Indian Oaks Living Center

F-F689 the facility must ensure that residents are provided assistive devices necessary to prevent an avoidable accident from occurring. The document stated meeting was attended by ADM, MD, MDR, DON, ADON B, and other key leadership.

Review of Adaptive Equipment Tally Report dated 02/05/25 revealed 6 residents who had adaptive equipment updated on their Kardex to include Resident #1 - 1 cup with lid for all liquids.

Review of the coffee temperature log reflected coffee temperatures being taken with the following dates and temperatures observed in new process beginning 02/05/25:

02/04/25: 145 PM (no location specification) (in degrees Fahrenheit)

02/05/25: Back Hall 130, Front 125 AM/ Back Hall 130, Front 127 (in degrees Fahrenheit)

02/06/25: Back Hall 130, Front 130 AM/ Back Hall 130, Front 130 (in degrees Fahrenheit)

Review of 22 resident hot liquid evaluations reflected each had identified concern related to individual diagnosis, focus to include potential for injury related to hot liquid spill and interventions that included referral to therapy for screening and apply/encourage use of lid to hot liquid cup.

Review of in-service dated 02/04/24 titled Kardex contained 6 signatures.

Review of in-service dated 02/04/25 titled Feeding- all staff need to have training before feeding anyone including non-clinical management. The document contained 21 staff signatures which included CMAs, CNAs, and Admin staff.

Review of in-service dated 02/04/25 titled adaptive tools- any resident who has an adaptive tool for meals (ex. Spoon, fork, plate, cup) must be at every meal. Signed by 25 staff members.

Review of in-service dated 02/04/25 titled resident rights contained 16 signatures.

ANE, resident rights, Kardex, respect and dignity, accidents, hot liquids, tray card accuracies text status 02/04/25

Review of in-service sheet dated 02/04/25 contained 12 signatures from kitchen/ dietary staff that reviewed tray card accuracy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0689 Review of in-service specific to NAIT on Kardex and adaptive tools signed off on 02/04/25.

Level of Harm - Immediate Review of 34 Kardex locating competency checks completed by facility and signed off by direct care staff jeopardy to resident health or dated 02/05/25. safety

Review of 3 additional Kardex locating competency checks completed by facility and signed off by staff dated Residents Affected - Few 02/06/25.

An observation on 02/06/25 between 12:00 PM and 01:00 PM of lunch services, 2 nurses were observed in

the dining room checking all meal tray tickets and supervising CNA's and NAIT's. Staff that required assistive devices were observed provided with their assistive device. NAIT T observed, and knowledge check completed.

In an interview on 02/06/25 at 01:43 PM with RN CC, she stated she works PRN (as needed) and stated she also helps to check meal trays before delivery to the residents' rooms. She stated she has been trained on Kardex and safe environment. She stated she would verify diet is correct and check for allergies on the meal trays and would determine if a resident required an assistive device by looking at the Kardex. She stated that if she found a concern related to an inaccurate meal ticket or question about the assistive device, she would report it to ADON A. She stated it was important to provide an assistive device and failure to do so could result in harm to the resident.

In an interview on 02/06/25 at 01:59 PM with CNA S, she stated she received training and inservices that included abuse and neglect, resident rights, locating the Kardex, preventing accidents/ hot liquids, and promoting a safe environment before the start of her shift by ADON A. CNA S was asked to locate the Kardex on a resident and surveyor observed competency. CNA S stated it was important to provide the required assistive devices to resident or it could result in spillage and injury such as burns.

02/07/25:

A binder of in-services and training was provided: it contained a log documenting the following training:

On 02/04/25 and 02/05/25 training was completed on Resident Rights, Kardex, Respect and Dignity, Accidents and Prevention, Hot Liquids, Tray Card Accuracy, and Abuse and neglect. The trainers involved in completing the training of staff included RDBD, DON, ADM, DCE, CR, and ADON A. Of 131 staff members 105 were marked as educated which accounted for 80 percent of the staff, and the remained is ongoing.

In an interview on 02/07/25 at 09:10 AM with VPO She stated a care feed system (a system that communicated with all staff via text) in-services facility wide to all staff related to Resident Rights, Kardex, Respect and Dignity, Accidents and Prevention, Hot Liquids, Tray Card Accuracy, and Abuse and neglect was sent to all staff. She stated the staffing list was then divided and each of the leadership trainees was in charge of educating staff either in person or via phone. Staff was asked questions in regard to the topics listed above and after they successfully verbalized understanding and competence in the subject they were marked as completing the training. Sign in sheets were also provided and reviewed with staff signatures for training that was completed in person.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0689 On 02/07/25 from 12:00 PM through 04:00 PM surveyor reached out to care staff with a focus on CNAs and NAITs, to include PRN staff and a mixture of different shifts. Of the 15 staff members contacted, 8 responded Level of Harm - Immediate and confirmed competency on the trained subjects and knowledge checks were completed over the phone- 2 jeopardy to resident health or of which were also observed in person accessing the Kardex and being able to identify and locate assistive safety devices. During these interviews staff stated they received various inservices which included Kardex and meal tickets, accidents, hot beverages, abuse and neglect, and assistive devices. Staff stated that Residents Affected - Few knowledge was assessed by leadership staff through the employees verbal understanding and competency checks as well as in person verifications with locating the Kardex. Staff provided the surveyor verbal understanding of locating the Kardex, described where to locate information regarding assistive devices, and gave examples of negative outcomes that could occur when assistive devices are not provided. Staff verified for this competency included:

- NAIT U (day shift)

- CNA V (night shift)

- CNA W (night shift and PRN)

- CNA X (day shift)

- CNA Y (works both day and night shifts) in person competency verification also completed.

