Health Inspection

Elgin Nursing And Rehabilitation Center

Inspection Date: April 25, 2025

Total Violations 1

Facility ID 676180

Location ELGIN, TX

Inspection Findings

F-Tag F686

The facility failed to ensure Resident # 249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2025 through 04/20/2025. Resident # 249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement.

Resident #249 remains hospitalized .

Actions for Resident Involved * On 4/24/2025 the Treatment Nurse was re-educated on completing thorough skin assessments by the Director of Nurses and suspended.

Identification of Others * On 4-24-2025, the nursing facility conducted 100% head to toe assessment to ensure that residents with skin alterations were identified and documented. All skin assessments were documented on the PCC total body skin assessment form and saved in the resident's medical record. For any alterations in skin integrity, orders will be reviewed, and documentation reviewed to ensure license staff are following facility skin assessment and pressure ulcer prevention and management policy. * 3 residents were identified with newly developed rashes, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 resident identified with MASD to the sacrum, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect treatment. * 1 open blister was identified, MD was notified, orders for treatment were received, RP was notified, and care plan was updated to reflect the treatment.

Systemic Changes/ Education

On the Director of Nursing initiated education with 100% of licensed staff. Education was completed 4-24-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift.

08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some * Skin Assessment Policy * A full body, or head toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include

On 4/24/25 The Regional Clinical Specialist initiated the following education with 100% of licensed staff.

Education will be completed 4-25-2025. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training contents. * Skin Assessment Policy * A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. * The DON and/or designee will provide oversight of completion of skin assessments up-on admission/re- admission and weekly thereafter and will document on the findings on the facility clinical [NAME]-up form.

08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some * the documentation of each assessment is noted in PCC by the nurse completing assessment. The Director of Nurses/ designee will run the Total Body Skin Assessment from PCC each weekday, audit for missing assessments, and assign completion as appropriate. * Pressure Ulcer Prevention and Management Policy * Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury or skin alteration. Findings will be documented in the medical record. * Assessments of pressure injuries or skin alterations will be performed by a Licensed Nurse (Licensed Vocational Nurse and Registered Nurse) and documented in the medical record. Documentation will include

the site, type, stage, measurement, presence of exudate and amount, odor, wound bed. surrounding skin color, surrounding tissue edges, tunneling, undermining and response to treatment. * The attending physician will be notified of: * The presence of a new pressure injury or skin alteration upon identification. * The progression towards healing, or lack of healing, of any pressure injuries or skin alteration weekly. * Any complications (such as infection, development of a sinus tract, etc.) as needed. * The notification of the physician is noted in PCC and will be tracked for completion by the DON and/or designee through the review of the PCC 24 hrs. report. * Skin Integrity Management System. The documentation of this training is recorded on the facility's Inservice Training Report. * Notification of Changes Policy- The documentation of this training is recorded on the facility's Inservice Training Report.

On 4-24-2025, the Regional Clinical Specialist re-educated the Director of nursing and ADONS on monitoring the skin integrity system to include completion of weekly skin assessment for each resident.

Training recorded on the facility Inservice Training Report * Comprehension of training was verified by having nurses voice understanding of the training and repeat back training content.

Monitoring

The Director of Nursing or designee will audit PCC total body assessment each weekday to ensure timely completion of skin assessments for each resident. o The PCC total body assessment audit will be documented on the facility's Clinical Stand-up Meeting form.

The Director of Nursing and/or designee will ensure competency of the Licensed Nurses (Licensed Vocational Nurses and Registered Nurses) weekly x 4 by return demonstration of head-to-to-toe assessment and visual inspection of the resident's skin. o The verification of licenses nurse's competency will be documented on the facility Skin Assessment competency form.

The Director of Nursing or designee will review the pressure ulcer log weekly following wound measurements to ensure that up-on identification of a new wound the physician was notified and that the wound assessments reflect the change in condition. o The review of the pressure ulcer log will be documented on the facility Clinical Stand-up Meeting form. o For any new admissions or resident requiring daily attention on the weekend, the on-call facility nurse manager will monitor for completion of assessment and ordered treatments.

The Director of Nursing or designee will monitor compliance each weekday morning. The results of the findings will be discussed in the monthly QAPI meeting for three months and the plan will be continued as needed. o The compliance monitoring will be documented on the facility's monthly QAPI form.

Skilled Wound Care Physician group will provide weekly review of residents with wounds. o Skilled Wound Care Physicians will provide weekly assessment and review of the residents with wounds by conducting weekly rounds. Rounds will be documented on the SWC provider Communication Log for Daily Rounds.

