Calder Woods

During an interview on 08/11/25 at 3:35 p.m., RN V said Resident #1 was crying and in pain after

Resident #1 approximately 1.5 hours later and she was sleeping.

She said she did not document Resident #1's status in the nurse progress notes.

She said she was aware she should have documented in the nurse progress notes.

She said not documenting resident status could delay care or treatment.

Record review of the facility policy Incontinence briefs and pad handling dated 11/18/24 indicated .Documentation associated with handling incontinence briefs and pads includes: -date and time of care -name and title of any staff member who assisted with care .

Record review of the facility policy Charting and Documentation dated 10/11/21 indicated All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record.

The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Documentation in the medical record is primarily electronic; however, there may be some manual documents that are uploaded into the record. 1.

The following information is to be documented in the resident's medical record: a.

Objective observations; b.

Medications administered; c.

Treatments or services performed; d.

Changes in the resident's condition; e.

Events, incidents, or accidents involving the resident; and f.

Progress toward or changes in the care plan goals and objectives. 2.

Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

676109 08/11/2025

Calder Woods 7080 Calder Beaumont, TX 77706

Findings included: 1.

Record review of Resident #3's admission Record dated 08/11/25 reflected an [AGE] year-old female admitted to the facility on [DATE].

Diagnoses included Major Depressive Disorder, hypertension (high blood pressure), and constipation.

Record review of Resident #3's Comprehensive MDS assessment dated [DATE] reflected her BIMS score was 99 (unable to complete the interview).

The other fields of the MDS assessment were not yet filled out except for her diagnoses which included depression, a hip fracture, and hypertension (high blood pressure).

Record review of Resident #3's Care Plan reviewed on 8/11/25 reflected it had no information or interventions related to infection control.

During an observation and interview on 08/11/25 at 9:49 AM, Resident #3 was awake and lying in bed. CNA B and CNA C entered the room and did hand hygiene, closed the door, and closed the blinds. CNA B and CNA C put on gloves. CNA B lowered the resident's brief and cleaned her perineal area appropriately.

CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B and CNA C assisted Resident #3 to turn onto her side and CNA B cleaned her buttocks. CNA B rolled the dirty brief inward and threw it away. CNA B removed her gloves and placed new gloves on without completing hand hygiene. CNA B placed a clean brief, adjusted the resident, and covered her. CNA B and CNA C cleaned up the supplies and completed hand hygiene.

During an interview with CNA B on 08/11/25 at 9:57AM, she stated she completed hand hygiene first.

She stated she would do hand hygiene before, between, and after incontinent care.

She stated she realized she had not done hand hygiene after incontinent care and glove changes, and she should have.

She stated she was trained to complete hand hygiene after glove changes and when going from a dirty to clean brief.

She stated the risk of not performing hand hygiene was that infection could spread.

During an interview with LVN A on 08/11/25 at 12:57 PM, she stated hand hygiene should be completed before care, after the change (brief change) itself, and before leaving the room.

She stated staff were trained on hand hygiene for infection control purposes.

During an interview with the Director of Nursing on 08/11/25 at 1:25PM, she stated the expectation was for the facility staff providing incontinent care to perform hand hygiene before starting care, when changing gloves (such as when the gloves were dirty), and after care.

The DON stated the ADON and herself were responsible for training about hand hygiene.

The Director of Nursing stated not completing proper hand hygiene could cause cross contamination.

Record review of a facility In-service Training Report, dated 07/09/25, reflected: CNA B and CNA C's signatures on the first page.

The second page included, .Incontinent Care.7.

Remove old brief and place in bag.

Remove gloves, wash hands and reapply gloves.10.

Remove gloves and place in bag. 11.

Wash hands and apply new gloves. 12.

Apply new brief or pad 13.

Remove gloves and wash hands.

Record review of the facility policy titled, Incontinence briefs and pad handling, long-term care dated 11/18/24, reflected .perform hand hygiene, put on gloves.remove and discard your gloves, perform hand hygiene, put on clean gloves.discard soiled brief.remove and discard your gloves.perform hand hygiene.