- CNA Z (PRN) in person competency verification also completed.

- CNA AA (new hire)

- CNA BB (new hire)

**NAIT T was interviewed to confirm understanding during a meal services observation prior to these interviews.

In an interview on 02/07/25 at 04:31 PM with DON, she stated the training completed by leadership and knowledge verifications with 80% of staff, stating education began immediately on 02/04/25 after notification of the incident. She stated that staff are required to check meal tray tickets and Kardex for the use of assistive devices and encouraged to ask questions if they do know something to prevent an injury from occurring. She stated retraining was immediately completed for NAIT T on 02/04/25 and said that through

this experience they have modified their practices and licensed nurses are to supervise all CNAs and NAIT's

during meal services. She said all residents who require assistive devices should and will be provided them to include modified cup with lid, weighted spoons, special plates etc. she stated training and implementation of corrective processes are also ongoing.

In an interview on 02/07/25 at 05:00 PM with the ADM she stated it was her expectation that NAIT's always worked with a certified nurse aide and were supervised by nursing staff during meal services. She stated failure to provide the required assistance to residents or necessary devices could result in injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0689 The administrator was notified the IJ was removed on 02/07/25 at 04:30 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate Level of Harm - Immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their jeopardy to resident health or corrective systems. safety

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 50360

Residents Affected - Many Based on Observation, Interview and Record Review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled (a system of recordkeeping that ensures an accurate inventory of medication by accounting for controlled medications that have been received, dispensed, administered, and/or, including the process of disposition) for )4 of 6 Narcotic Count Sheets reviewed for Change of Shift Narcotic Counts.

The facility failed to ensure all controlled medications were accurately reconciled at the start and end of each shift.

This failure could place residents at risk of misappropriation by drug diversion and could result in diminished health and well-being.

Record Review of the Change of Shift Narcotic Counts for the 100 Hall on 02/05/2025 at 2:20pm, of the Change of Shift Narcotic Counts for the 100 Hall revealed missing documentation for 02/04/2025 for the night shift.

Record Review of the 200/300 Hall count sheet on 02/05/2025 at 2:20PM revealed missing documentation for night shift on 02/03/2025 and the day and night shifts for 02/04/2025.

Record Review of the 600 Hall count sheet on 02/05/2025 at 11:52AM revealed missing documentation for night shift on 02/01/2025.

Record Review of the 700 Hall count sheet on 02/05/2025 at 11:58AM revealed missing documentation for night shift on 02/01/2025, and night shift on 02/03/2025.

During an interview with the DON on 02/06/2025 at 9:52AM, she stated it is was the expectation that the off-going nurse and the on-coming nurse count the narcotics together and both sign on the Narcotic Count sheet in the appropriate column. She further stated the staff are trained via the online training avenue and

during their 3 day in-person orientation. The DON stated to ensure compliance for narcotic counts ,that at the end of the month the sheets are gathered and reviewed. The DON stated if there are missing signatures, the individual staff are retrained. The DON stated the Pharmacy consultant also audits the sheets and this helps identify trends. The DON stated that a negative outcome of not consistently following the narcotic count expectations was a possibility of a drug diversion.

During an interview with the WFM on 02/07/2025 at 4:00PM, she stated CMAs and nurses are oriented to

the change of shift narcotic count expectation during their three-day orientation period.

Record Review of Competency check off sheets on 02/07/2025 at 4:00PM demonstrates the narcotic count competency expectation.

Record Review of the State Operations Manual at S483.45(b)(3) stated The facility, in coordination with the licensed pharmacist, provides for:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0755 o A system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications; Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40884 potential for actual harm 49099 Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure each resident received and

the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that:

1.

a) The test tray of the lunch meal on 02/06/25 was lukewarm, unappetizing in appearance (no seasoning observed, and soggy roll on the plate), not cooked well (related to beef and pasta noodles) and lacked seasoning and flavor.

b) The facility failed to provide palatable food that was attractive or appetizing to residents' who complained

the food did not look or taste good.

2. The facility failed to follow the puree diet recipe. The puree scramble eggs recipe required three tablespoons and one teaspoon of food thickener. There was not a recipe for oatmeal.