The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/ or designee reviews the documentation in PCC during the morning clinical meeting.

The facility will evaluate the effectiveness of this plan during the Monthly Quality Assessment and Assurance Committee Meeting attended by at least the Administrator, Director of Nursing, Medical Director and at least three other staff members and the Infection Preventionist. The facility QAPI Committee reviews facility trends including Pressure Ulcer Reports and completion of weekly skin assessments.

An Ad Hoc QAPI was conducted on 4-24-2025, by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist concerning pressure ulcers and to develop the above-mentioned plan of care.

We respectfully submit this action plan for the removal of Immediate Jeopardy.

The Survey Team monitored the POR on 04/24/2025 through 04/25/2025 as followed:

In an interview on 04/25/2025 at 1:23 pm LVN P (6-2 shift) stated she was in-serviced on skin and wound care on 4/24/2025 by the DON and the Nurse Consultant. The in-service was on wound and skin assessments and how to do assessments and notification of changes. We do weekly skin assessments on everyone in the building, on new admits, readmits and residents with change of condition. Know how to properly assess the resident. Know what to look for on a head-to-toe assessment. Know the 2 forms total body assessment do this on everyone whether they have wounds or do not have wounds. The 2nd form is what we do in iPad, and we do the wound assessment on it, and we take a picture of the wound we fill out

the characteristics progress of the wound and it automatically does the measurements of the wound.

Document this on a skin assessment form and it has the width length and depth for the nurse to document.

The total body assessment- document skin color, temperature, moisture, condition and enter the number of wounds. I cannot recall everything on the skin assessment without looking at the form. The nurse documents

the type of wound she stated LVN's could not stage a wound and would need someone else to stage such as RN or the Physician or Nurse Practitioner. If Resident has a burn put what type of degree of burn and would refer to RN or Physician for assistance if needed. Document if there was any slough if resident has staples how many does the resident have. The measurements of the wound how long the resident had the wound. Was the resident admitted with the wound.

In an interview on 04/25/2025 1:48 pm LVN Q (6-2 shift) stated she was in-serviced on skin and wound care

on 4/24/2025 by the Nurse Consultant and the DON did the in- service. Every time do a skin assessment do

it weekly, any new admits, readmits, or change of condition. Inservice on notification of changes. I had to repeat what I learned during in-service to the DON. We have a list of who gets a skin assessment included people with wounds and without wounds every day. We must do head to toe assessment if there are some findings any bruises any skin tears pressure ulcer, we must make sure the pressure points are not red. She stated head to toe assessment was looking at the scalp, all areas of the ears, underneath both arms - arm pits, both arms, stomach area, if a female look under the breast and if a male would look under [NAME] the scrotum. I would open the buttocks area and look to determine if there was any wounds or area inside the buttocks look outside the buttocks, especially the sacral area. If have any fat rolls anywhere on the body look under the fat rolls. Would look at the thighs, both upper and lower leg extremity, look at ankles, heels, underneath the feet and in between toes. Would follow the skin assessment and document any findings of

the skin assessment of the resident on the skin assessment. If find a pressure ulcer I will do skin assessment

on IPAD we can take picture of the wound, I would look first photo how it looked and if needed to take another photo would take another photo. After the picture is taken on the IPAD it directs you what to do next.

And you would click on options and the IPAD would measure the wound. You would point the iPad to the head of the resident and take picture and it would show you the measurements of where the wound was located. When you take a picture it gives option where it says where is the position where the head of the patient point the camera to the wound it tells where is the location of the wound and click on it and it gives you a diagram of the person it has option to rotate to get the actual site of the wound it will ask all characteristics of the wound such as is it draining, does it have an odor s/s of infection and gives the option it gives to measure but as an LVN cannot stage. I would call the doctor and get orders and treat per doctor order. Notify the doctor notify the DON notify family I have to make sure to document progress notes and on

the skin assessment and care plan it.

In an interview on 04/25/2025 at 2:15 pm LVN R (6-2 shift) stated she had been in-service on 4/24/2025 by DON and Nurse consultant. She stated she had to repeat what was covered during the in-service to the DON. We went over the head-to-toe assessment and the wound care assessment and notification of changes. We are to do weekly skin assessments and we have a list of skin assessments due every day.

