had the right to exercise the resident's rights for one (Resident #2) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #2's representative was involved in the decision making before inserting a catheter. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Included:Record review of Resident #2's face sheet revealed Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's face sheet identified his representatives were family members. Diagnosis included: Acute Prostatitis (painful bacterial infection and inflammation of the prostate gland causing pelvic pain, urgent, frequent or painful urination), Lack of Coordination, Cognitive Communication Deficit, Benign Prostatic Hyperplasia (pain and discomfort while urinating and inability to empty the bladder completely), Muscle Weakness and Mild Cognitive Impairment. Resident #2's face sheet revealed family members were listed as emergency contacts but they were not listed as POA. Record Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 08 which meant he had moderate cognitive impairment. The MDS revealed Resident #2 had difficulty communicating when he tried to make himself understood. Resident #2 missed some part or intent of message regarding his ability to understand others. Resident #2's MDS revealed it was very important to have family involved in discussions about his care. Record Review of Resident #2's Care Plan dated 11/11/25, revealed he had the need to urinate frequently and had decreased cognition. The resident's care plan revealed he had mild cognitive impairment. He yelled out for momma and please help me frequently which required frequent monitoring and redirection. The facility's approach was to determine if the resident was considered to have or not to have capacity to make medical decisions as evidenced by physician's order, psychological assessment, capacity declaration, or guardianship paperwork. The approach also included to encourage Resident #2's decision making when able with simple task, such as choice in clothing, snacks, and activities. Record Review of Resident #2's progress notes on 12/21/25 at 11:00 a.m. by RN-A revealed he was having difficulty in voiding and hollering that he needed to go pee despite going to the bathroom and not voiding. RN-A spoke with doctor and received an order to insert a catheter. Resident #2 continued stating he had to go pee even after catheter insertion. Interview on 12/23/25 at 11:06 a.m. with the DON revealed RN-A stated the nurse aide said Resident #2 had been saying he needed to void several times but was not putting out anything. RN-A got an order from the doctor for an in and out catheter. RN-A sent a text message to LVN-B letting her know about the order. DON stated Resident #2 told LVN-B no to having the catheter put in. RN-A went and explained the procedure to Resident #2, and he allowed her to proceed. DON stated Resident #2 had an enlarged prostrate which would have caused bleeding. Interview on 12/23/25 at 11:16 a.m. with the Admin revealed Resident #2 told LVN-B no to the catheter. RN-A explained the process to Resident #2, and he allowed her to insert the Residents Affected - Few Page 1 of 4 676394 676394 12/23/2025 Woodlands Place Rehabilitation Suites 5600 Woodlands Trail Denison, TX 75020

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter. RN-A said Resident #2 said it was hurting, but she explained it would hurt due to his enlarged prostrate. Admin stated they normally would have called the family before placing a catheter. He stated a family member was in the other family member's room on the next hall. He stated the family member was POA. Admin stated both RN-A and LVN-B were written up for not contacting the family. Interview on 12/23/25 at 11:58 a.m. with Resident #2 stated he had no problems with any staff. He shook his head yes when asked if he was going home today and then he fell asleep. Interview on 12/23/25 at 12:03 p.m. with the RP revealed Resident #2 had felt like he had to use the restroom the entire time he had been at the facility due to his enlarged prostrate. She did not understand why the facility did not call them to let them know before they placed the catheter. RP stated she and another family member had POA. She stated Resident #2 had dementia and did not remember a lot of things. Interview on 12/23/25 at 12:15 p.m. with the FM revealed the facility did not call any of the family. FM stated RP and another family member had power of attorney over Resident #2. Attempted interview with Physician on 12/23/25 at 3:25 p.m. a voice message was left on his office phone requesting a return call. Attempted interview with Physician on 12/23/25 at 3:37 p.m. to his cell phone number, a voice and text message were sent requesting a return call. Interview on 12/23/25 at 3:41 p.m. with RN-A, she stated she was the on-duty nurse on the weekend. She stated Resident #2 always yelled he had to go to the bathroom. She stated he had been taken to the bathroom [ROOM NUMBER] times in 30 minutes. She had called the Doctor and received orders for Resident #2 for an in and out catheter. She said she delegated to LVN-B to do it since the resident was on her hall. RN-A went to check on Resident #2 and LVN-B had not placed the catheter. She explained the process to Resident #2 and started to insert the catheter. RN-A stated one thing they did wrong was nobody called the family first. RN-A stated she assumed LVN-B had called the family and vice versa. RN-A stated they should have called the family. RN-A stated she would usually call the family after she got an order but did not usually call to get permission to insert a catheter. RN-A stated she assumed LVN-B called the family because it was her resident. She stated Resident #2's family was always in the building. Interview on 12/23/25 at 4:18 p.m. with LVN-B, she stated she received a text from RN-A which stated Resident #2's doctor gave orders for a catheter to be placed. LVN-B stated RN-A had come in and placed the catheter. LVN-B stated she was told 12/22/25 that she was written up for not informing the family of the orders for the catheter. She stated she was not the nurse who requested the order and did not put the catheter in, so she did not feel she was responsible for notifying the family. Interview on 12/23/25 at 5:55 p.m. with the Admin, he stated Resident #2's family should have been called regarding the doctor's order. Record Review of the facility's Nursing Policies and Procedures with subject Physician and Other Communication/Change in Condition dated 5/5/23, reflected under policy was to provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Under Procedures: 1. Complete assessment of the patient/resident which may include but is not limited to: .K. Patient/resident/family wishes.5. The patient/resident and patient's/resident's family member/legal representative will be notified of any changes in medical condition or treatment plan as indicated by HIPPA directives. Record Review of Resident Rights in the facility's Admissions Handbook, dated March 2023, revealed under 18. Notice of Changes in Condition. The facility must.notify.resident representative or interested family member when: .it is necessary to alter treatments significantly (that is, a need to discontinue or change an existing form of treatment). 676394 Page 2 of 4 676394 12/23/2025 Woodlands Place Rehabilitation Suites 5600 Woodlands Trail Denison, TX 75020