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

The findings include:

1. An observation on 02/06/25 at 01:34 PM, a lunch test tray was sampled. The test tray consisted of beef stroganoff pasta noodles, green beans, roll, tea, and water. Initial observation and appearance of the meal, no seasoning was observed on the green beans, the roll appeared soggy as it was placed on the same plate with the beef stroganoff pasta noodles and had soaked up the fluids from the pasta water and gravy. The beef gravy had an oily/fatty appearance. In tasting the meal, the pasta noodles texture was overcooked and felt mushy and dissolved in mouth. The gravy with the beef had very little flavor, felt greasy and watered down in taste; the beef mixed in the gravy was tough. The green beans did not have seasoning observed and did not taste like they had any seasoning. The top of the roll was a good texture, but the bottom was soggy as it has soaked up juices from the pasta noodles and gravy. The overall temperature of the meal was lukewarm.

Review of Resident #3's face sheet dated 02/07/25 reflected a [AGE] year-old female admitted to the facility

on [DATE REDACTED] with a diagnosis that included cerebrovascular disease (condition that affects blood flow to brain), chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), major depressive disorder (mood disorder characterized by persistent feelings of sadness and loss of interest), pneumonia (infection of the air sacs in one or both lungs), and bed confinement status.

Review of Resident #3's Quarterly MDS assessment dated [DATE REDACTED] reflected a BIMS score of 11 indicating moderate cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0804 Review of Resident #3's physicians orders reflected an order with a start date of 05/09/24 for RCS (reduced concentrated sweets) diet, regular texture, thin/regular consistency, divided plate. Level of Harm - Minimal harm or potential for actual harm In an interview and observation on 02/06/25 at 03:32 PM in Resident #3's room, she was observed with a fast-food bag and eating a fried chicken sandwich, waffle fries, and 32 oz drink. Resident #3 stated that she Residents Affected - Some was served and ate the lunch meal consisting of the beef stroganoff noodles. Resident #3 stated she did not like the gravy on the noodles and the meat saying, it had no flavor. She stated the green beans had no seasoning and she could not eat the roll because it was soaked from the fluids coming from the pasta and gravy. She stated she had the meal in her room and when it arrived to her it was cold. Resident #3 stated

she was left hungry and that is why she ordered the fast food that she was observed eating.

Review of Resident #39's face sheet dated 02/07/25 reflected a [AGE] year-old female admitted to the facility

on [DATE REDACTED] with a diagnosis that included type 2 diabetes without complications (condition resulting from insufficient production of insulin causing high blood sugar), essential (primary) hypertension (high blood pressure), polyneuropathy (damage to peripheral nerves throughout the body), and age-related debility.

Review of Resident #39's Quarterly MDS assessment dated [DATE REDACTED] reflected a BIMS score of 12 indicating moderate cognitive impairment.

Review of Resident #39's physicians orders reflected an order dated 05/09/24 for a RCS (reduced concentrated sweets) diet, regular texture, thin/regular consistency.

In an interview on 02/06/25 at 03:37 PM with Resident #39, she stated the beef stroganoff was not appealing to her, so she ordered a hamburger from the always available menu. Resident #39 stated she felt the hamburger was undercooked and sent it back and requested a new one. Resident #39 stated the new burger was still not hot enough or appetizing and was only semi-warm she stated she ate only enough to be able to take medications so she wouldn't have to take them on an empty stomach.

Review of Resident #19's face sheet dated 02/07/25 reflected a [AGE] year-old male admitted to the facility

on [DATE REDACTED] with a diagnosis that included type 2 diabetes mellitus without complications (condition resulting from insufficient production of insulin causing high blood sugar), generalized muscle weakness, contracture of the right hand (type of scarring or fibrosis that stiffens and tightens tissues reducing range of motion), and personal history of traumatic brain injury.

Review of Resident #19's Quarterly MDS assessment dated [DATE REDACTED] reflected a BIMS score of 15 indicating cognition intact.

Review of Resident #19's physicians orders reflected an order dated 05/09/24 for a RCS (reduced concentrated sweets) diet, regular texture, thin/regular consistency, built up utensils.

In an interview on 02/06/25 at 03:41 PM with Resident #19, he stated he was served and ate the beef stroganoff for lunch. He stated the food didn't have good flavor. He stated he had to put salt on the green beans because they didn't have any seasoning, and that the food was lukewarm and not very hot.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0804 Review of Resident #18's face sheet dated 02/07/25 reflected am [AGE] year-old male admitted to the facility

on [DATE REDACTED] with a diagnosis that included type 2 diabetes mellitus with diabetic peripheral angiopathy with Level of Harm - Minimal harm or gangrene (condition resulting from insufficient production of insulin causing high blood sugar with potential for actual harm complications), adjustment disorders, dementia-without behavioral disturbance-psychotic disturbance-mood disturbance- and anxiety, and hyperlipidemia. Residents Affected - Some

Review of Resident #18's comprehensive MDS assessment dated [DATE REDACTED] reflected a BIMS score of 12 indicating moderate cognitive impairment.

Review of Resident #18's physicians orders reflected an order dated 11/23/24 for a RCS (reduced concentrated sweets) diet, regular texture, thin/regular consistency, for diabetes large protein portions with meals, renal precautions.

In an interview and observation on 02/06/25 at 03:49 PM with Resident #18 and his family, an observation was made of Resident #18 in his room with family member at bedside. Resident #18 was being fed breakfast cereal in a cup by his family member. Resident #18 stated he was served the beef stroganoff for lunch and said it was not good and had no seasoning. Resident #18's family member stated that he complained to her about the food, and she tasted it and said it was not good and the noodles were not cooked well. Resident #18's family member stated he was still a little hungry after, so she brought him some breakfast cereal to eat.