Also, we do skin assessments on any new admit, readmit and any resident with a change of condition even if

we had already completed a skin assessment on that resident for the week we would do a new skin assessment. First Check in hair and scalp, behind ears and in ears, check in the nose, check arm pits, and stomach chest area. If a female check underneath the breast, check boney prominences check the back and coccyx, need to spread the buttocks cheeks, and check the entire bottom, if male check underneath the scrotum. Check the entire body. The assessments- skin and wound use the iPad take picture of the wound and it automatically prompts you what to do it will measure the wound on the IPAD and report exactly where

the wound is located. She stated LVNS did not stage a wound. There would be a diagram of a picture of a body and the where the wound was found on the body would be located on the diagram. She stated If I found a new wound I would assess it- if there was drainage, measurement, any eschar, bleeding and what was listed on the skin assessment you would check if there were any black areas in the wound. I would document it and notify the doctor, the DON, the ADON and the family. I would document if there was a new physician order and do the treatment to the skin concern and then I would do a nurses note, skin assessment, wound assessment, change of condition nurses note and write it on the care plan information of

the wound and physician order. I would complete a skin assessment form. We do skin assessments every week, on admission, readmission and when change of condition - on every resident if they do or do not have

an existing skin concern.

In an interview on 04/25/2025 at 2:32 pm LVN S, 6-2 shift DON and Nurse Consultant did in-service on 4/24/2025. We are to complete skin assessments on every resident weekly and in-service on notification of changes. I had to repeat what was told to us during the in-service I repeated to the DON. We are given 08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 of 1 kitchen reviewed for food and nutrition services.

The facility failed to ensure Dietary [NAME] L followed the puree recipe for biscuits and added apple juice instead of water or stock to the bread puree.

This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life.

Observation on 04/23/2025 at 10:20 AM, revealed Dietary [NAME] L placed 6 biscuits into the puree blender.

She did not measure apple juice and poured apple juice on top of the biscuits and began to puree the biscuits. The biscuit puree was very thin almost liquid form. Dietary [NAME] L continued to add the apple juice. There was a recipe for puree fish hanging on the top shelf for the Dietary [NAME] L could review when

she pureed the fish. However, there was not a recipe for puree biscuits.

Interview on 04/23/2025 at 10:30 AM, Dietary [NAME] L stated she always used apple juice when she purees bread. She stated she had puree bread so many times she did not need to review the recipe. Dietary [NAME] L stated the recipe was in a manual in the manager's office on a shelf toward the back of the kitchen. She stated she did not measure the apple juice and did not know how much apple juice was needed to puree biscuits. Dietary [NAME] L stated there were six residents on the puree diet. She stated she was recently in-service on how to puree food and she did have training on pureeing food. She did not recall the date.

Review on 04/23/2025 at 10:35 AM, of the biscuit puree recipe reflected food thickener bulk use 1 tablespoon plus 3/4 teaspoon for 5 servings. Water or stock use 1/2 cup plus 2 tablespoons. Prepare slurry (a mixture typically made from a thickening agent, such as flour or cornstarch, which is used to thicken food).

Process until smooth using 1 oz of slurry per biscuit. Chill and hold at 41-degree Fahrenheit or below for service.

Interview on 04/23/2025 at 10:50 AM, the Dietary Manager stated stock was the same as apple juice . She stated the Dietary [NAME] L did not prepare the puree biscuit correctly. She stated she was expected to follow the recipe and to measure the apple juice and Dietary [NAME] L did not do either one of these instructions. She stated she had in-service the staff few months ago on how to puree food and Dietary [NAME] L was in the in-service.

Interview on 04/23/2025 at 11:50 AM, the Dietary Consultant stated all cooks were expected to follow all recipes including puree recipes. She stated the apple juice was not appropriate to use when pureeing biscuits or any type of bread. Dietary Consultant stated gravy would have been the better option to use when puree biscuits and use thickener if needed. She stated when pureeing any type of food, the cooks were expected to use the spoon test to place the puree food on back of the spoon and if it did not fall into the bowl,

it was at the correct consistency. She stated Dietary [NAME] L will be re-educated on how to puree food correctly and will observe Dietary [NAME] L when she pureed food. She stated she was a new consultant to

this facility and will ensure all dietary staff was re-educated on puree food.

In an interview on 04/24/2025 at 10:00 AM, the Administrator stated he expected the cooks to follow the recipe when preparing puree food or any type of food. He stated there was a possibility if the puree food was not the correct consistency, a resident may aspirate when eating the puree food. The Administrator stated

the Dietary Manager was responsible to monitor the kitchen and the kitchen staff and he was responsible for monitoring the Dietary Manager.

Review on 04/24/2025 the facility in-service training, dated, 03/20/2025, reflected puree consistency in-service was given to all dietary staff including Dietary [NAME] L. Dietary Manager and Dietary Consultant gave the in-service.