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 with indwelling urinary catheters receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #4) of three residents reviewed for Urinary Catheter or Urinary Tract Infection.-The facility failed to ensure that Resident #4 received care and services to avoid catheter-associated urinary tract infections to the extent possible as evidenced by not demonstrating sterile technique during indwelling urinary catheterization of Resident #4. This failure could place all residents requiring indwelling urinary catheters and catheter care at risk for catheter associated urinary tract infections or complications that could lead to serious harm.Record review of Resident #4's face sheet dated 12.23.2025 at 12:30 p.m. indicated he was a [AGE] year-old male admitted to this facility on 12.08.2025 with a diagnosis of obstructive and reflux uropathy (blockage of the passing of urine from the bladder), hyperlipidemia (high cholesterol level), muscle weakness, type two diabetes with hyperglycemia (high level of sugar in the blood), gastroesophageal reflux disease (relating to stomach acid), a fall, and encounter for orthopedic (related to bone or muscle) aftercare. Interview on 12.23.2025 at 2:58 p.m. with Resident #4 indicated an alert and oriented elderly male who stated he was admitted for physical therapy after a fall that required right knee surgery. He said he must have a catheter to help him urinate. He said the nurses removed his catheter earlier that day. He said he was uncomfortable and wanted to take a nap. He said, I wish they would hurry up and put the catheter back in I need to pee. [sic] Interview on 12.23.2025 at 3:45 p.m. with LVN E indicated she had worked at this facility for five years. She stated verbal orders from the NP had been received on 12.23.2025 to re-insert an indwelling urinary catheter for Resident #4. Observation for 12.23.2025 at 3:48 p.m., LVN E gathered supplies to include a sterile kit for the indwelling urinary catheter insertion for Resident #4. She explained the procedure to the resident and cleaned the surface of the bedside table to place supplies for the procedure. She washed her hands, put on PPE, and proceeded with the procedure. After LVN E opened the sterile indwelling urinary catheter kit, she stopped and looked down at the contents of the box. She stated, I can't remember how to proceed. [sic]. After approximately two minutes, LVN E turned to the surveyor and asked how to continue with the procedure. The surveyor asked how the facility policy and procedure guided the process. LVN E continued to stare at the contents of the indwelling urinary catheter box. LVN E was observed to pick up a drape used to protect skin, linens, and resident clothing against urine. She stated, I don't need this [sic] and was observed to lay the drape aside. LVN E took out two individually wrapped pairs of sterile gloves and put on one pair without washing her hands after removing dirty gloves. She was observed to not connect the urine drainage bag to the sterile indwelling urinary catheter tube prior to inserting the sterile tube into the urinary meatus (the opening leading to the interior of the urinary system). The drainage bag was not noted to be pre-connected. Interview with LVN E on 12.23.2025 at 4:16 p.m. indicated she realized she failed to maintain sterile technique by not washing her hands after removing dirty gloves to put on sterile gloves. She realized she failed to connect the urinary drainage bag to the end of the sterile catheter tube prior to inserting tube into the urinary meatus. LVN E stated her future expectation would be to review and follow policy and procedures to prevent the risk of introducing bacteria into a resident's bladder and causing a CAUTI. Interview with the DON on 12.23.2025 at 4:30 p.m. indicated the facility did not use written policies and procedures for inserting indwelling urinary catheters to male or female residents. The DON stated a Lippincott Manual; 9th Edition 676394 Page 3 of 4 676394 12/23/2025 Woodlands Place Rehabilitation Suites 5600 Woodlands Trail Denison, TX 75020

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few printed in 2023 was used for standards of nursing care. Skill check off for all nursing staff is done annually. Review of the Lippincott Manual instructions for Indwelling Urinary Catheter Insertion indicated these areas were not followed. To use sterile techniques when inserting, manipulating, and maintaining the indwelling urinary catheter.Maintain a sterile, continuously closed drainage system.Place a fluid-impermeable pad on the bed between the resident's legs and under the hips.Using sterile no-touch technique to open the insertion kit wrap.Wash hands prior to donning (putting on) sterile gloves.If the urine drainage bag is not preconnected, attach it to the other end of the catheter using sterile gloves. 676394 Page 4 of 4