In an interview on 02/07/25 at 10:07 AM with the DM, she stated it was her expectation that all residents received a fine dining experience. She stated she expected for the food to by flavorful and enjoyed, for the presentation to be good, and for residents to have the meal to their liking. She stated a potential negative outcome of residents not enjoying their food could result in the potential for weight loss.

In an interview on 02/07/25 at 05:00 PM with the ADM she stated it was her expectation that the food quality and taste be fit for the residents. She stated she expected the food to be restaurant style, have good presentation, and should be palatable. The ADM stated that a potential negative outcome of poor-quality food is the potential for residents to have poor intake which could result in weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0804 2. Observation and interview on 02/07/2025 at 6:45 AM until 7:15 AM, DC K placed eggs into the puree equipment and proceeded to puree the eggs. When she observed the eggs, she stated she needed to add Level of Harm - Minimal harm or thickener to the eggs. She reviewed the recipe and it revealed to add 3 tablespoons and 1 teaspoon per 10 potential for actual harm servings. DC K was preparing 10 servings. She stated there was not a tablespoon in the kitchen and she had

an 8 ounce measuring cup. DC K proceeded to place the thickener in the 8-ounce measuring cup. DC K Residents Affected - Some stated I guessed how much thickener a tablespoon would be when I put the thickener in the 8-ounce measuring cup. The DC K was going to puree the oatmeal and placed the oatmeal into the puree equipment.

She walked to the recipe manual and was going to review the recipe to determine how much thickener or if needed milk to put into the oatmeal. When she reviewed the recipe manual, there was not a recipe for oatmeal. The DC K stated I will need to guess if the oatmeal needs milk or thickener. She pureed the oatmeal and placed some thickener and milk into the oatmeal and turned on the puree equipment. She stated she was using her judgement if the oatmeal needed milk or thickener. The DC K also placed 10 blueberry muffins in the puree equipment and proceeded to puree and when she observed the consistency,

she reviewed the recipe and she stated she would need to guess how much thickener and milk to place in

the puree equipment due to not having the correct measuring cup/spoon to follow the recipe.

Observation on 02/07/2025 at 7:00 AM, the Dietary Manager was also attempting to locate the puree oatmeal recipe and she was unable to locate it in her office or in the recipe manual.

Interview on 02/07/2025 at 7:25 AM, DC K stated she did not follow the puree recipe for the eggs due to not having the correct measuring cup to measure the milk and the thickener. She stated she needed to review

the oatmeal recipe to ensure she was certain exactly how to prepare the oatmeal. She stated if the puree eggs, puree oatmeal and/or puree muffins was not at the correct consistency there was a possibility the residents on puree diet would not receive the correct nutrition they needed. She stated she had been in serviced on how to puree food. She stated she had been a cook over a year.

Interview on 02/07/2025 at 7:35 AM, the Dietary Manager stated DC K did not have the proper equipment such as a tablespoon to measure the correct portion of milk and food thickener. She stated DC K did not follow recipe for the eggs and muffin according to the recipe. The Dietary Manager stated the dietary department did not have a recipe for puree oatmeal and it was expected to have all recipes prepared for the residents in the recipe manual. She stated if a resident did not receive the correct consistency with puree food there was a possibility there may be lumps of food. She stated she did observe the puree food and there were no lumps, and it was the correct consistency.

Interview on 02/06/2025 at 10:45 AM, the Administrator requested protocol of following recipes and preparing food policy or protocol. This was not provided at time of exit.

Interview on 02/07/2025 at 1:45 PM, the Administrator stated the dietary staff was expected to have the correct equipment to measure thickener and milk to ensure the pureed food is prepared correctly. She stated

she was not a nurse and could not determine what may happen to a resident if they did not receive the correct consistency of pureed food.

Record review of the facility's Diets Offered by the Facility, not dated, reflected:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0804 The facility is committed to providing the best nutritional care possible to its residents. All residents will receive diets as ordered by the attending physicians. There are many different names for similar diets. Diet Level of Harm - Minimal harm or order terminology should be standardized to ensure that the correct diets are served. The facility embraces a potential for actual harm high liberalized diet philosophy to support health and quality of life and promote food satisfaction levels with

the residents. Residents Affected - Some

A policy for food palatability was requested from the ADM 02/07/25 at 01:24 PM, she stated there was not a specific policy related to food palatability.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40884

Residents Affected - Few Based on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for two (2) of ten (10) residents (Resident # 50 and Resident # 241) reviewed for food allergies.

The facility failed to honor Resident #50's food preference according to her meal ticket and failed to ensure Resident #50 was not served beef, which her meal ticket reflected she disliked.

The facility kitchen failed to honor Resident # 241's food allergies according to her meal ticket and served her products containing gluten (oatmeal, blueberry muffin, dinner roll, and egg noodles) which her meal ticket stated she had an allergy to gluten.

This failure placed the resident at risk of consuming a food allergen and of receiving and consuming foods not of their preferred preference which could result in diminished health status.