Requested a policy on preparing puree diets on 4/23/2025 at 10:50 AM, Dietary Manager stated they referred to the puree recipe for their policy. 08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation.

1. The facility failed to ensure Dietary Aide K wore a beard guard when standing over clean dishes in the

dishwashing room.

2. The facility failed to ensure Dietary [NAME] M used proper hand hygiene during food preparation.

These failures could place residents who ate food from the kitchen at risk for foodborne illness.

1. Observation on 04/22/2025 at 9:10 AM, Dietary Aide K was not wearing a beard guard when standing in

the dishwasher room over clean dishes. His beard growth was approximately 10 inches.

Interview on 04/22/2025 at 9:15 AM, Dietary Aide K stated he was expected to wear a beard guard anytime

he was in the kitchen area. He stated if hair fell on to plates and the hair transferred to residents' food there was a possibility a resident may become ill with some type of stomach issues (when asked what type of stomach issues he did not respond to the question). He stated germs were located on hair. Dietary Aide K stated he had been in-service on wearing beard guards. He stated it was in February 2025 or March 2025.

He did not recall the exact date.

2. Observation on 4/22/2025 at 9:25 AM, Dietary [NAME] M was not wearing gloves. He touched the right

side of his shirt with his middle finger, ring finger and fore finger on his right hand. Dietary [NAME] M touched

the area of a large cooking spoon where the cook later used when stirring food for lunch without sanitizing his hands. He removed gloves from the glove box when his right middle, ring and fore fingers touched the Touchette's (area of the glove for the fingers), and he did not sanitize or wash his hands. Dietary [NAME] M continued to do food preparation with the gloves on his hands.

Interview on 04/22/2025 at 9:30 AM, Dietary [NAME] M stated he did not wash or sanitize his hands when he touched inside the serving spoon and did use the serving spoon in the pots on the stove when placing potatoes in the pots. He stated he did not wash his hands prior to placing new gloves on both hands. Dietary [NAME] M stated he did touch his shirt. He stated his shirt was considered contaminated and if he touched anything contaminated, he was to wash his hands immediately. He stated there was a possibility germs from his shirt may cross contamination. Dietary [NAME] M stated germs may transfer to the food from his hands.

He stated if a resident ate food with germs on it there was a possibility a resident may become ill with stomach problems such as vomiting. He stated he had been in-service on hand hygiene but did not remember the date of the in-service.

Interview on 4/24/25 at 8:30 AM Dietary Manager stated hair nets or cap and beard guard on facial hair are required for all staff while in the kitchen. Dietary Manager stated it could negatively affect a resident if hair restraints are not worn by a resident receiving food with hair in it. Dietary Manager stated it was her responsibility to ensure beard restraints were worn by the male staff in the kitchen. Dietary Manager did not answer why dietary aide did not properly wear a beard guard while in the kitchen even though he had facial hair. She stated all staff were to wash hands after touching anything.

Interview on 04/24/25 at 12:30 PM the Administrator stated his expectation was that hair restraints were to be worn by all staff in the kitchen. The ADM stated if hair restraints are not worn there was a possibility a hair may fall into food. He stated there was a possibility if a resident ingested a hair the resident may become ill with some type of stomach issues. The Administrator stated he was not a nurse and did not know the extent of stomach illness getting into the food. The ADM stated all kitchen staff are responsible for wearing hair restraints and that ultimately the DM was responsible for ensuring hair restraints are worn by all staff in the kitchen.

Record review of the Facility's Policy on Employee Sanitation, dated 05/10/2018 reflected:

1. Hair restraints, such as hats, hair coverings or nets, caps and beard/moustache restraints or other

effective hair restraints are worn to keep hair from contacting food and food-contact surfaces.

2. Hand washing:

a. Immediately before engaging in food preparation including working with exposed food, clean equipment, utensils, and unwrapped, single-service and single-use articles. b. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. 08/28/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 04/25/2025 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51511 Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #40 and Resident #1) of 18 residents reviewed for infection control practices.

1. The facility failed to ensure the Treatment nurse used a cleaning technique on Resident #40's Stage 3

sacral pressure ulcer that did not cross contaminate the pressure ulcer.

2. The facility failed to ensure that MA C performed hand hygiene prior to medication administration for

Resident #1.

The failure related to wound care technique could place residents at risk for healthcare associated cross contamination leading to worsening of pressure ulcers discomfort, pain, and potential infections. The failure with hand hygiene prior to medication administration could place the residents at risk for healthcare associated cross contamination and possible infections related to the contamination of the environment and oral medications.

