The Laurenwood Nursing And Rehabilitation

The facility failed to refer Resident #12, who had mental illness, to the state designated service for review.

This failure could place residents at risk of missed PASSR services.

Findings included:

Record review of Resident #12's Quarterly MDS Assessment, dated 05/08/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE].

Her BIMS score was 8, which reflected her cognitive skills for daily decision making were moderately impaired.

Her diagnoses included bipolar disorder and schizophrenia.

She did not have dementia.

The MDS did not include PASSR status.

Record review of Resident #12's Comprehensive Care Plans, dated 05/05/26, reflected:Resident had unspecified psychosis, schizoaffective disorder, and bipolar disorder.

The resident could see and hear people in her room trying to rape her.

Facility interventions included:Give medications as ordered and evaluate with psychological care.

Record review of Resident #12's PASSR Level-I screening, dated 12/08/25, reflected the resident did not have mental illness and did not have dementia. In an observation on 06/02/26 at 11:25 AM, Resident #12 was sleeping and not available for interview. In an interview on 06/04/26 at 2:45 PM, the MDS Coordinator said she received Resident #12's PASSR Level-I screening and did not submit a new one.

She said she was not supposed to correct the PASSR Level-I screening and did not know the effect it could have on the resident if it was incorrect.

She said she did not know who was responsible for overseeing her work. In an interview on 06/04/26 at 3:40 PM, the DON revealed PASSR was data entry and she would look at the PASSR Level-1 screenings that were received by the facility to ensure they were put in SIMPLE correctly.

The DON said she did not know the process to follow if the PASSR Level-I screening received was inaccurate.

The DON said the resident could be at risk for missed services if the PASSR Level-I screening was incorrect.

Review of the facility's policy and procedure, PASSR Requirements and Level I and Level II, dated December 2025, reflected: .2.

Review the Level 1 screen, at least quarterly, and assure it is filed in the medical record and accurately reflects the patient's/resident's current status.3.

Ensure that the appropriate state designated agency is contacted for any resident/patient requiring a Level II screen either on preadmission, annually, or upon learning of an SMI/ID diagnosis that was previously unknown or undetermined.

During an interview on 06/03/2026 at 12:08 p.m., the DA said she was responsible for writing the date on all canned goods and the date was when the facility received the items.

She explained that when stocking the canned goods, if she noticed a dent she would remove the can from the storage area and place it in the DM's office. In a record review of the facility's Food Safety and Sanitation policy, dated 2023, revealed: .3.

Food Purchasing. e.

Bulging or leaking cans, cans with severe dents on the seam or broken containers of food will not be used.4.

Food Storage.Canned and dry foods without expiration dates should be used within six months of delivery or according to the manufacturer's guidelines.In a record review of the U.S. FDA Food Code 2022 reflected: Section 6-301.20 Disposable Towels, Waste Receptacle.

Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.In a record review of the U.S. FDA Food Code 2022 reflected: Definitions 3.

Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.

675806 06/04/2026

The Laurenwood Nursing and Rehabilitation 330 W Camp Wisdom Rd Duncanville, TX 75116

when caring for Resident #19. In a follow-up interview on 06/04/26 at 10:29 AM, the DON said

and was not at risk for developing a MRSA infection from Resident #19.

The DON said Resident #19

and was cared for by nurses, not CNAs.

The DON said the nurses changed the resident briefs, not the CNAs. In an interview on 06/04/26 12:42 PM, LVN D said the CNAs were responsible for providing brief changes for Resident #4. In an interview on 06/04/26 at 1:19 PM, Hospice RN said Resident #4 was on Hospice and was immunocompromised.

She said Hospice was not made aware that Resident #19 was being treated for MRSA and should not have been in a room with Resident #4. In an interview on 06/04/26 at 3:05 PM, Physician revealed Resident #4 was at risk for developing infections because she had indwelling devices. He said Resident #19 was colonized (the bacteria is carried in the blood but is not causing an active infection) with MRSA and did not have an active MRSA infection in the urine. He said he did not know why Resident #4 was kept in the room with Resident #19 and he was going to go and assess each resident and draw more labs on Resident #19. He said the decision to keep them in a room together needed to be done in accordance with policy and procedure.

Record review of the facility's policy and procedure, Multidrug-Resistant Organisms, dated December 2025, reflected: .Room Placement .4. A resident with a multidrug-resistant organism may need to be separated from a roommate who has any of the following: a device such as an indwelling urinary catheter, gastrostomy feeding tube, or intravenous access line; a pressure ulcer or other open skin wound including a postoperative wound; or significant immunosuppression (due to malignancy, chemotherapy, etc.).5.

The resident need not be moved from his/her room until after screening is done and the need for Contact Precautions is determined.6.

Depending on the situation, placement may include the following:a.

Placement in a room with someone else who is colonized or infected with the same organism, but does not have any other infection (cohorting);b.

Placement with someone who does not have invasive devices or wounds;c.

Placement in a private room, if possible.7. A resident who is infected or colonized with a multidrug-resistant organism will be permitted to participate in group meals and activities if draining wounds are covered, bodily fluids are contained, and he/she observes good hygiene practices. 3.

Record review of Resident #42's Quarterly MDS Assessment, dated 03/22/26, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE].

His BIMS score was 13, which indicated his cognitive skills were intact.

The resident had an in-dwelling catheter and was always incontinent of bowel movement.

His diagnoses included stroke and respiratory failure.

The resident was dependent on staff for toileting hygiene.

Record review of Resident #42's Comprehensive Care Plan, dated 09/11/23, reflected:ADL self-care performance deficit related to decreased mobility.Facility interventions included: Dependent on staff for toilet use In an observation on 06/03/26 at 11:35 AM of incontinence care for Resident #42, CNA A folded down the resident's brief, cleaned the penis and scrotum, cleaned the buttocks, and did not change gloves or perform hand hygiene. CNA A applied barrier cream, placed a clean brief, and straightened the sheets with her soiled gloves. In an interview on 06/03/26 at 12:05 PM, CNA A said she was trained months ago to perform hand hygiene after changing gloves. CNA said she messed up this time and failure to perform hand hygiene could lead to contamination, germs, and infection. In an interview on 06/04/2026 at 10:29 AM, the DON said hand hygiene was supposed to be performed after glove changes and training was completed with staff.

The DON said monitoring was in place and management observed staff for hand hygiene.

The DON said residents were at risk for the spread of infection if hand hygiene was not performed.

Record review of the facility's policy, Hand-Washing/Hand Hygiene, revised December 2025, reflected: This facility considers hand hygiene the primary means to prevent the spread of infections.7.

Use an alcohol-based hand rub; or, alternatively, soap (antimicrobial or non-antimicrobial) and water forthe following situations.:m.

After removing gloves.

675806 06/04/2026

The Laurenwood Nursing and Rehabilitation 330 W Camp Wisdom Rd Duncanville, TX 75116