Findings included:

1. Review of Resident #50's face sheet, dated 02/06/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident #50 had diagnoses which included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), gastro-esophageal reflux disease without esophagitis ( a burning sensation in the chest or throat, a dry cough, and difficulty with swallowing), and neurocognitive disorder with Lewy bodies ( a progressive form of dementia that affects a person's ability to think, reason, and process information).

Review of Resident #50's Quarterly MDS Assessment, dated, 01/25/2025, reflected Resident #50 rarely/never understood others. Resident #50 had poor short- and long-term memory recall. Resident #50 decision making ability was severely impaired (she rarely/never made decisions). Resident #50 was dependent on staff for eating, oral hygiene, showers, dressing, personal hygiene, transfers, and bed mobility.

Review of Resident #50's Comprehensive Care Plan, with a completion date of 01/14/2025, reflected Resident #50 had a self-care deficit related to cognitive impairment. Interventions: Resident #50 required one staff assistance with bathing, eating, showers, dressing, grooming, hygiene, mobility, toileting, and transfers. Resident #50 was at risk for nutritional deficits and/or dehydration risks related to prescribed therapeutic altered diet. Intervention: Therapeutic diet as ordered. Educate Resident #50 and/or family regarding nutritional needs, recommended diet and offer care choices as indicated.

Review of Resident #50's weight records and she did not have a significant weight loss.

Observation on 02/04/2025 at 12:16 PM, Resident #50 was sitting at a table being fed by CNA I in the dining room located on the 600 hall. Resident #50's meal ticket reflected she disliked spicy food and beef. Resident #50's meal was pureed taco beef meat. She did not eat very much of the beef.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 Interview on 02/04/2025 at 1:05 PM, CNA I stated she did not notice Resident # 50's meal ticket. CNA I stated the nurse checked meal ticket prior to meal trays being delivered to Resident # 50. Level of Harm - Minimal harm or potential for actual harm Interview on 02/04/2025 at 1:16 PM, LVN M stated she did compare each resident's meal ticket to their meal. LVN M stated she ensured the residents was receiving the correct diet. LVN M stated she did not notice their Residents Affected - Few likes and dislikes.

Interview on 02/04/2025 at 1:30 PM, Resident #50 was not interview able.

2. Review of Resident # 241's face sheet, dated 02/06/25, reflected a [AGE] year-old female admitted to the facility on [DATE REDACTED]. Resident # 241 had diagnosis of encephalopathy (a brain disease that alters brain function or structure), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar levels), cerebral infarction (stroke), muscle weakness, respiratory failure, urinary tract infection, influenza (flu), and difficulty walking. Allergies of Codeine, Phenobarbital, Chocolate, Corn, and Gluten.

Review of Resident # 241's Comprehensive Care Plan dated 01/23/25, reflected Resident # 241 had allergy to codeine and phenobarbital. No food allergies listed. Interventions of Ensure a list of my allergies go with me to the physician, pharmacy, and hospital. Post allergies on chart and comprehensive orders.

Review of Resident # 241's Clinical Physician Orders dated 1/23/25 reflected a diet order of RCS (Reduced concentrated sweets) Soft and Bite sized texture, thin/regular consistency liquids.

Review of Resident # 241's Dietary Manager Nutrition Tool dated 01/24/25 reflected diet information of a therapeutic diet type, regular diet texture, and thin fluid consistency. No documentation of food allergies recorded.

Review of Resident # 241's RD Nutrition assessment dated [DATE REDACTED] reflected a diet ordered of RCS Soft/Bite sized with House Shake TID. No documentation of food allergies recorded.

Review of Resident # 241's meal ticket slip dated 02/06/25 reflected a diet order of RCS Soft/Bite Sized Regular Thin Liquids. Allergies of Chocolate, Corn, Gluten. Dislikes of Chocolate, All Cheese, All Creamy items, Corn.

Observation on 02/05/2025 at 8:45 AM, Resident # 241 in room eating breakfast of scrambled eggs, blueberry muffin, sausage, oatmeal, orange juice, and milk. Observation of Resident # 241's meal slip stated

she has allergies to corn, gluten, and chocolate. Dislikes of chocolate, all cheese, all creamy items, corn.

Observation on 02/06/2025 at 1:32 PM, Resident # 241 in room of lunch tray being delivered consisting of beef stroganoff over egg noodles, green beans, dinner roll, spiced apples, iced tea, and iced water.

Observation of Resident # 241 meal slip stated she had allergies to corn, gluten, and chocolate. Dislikes of chocolate, all cheese, all creamy items, corn.

