Bandera Nursing & Rehabilitation

F-F690 - The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

Date: 4-4-25

Corrective Action:

Resident was being treated for a pain/discomfort with PRN medications prescribed to treat chronic pain/bladder spasms. Was being monitored by licensed nurse. Resident was sent to hospital for evaluation & treatment.

Regional Nurse provided in-service to DNS/Admin/Admin in- training /ADNS regarding the following areas:

1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative.

2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.)

3. Notifying medical provider of the change in condition (increased pain).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 676233 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676233 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bandera Nursing & Rehabilitation 222 Fm 1077 Bandera, TX 78003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 4. Adhering to physician's orders and recommendations.

Level of Harm - Immediate 5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being jeopardy to resident health or of our residents during the nurse / shift change report. safety 6. Documentation of the resident's status and delivery of care provided according to the plan of care. Residents Affected - Some 7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.)

8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R).

9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria.

10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly.

11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting).

Comprehension of the training was verified through return demonstration and/or follow up questioning. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain.

Administrator and Director of Nursing conducted an AdHoc Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director on _4/4/2025____ to review plan of removal / immediate corrective action plan implemented.

Date Completed: 4/4/2025

Risk Identification:

All residents who have experienced a significant change in condition may be at risk.

Director of Nursing/Assistant Director of Nursing conducted 100% audit/assessment/evaluation of all current/active residents; to include but not limited to residents with bladder and bowel issues, incontinence and indwelling catheters, to identify any signs or symptoms (s/s) of a change in condition and validated that

the medical provider has reported to the PCP for physician's review and to ensure appropriate plan of care is

in place. This includes residents with bladder and bowel issues.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 676233 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676233 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bandera Nursing & Rehabilitation 222 Fm 1077 Bandera, TX 78003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Outcome: Change in condition on 4/4/25 on 2 residents :outcome: MD and family notified. We were provided with new orders that were implemented. Level of Harm - Immediate jeopardy to resident health or Date Completed: 4/4/2025 safety Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any changes Residents Affected - Some in conditions to ensure proper notification of the Medical Doctor (MD) and family representatives and to ensure appropriate interventions were in place.

Outcome: There were no negative outcomes identified.

Date Completed:

Systematic Changes:

Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to

the nurse working his/her next scheduled shift: Comprehension verified through follow up questions. Questions to include: What is a change in condition and examples, Who do you report change in condition to, What do you do when a resident is experiencing more and bladder and bowel pain.

1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the significant change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative.

2. Nurse conducting a proper assessment and documenting in the E.H.R.

3. Adhering to physician's orders and recommendations.

4. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nursing shift change report process.

5. Documentation of the resident's status and delivery of care provided according to the plan of care.

6. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.)

7. Nurses will conduct on-going monitoring of the resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R).

8. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 676233 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676233 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bandera Nursing & Rehabilitation 222 Fm 1077 Bandera, TX 78003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, Level of Harm - Immediate urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in jeopardy to resident health or urine odor, color, amount of urine and hematuria. safety 10. Abuse & Neglect (ANE)- Identifying Prevention and Reporting Residents Affected - Some 11. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record.

12. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record.

13. Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record.

Director of Nursing / Designee will ensure all licensed nursing staff will be educated to include nurses on leave/agency/Part time staff (PRN staff) -Nurses will be in serviced prior to working their next shift.

DNS/ Designee will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires.

Monitoring:

Director of Nursing / Assist. Director of Nursing will review nursing 24hr reports, progress notes and SBARS/change in condition and abnormal labs during the morning clinical review meeting (5-7 days per week) and to ensure that appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within

the medical record. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder.

Director of Nursing / Assist. Director of Nursing will conduct at least daily rounds (5-7 days per week) to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented with in the electronic health record (EHR).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 676233 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676233 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bandera Nursing & Rehabilitation 222 Fm 1077 Bandera, TX 78003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random audits of documentation of progress notes, Medication Administration Record (MARS) (pain meds) as well as staff Level of Harm - Immediate interviews to identify any Signs and symptoms (s/s) of a resident with a change in condition and will ensure jeopardy to resident health or appropriate documentation, notifications and appropriate interventions are in place and documented with in safety the electronic health record (EHR). The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. Residents Affected - Some The monitoring logs will be retained in the Administrator's survey binder.

Director of Nursing / Assist. Director of Nursing will conduct at least 3 times per week random interviews with

the nursing team members to identify competency/comprehension of the following: Identifying signs and symptoms (s/s) of a urinary tract infection, increased pain, and other signs of a change in condition as well as the process for reporting the identified change in condition to the license nurse, the process for the nurse to conduct an assessment, will ensure appropriate documentation, MD and family notifications as well as ensuring appropriate interventions are in place and documented with in the electronic health record (EHR).