Review of Resident #40's face sheet dated 04/16/2025 revealed Resident #40 was a [AGE] year old female admitted to the facility on [DATE REDACTED] with a diagnoses of Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit), Dysphagia (difficulty swallowing), Parkinson's Disease with Dyskinesia (a progressive disorder that affects the nervous system), Neurocognitive disorder with Lewy Bodies (a dementia where protein deposits develop in nerve cells in the brain), and unspecified Fracture of Sacrum (a broken bone in the lower back near the tailbone).

Record review of Resident #40's MSD assessment, dated 04/16/2025, reflected Resident #40 was readmitted to the facility on [DATE REDACTED] following a short-term hospital stay. MDS assessment had not been completed at the time of the survey.

Record review of Resident #40's care plan reflected a focus area, dated 04/23/2025, reflected The resident has stage 3 pressure ulcer to sacrum date of development 4/21/25 r/t skin frailty, immobility and incontinence. Goal included, resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target date: 06/28/2025.

Observation on 04/23/2024 at 8:18 AM revealed the Treatment Nurse in Resident #40's room to provide wound care. She removed the dressing covering the wound, then provided incontinent care to Resident #40.

She wiped feces off the resident's perianal area with a moist perineal wipe and used the soiled wipe to wipe

the skin around the open wound. She later used clean moistened gauze to wipe the skin surrounding the wound, before using the soiled gauze to wipe the open wound bed.

Interview with Treatment Nurse on 4/24/25 at 09:20 AM stated that the proper technique for performing wound care is to wipe from the inner aspect of a wound and clean outward to prevent cross-contamination of

a wound. Stated, that wasn't ideal at all when informed that she wiped around the open wound when cleaning feces off the resident's skin, and then later wiped the surrounding skin before cleaning the wound bed with the same moistened gauze during wound care to Resident #40. She stated that the resident could get an infection if the wound was contaminated with feces.

Interview on 4/24/25 at 02:32 PM with DON stated that her expectations for wound care technique is that the wound bed be cleaned from the center of the wound bed outward. Stated that fecal contamination of the wound could lead to a wound infection and decline of the wound. Stated that hand hygiene should be done prior to medication administration per policy. Stated that the staff could cross contaminate the resident if hand hygiene is not performed.

Interview on 4/24/25 at 03:31 PM with Administrator stated that his expectation is that incontinent care be performed prior to proceeding with wound care. Stated his expectation was that hand hygiene should be performed prior to medication administration. wound, there is a possibility that a resident may need further intervention such as antibiotics. Stated that there is a possibility of cross contamination if staff did not wash or sanitize hands prior to administering medications to a resident. Stated that the resident has a potential to develop stomach issues such as nausea and vomiting, depending on the type of bacteria.

Review of facility's policy on Infection Prevention and Control Program dated 05/13/2023, reflected All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.

Review of the facility's policy on Pressure Ulcer Prevention and Management dated 08/15/2022, reflected

The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.

Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to:ii.

Minimize exposure to moisture and keep skin clean, especially of fecal contamination.

Record review of Resident #1's face sheet, dated 04/23/2025, reflected Resident #1 was a [AGE] year old female admitted to the facility on [DATE REDACTED] with a diagnosis of Seizures, Vascular Dementia (dementia related to the blood vessels of the brain), Anxiety, and transient cerebral ischemic attack (a brief stroke-like attack wherein symptoms resolve withing 24 hours).

Record review of Resident #1's MDS assessment, dated 02/20/2025, reflected Resident #1 had a BIMS score of 12, indicating moderate cognitive impairment.

Record review of Resident #1's care plan reflected a focus area, dated 03/03/2025, The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia. Interventions indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness.

Observation on 04/23/25 at 09:43 AM revealed MA C did not perform hand hygiene when entering the Resident's room prior to administering oral medications to Resident #1.

Interview with MA C on 4/24/2025 at 9:48 AM stated that she did not perform hand hygiene prior to administering medications to Resident #1. Stated that normally she would clean from the inner part of the wound to the outer surrounding skin. Stated that the resident could possibly get an infection if hand hygiene was not performed prior to medications.

Review of the facility's policy on Infection Control, dated 05/13/2023, reflected Hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures.

Review of the facility's policy on Medication Administration, dated 10/01/19, reflected, Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and medications given via enteral tubes. 08/28/2025

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Elgin Nursing And Rehabilitation Center

Inspection Findings

F-Tag F686

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