Observation on 02/06/2025 at 4:15 PM, of facility kitchen pantry revealed container of oatmeal and package of egg noodles not to be gluten free. Further observation of kitchen revealed no gluten free food items in kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 Interview on 02/04/2025 at 11:57 AM, with Resident # 241's RP revealed no concerns except with the food. RP stated Resident # 241 had allergies that are not being honored as Resident # 241 is allergic to gluten, Level of Harm - Minimal harm or corn, chocolate. RP stated he had discussed the Resident 241's food allergies with the nursing staff to potential for actual harm remind them of the residents' allergies. RP stated sometimes his wife is more forgetful than others and he was unsure if the Resident 241 would remember not to eat products that contain items, she is allergic to. Residents Affected - Few

Interview on 02/05/2025 at 8:45 AM, Resident # 241 revealed she did not normally eat oatmeal or muffins when she was at home. Resident # 241 stated she normally ate gluten free products, so it did not upset her stomach. Resident # 241 stated since being in the nursing home she had been eating products that contain gluten since that is what she is being served and she is hungry. Resident # 241 stated that sometimes she has an upset stomach after eating.

Interview on 02/06/2025 at 1:43 PM, RN CC stated this was her first shift she had worked at this facility and

the first time she had performed meal pass tray check as she normally works at a different facility and normally works the 10:00 pm-6:00 am shift and there are no meals during that shift. RN CC stated that the meal tray check consists of making sure diet is correct and check for allergies or assistive devices needed.

RN CC stated the resident information pertaining to diet is in the Kardex for reference if a staff member is unsure of resident needs. RN CC stated if a resident received an item, they are allergic to it can cause harm or possible hospitalization . RN CC stated she was not sure if the meal items Resident # 241 received contained gluten or not. RN CC stated she did not feel the meal tray Resident # 241 received posed a threat to the resident.

Interview on 02/06/2025 at 1:59 PM, CNA S stated after the resident meal trays are checked by the nurse then they are passed to the CNAs to pass to the residents and assist with meal set up. CNA S stated staff can look in the Kardex to identify resident needs. CNA S stated if residents receive food items, they are allergic to they can have an allergic reaction or possible require hospitalization .

Interview on 02/06/2025 at 4:00 PM, the DM stated the muffin and the dinner roll that Resident # 241 received were not gluten free products. The DM stated the oatmeal and egg noodles that Resident # 241 received was gluten free products. The DM stated staff receive training or in-services when an incident occurs. The DM stated during meal service for residents with allergies and preferences that when the meal trays are being assembled allergies and preferences are called out for each individual meal ticket as that tray is being prepared to ensure accuracy.

Interview on 02/07/2025 at 10:55 AM, the Dietary Manager stated the dietary staff will check the meal ticket and compare it to the resident's meal prior to leaving the kitchen. She stated if a resident received something

they did not like and it was documented on the meal ticket, there was a possibility a resident may not eat the food and may not receive the nutrients the resident need for the day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 Interview on 02/07/2025 at 3:35 PM, the DON stated the nurse checks the resident meal trays for accuracy

before handing off to the CNA to pass to the resident. The DON stated if nurse is unsure of something on a Level of Harm - Minimal harm or tray such as an allergy or an assistive device then the nurse is supposed to check with the ADON or the DM potential for actual harm for clarification before passing the meal tray to the resident. The DON stated if the meal tray has an item the resident is allergic to then the nurse is supposed to request a new meal tray for the resident. The DON stated Residents Affected - Few the IDT team meets to discuss each resident needs in the care plan process. The DON stated after the IDT team meets then the information for each resident is communicated with the direct care staff and ancillary staff as pertaining to their job roles. The DON stated the facility has gluten free food items in stock.

The DON stated a resident receiving a food item with gluten when they have a gluten allergy could result in

an upset stomach. The DON stated the ADON Clinical management responsible for training the nursing staff

on how to effectively perform meal tray check this is training conducted in the nursing floor orientation.

Interview on 02/07/2025 at 4:30 PM, the ADM stated if a resident receives a meal tray with food items, they are allergic to then the expectation is for nursing to ask for new meal tray.

The ADM stated if a resident received food items, they are allergic to then they could suffer a negative health outcome.

The ADM stated it is the responsibility of the IDT team and ultimately DM for dietary staff and the DON for nursing staff to ensure meal tray accuracy before the resident receives the meal tray.

The ADM stated prior to 02/07/2025 gluten free products were not in the facility and the ADM was not aware of any accommodations being made for the residents' food allergies. The ADM stated she was not aware of prior residents having a gluten allergy. The ADM stated the DM meets with all new residents to acquire likes and dislikes and records this information on the nutrition tool. The ADM stated she was unsure if the nutrition tool form had anything about allergies.

48917

Based on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for two (2) of ten (10) residents (Resident # 50 and Resident # 241) reviewed for food allergies.

The facility failed to honor Resident #50's food preference according to her meal ticket and failed to ensure Resident #50 was not served beef, which her meal ticket reflected she disliked.

The facility kitchen failed to honor Resident # 241's food allergies according to her meal ticket and served her products containing gluten (oatmeal, blueberry muffin, dinner roll, and egg noodles) which her meal ticket stated she had an allergy to gluten.

This failure placed the resident at risk of consuming a food allergen and of receiving and consuming foods not of their preferred preference which could result in diminished health status.

Findings included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 1. Review of Resident #50's face sheet, dated 02/06/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident #50 had diagnoses which included Level of Harm - Minimal harm or Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the potential for actual harm ability to carry out the simplest tasks), gastro-esophageal reflux disease without esophagitis ( a burning sensation in the chest or throat, a dry cough, and difficulty with swallowing), and neurocognitive disorder with Residents Affected - Few Lewy bodies ( a progressive form of dementia that affects a person's ability to think, reason, and process information).