The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder.

The facility will conduct a monthly Quality Assurance Performance Improvement (QAPI) meeting to review

the status and compliance notification to Medical Doctor, Nurse practitioner, or physician's assistant (MD/NP/PA) ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the Electronic Health Record (E.H.R.) Findings of audits and status of compliance will be reviewed to the Administrator and the Quality Assurance Performance Improvement (QAPI) committee during the monthly meetings for the next 2 months. The Director of Nursing / Assist. Director of Nursing will maintain a monitoring log of the interviews in order to identify compliance or need for additional training is necessary. The monitoring logs will be retained in the Administrator's survey binder.

The Surveyor monitored the POR on 04/05/25 as followed:

Observations were made on 04/05/25 from 1:04 PM - 1:10 PM of three residents' catheter tubing and bags. All three had clear drainage with no sediment noted.

During interviews on 04/05/25 from 11:32 AM - 1:28 PM, three RNs, three LVNs, one MA, and five CNAs from different shifts all stated they were in-serviced before working their shift on catheter care, communication during shifts, change in conditions, and signs and symptoms of a UTI. All stated a change in condition could be increased pain, altered mental status, or anything that is out of the resident's baseline. All staff stated that any change in condition should be relayed to the NP because it could indicate a bigger issue that could be occurring that needed to be addressed. They all gave signs and symptoms of a UTI such as altered mental status, burning during urination, dark urine, or increased pain. The aides and MA stated if they noticed any of those signs and symptoms, they would notify a nurse immediately. All stated a negative outcome of not getting orders for a suspected UTI could be sepsis or hospitalization . The nurses stated

during shift changes, instances of new skin integrity issues, new orders, or any change in condition with residents should be communicated to the oncoming nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 676233 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676233 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bandera Nursing & Rehabilitation 222 Fm 1077 Bandera, TX 78003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 During an interview on 04/05/25 at 12:20 PM, the ADM stated he was in-serviced by the RNC and was aware of the process for ensuring changes in conditions were identified and relayed to the MD/NP. He stated Level of Harm - Immediate all staff were being in-serviced before working their shifts. jeopardy to resident health or safety Review of the facility's Ad Hoc Meeting agenda, dated 04/04/25, reflected the ADM, MD, DON, and AIT were

in attendance. Residents Affected - Some

Review of an in-service conducted by the RNC, dated 04/04/25 reflected the ADM, DON, and ADON were in-serviced on the following:

1. The process for ensuring that changes in conditions have been identified, and reported to the medical provider, notify PCP of abnormal labs, also orders provided bb PCP nurse should be implemented as ordered and nursing should document in the electronic health record the notification of the change in condition to the MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative.

2. Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.)

3. Notifying medical provider of the change in condition (increased pain).

4. Adhering to physician's orders and recommendations.

5. Communicating pertinent information regarding the status of resident's condition to ensure the well-being of our residents during the nurse / shift change report.

6. Documentation of the resident's status and delivery of care provided according to the plan of care.

7. If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA.)

8. Nurses should conduct on-going monitoring of resident r/t the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R).

9. Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria.

10. Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly.

11. Abuse and Neglect (ANE_- Identifying Prevention and Reporting).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 676233 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676233 B. Wing 04/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bandera Nursing & Rehabilitation 222 Fm 1077 Bandera, TX 78003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Review of and in-service entitled Bowel and Bladder, dated 04/04/25 - 04/05/25 and conducted by the ADM and DON, reflected all nursing staff were in-serviced on identifying bowel and bladder issues and recognizing Level of Harm - Immediate changes in residents - increased use of PRN pain medications or increased pain with urination, and notifying jeopardy to resident health or the NP of those changes. safety

Review of and in-service entitled Peri Care/Catheter Care dated 04/04/25 - 04/05/25 and conducted by the Residents Affected - Some DON, reflected all nursing staff were in-serviced on the peri care audit tool and peri care steps to decrease

the risk of infection.

Review of assessments, dated 04/04/25, reflected all residents were assessed for pain, discomfort, or a change in condition by the DON and ADON. Two residents were determined to have a change in condition,

the MD was notified, and new orders were put in place.

Review of the facility's Monitoring Tool to review the 24-hour report, progress notes, SBAR/CIC, and labs daily, on 04/05/25, reflected it had been signed off as completed and they were in compliance on 04/04/25 and 04/05/25.

The ADM and DON were notified on 04/05/25 1:35 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 676233