Review of Resident #50's Quarterly MDS Assessment, dated, 01/25/2025, reflected Resident #50 rarely/never understood others. Resident #50 had poor short- and long-term memory recall. Resident #50 decision making ability was severely impaired (she rarely/never made decisions). Resident #50 was dependent on staff for eating, oral hygiene, showers, dressing, personal hygiene, transfers, and bed mobility.

Review of Resident #50's Comprehensive Care Plan, with a completion date of 01/14/2025, reflected Resident #50 had a self-care deficit related to cognitive impairment. Interventions: Resident #50 required one staff assistance with bathing, eating, showers, dressing, grooming, hygiene, mobility, toileting, and transfers. Resident #50 was at risk for nutritional deficits and/or dehydration risks related to prescribed therapeutic altered diet. Intervention: Therapeutic diet as ordered. Educate Resident #50 and/or family regarding nutritional needs, recommended diet and offer care choices as indicated.

Review of Resident #50's weight records and she did not have a significant weight loss.

Observation on 02/04/2025 at 12:16 PM, Resident #50 was sitting at a table being fed by CNA I in the dining room located on the 600 hall. Resident #50's meal ticket reflected she disliked spicy food and beef. Resident #50's meal was pureed taco beef meat. She did not eat very much of the beef.

Interview on 02/04/2025 at 1:05 PM, CNA I stated she did not notice Resident # 50's meal ticket. CNA I stated the nurse checked meal ticket prior to meal trays being delivered to Resident # 50.

Interview on 02/04/2025 at 1:16 PM, LVN M stated she did compare each resident's meal ticket to their meal. LVN M stated she ensured the residents was receiving the correct diet. LVN M stated she did not notice their likes and dislikes.

Interview on 02/04/2025 at 1:30 PM, Resident #50 was not interview able.

2. Review of Resident # 241's face sheet, dated 02/06/25, reflected a [AGE] year-old female admitted to the facility on [DATE REDACTED]. Resident # 241 had diagnosis of encephalopathy (a brain disease that alters brain function or structure), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar levels), cerebral infarction (stroke), muscle weakness, respiratory failure, urinary tract infection, influenza (flu), and difficulty walking. Allergies of Codeine, Phenobarbital, Chocolate, Corn, and Gluten.

Review of Resident # 241's Comprehensive Care Plan dated 01/23/25, reflected Resident # 241 had allergy to codeine and phenobarbital. No food allergies listed. Interventions of Ensure a list of my allergies go with me to the physician, pharmacy, and hospital. Post allergies on chart and comprehensive orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 Review of Resident # 241's Clinical Physician Orders dated 1/23/25 reflected a diet order of RCS (Reduced concentrated sweets) Soft and Bite sized texture, thin/regular consistency liquids. Level of Harm - Minimal harm or potential for actual harm Review of Resident # 241's Dietary Manager Nutrition Tool dated 01/24/25 reflected diet information of a therapeutic diet type, regular diet texture, and thin fluid consistency. No documentation of food allergies Residents Affected - Few recorded.

Review of Resident # 241's RD Nutrition assessment dated [DATE REDACTED] reflected a diet ordered of RCS Soft/Bite sized with House Shake TID. No documentation of food allergies recorded.

Review of Resident # 241's meal ticket slip dated 02/06/25 reflected a diet order of RCS Soft/Bite Sized Regular Thin Liquids. Allergies of Chocolate, Corn, Gluten. Dislikes of Chocolate, All Cheese, All Creamy items, Corn.

Observation on 02/05/2025 at 8:45 AM, Resident # 241 in room eating breakfast of scrambled eggs, blueberry muffin, sausage, oatmeal, orange juice, and milk. Observation of Resident # 241's meal slip stated

she has allergies to corn, gluten, and chocolate. Dislikes of chocolate, all cheese, all creamy items, corn.

Observation on 02/06/2025 at 1:32 PM, Resident # 241 in room of lunch tray being delivered consisting of beef stroganoff over egg noodles, green beans, dinner roll, spiced apples, iced tea, and iced water.

Observation of Resident # 241 meal slip stated she had allergies to corn, gluten, and chocolate. Dislikes of chocolate, all cheese, all creamy items, corn.

Observation on 02/06/2025 at 4:15 PM, of facility kitchen pantry revealed container of oatmeal and package of egg noodles not to be gluten free. Further observation of kitchen revealed no gluten free food items in kitchen.

Interview on 02/04/2025 at 11:57 AM, with Resident # 241's RP revealed no concerns except with the food. RP stated Resident # 241 had allergies that are not being honored as Resident # 241 is allergic to gluten, corn, chocolate. RP stated he had discussed the Resident 241's food allergies with the nursing staff to remind them of the residents' allergies. RP stated sometimes his wife is more forgetful than others and he was unsure if the Resident 241 would remember not to eat products that contain items, she is allergic to.

Interview on 02/05/2025 at 8:45 AM, Resident # 241 revealed she did not normally eat oatmeal or muffins when she was at home. Resident # 241 stated she normally ate gluten free products, so it did not upset her stomach. Resident # 241 stated since being in the nursing home she had been eating products that contain gluten since that is what she is being served and she is hungry. Resident # 241 stated that sometimes she has an upset stomach after eating.

Interview on 02/06/2025 at 1:43 PM, RN CC stated this was her first shift she had worked at this facility and

the first time she had performed meal pass tray check as she normally works at a different facility and normally works the 10:00 pm-6:00 am shift and there are no meals during that shift. RN CC stated that the meal tray check consists of making sure diet is correct and check for allergies or assistive devices needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 RN CC stated the resident information pertaining to diet is in the Kardex for reference if a staff member is unsure of resident needs. RN CC stated if a resident received an item, they are allergic to it can cause harm Level of Harm - Minimal harm or or possible hospitalization . RN CC stated she was not sure if the meal items Resident # 241 received potential for actual harm contained gluten or not. RN CC stated she did not feel the meal tray Resident # 241 received posed a threat to the resident. Residents Affected - Few

Interview on 02/06/2025 at 1:59 PM, CNA S stated after the resident meal trays are checked by the nurse then they are passed to the CNAs to pass to the residents and assist with meal set up. CNA S stated staff can look in the Kardex to identify resident needs. CNA S stated if residents receive food items, they are allergic to they can have an allergic reaction or possible require hospitalization .

Interview on 02/06/2025 at 4:00 PM, the DM stated the muffin and the dinner roll that Resident # 241 received were not gluten free products. The DM stated the oatmeal and egg noodles that Resident # 241 received was gluten free products. The DM stated staff receive training or in-services when an incident occurs. The DM stated during meal service for residents with allergies and preferences that when the meal trays are being assembled allergies and preferences are called out for each individual meal ticket as that tray is being prepared to ensure accuracy.

Interview on 02/07/2025 at 10:55 AM, the Dietary Manager stated the dietary staff will check the meal ticket and compare it to the resident's meal prior to leaving the kitchen. She stated if a resident received something

they did not like and it was documented on the meal ticket, there was a possibility a resident may not eat the food and may not receive the nutrients the resident need for the day.

Interview on 02/07/2025 at 3:35 PM, the DON stated the nurse checks the resident meal trays for accuracy

before handing off to the CNA to pass to the resident. The DON stated if nurse is unsure of something on a tray such as an allergy or an assistive device then the nurse is supposed to check with the ADON or the DM for clarification before passing the meal tray to the resident. The DON stated if the meal tray has an item the resident is allergic to then the nurse is supposed to request a new meal tray for the resident. The DON stated

the IDT team meets to discuss each resident needs in the care plan process. The DON stated after the IDT team meets then the information for each resident is communicated with the direct care staff and ancillary staff as pertaining to their job roles. The DON stated the facility has gluten free food items in stock.

The DON stated a resident receiving a food item with gluten when they have a gluten allergy could result in

an upset stomach. The DON stated the ADON Clinical management responsible for training the nursing staff

on how to effectively perform meal tray check this is training conducted in the nursing floor orientation.

Interview on 02/07/2025 at 4:30 PM, the ADM stated if a resident receives a meal tray with food items, they are allergic to then the expectation is for nursing to ask for new meal tray.

The ADM stated if a resident received food items, they are allergic to then they could suffer a negative health outcome.

The ADM stated it is the responsibility of the IDT team and ultimately DM for dietary staff and the DON for nursing staff to ensure meal tray accuracy before the resident receives the meal tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0806 The ADM stated prior to 02/07/2025 gluten free products were not in the facility and the ADM was not aware of any accommodations being made for the residents' food allergies. The ADM stated she was not aware of Level of Harm - Minimal harm or prior residents having a gluten allergy. The ADM stated the DM meets with all new residents to acquire likes potential for actual harm and dislikes and records this information on the nutrition tool. The ADM stated she was unsure if the nutrition tool form had anything about allergies. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 40884

Residents Affected - Some 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 DC K used proper hand hygiene during food preparation.

2. The facility failed to ensure DC L wore a beard guard when standing over food prep table.

This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Findings included:

1. Observation on 02/07/2025 between 6:40 AM and 7:15 AM, DC K began to prepare puree meal. DC K did not wash her hands prior to preparing puree food. She did not wear gloves or wash hands when she was placing food in the puree equipment. DC K touched the following during the process of preparing puree food: her clothes, menu manual, an empty plastic bag, top of cardboard box, plastic container drawer where utensils were stored, surveyor shirt, and the right side of upper portion of her pants. DC K touched the top of blueberry muffins located on the steam table and the top of blueberry muffins she carried from the steam table to the area where the puree machine was located. DC K's tip of middle finger and forefinger touched

the egg pureed food when transferring the eggs from the puree container to the silver container for the steam table. DC K would scoop oatmeal into silver container to puree the oatmeal. When she was scooping the tips of her middle, ring and forefinger touched the oatmeal located inside silver container. DK C did not wash or sanitize her hands between tasks. [NAME] C never washed or sanitized her hands the entire time she was being observed in the kitchen. DC K never washed her hands during the entire process of pureeing eggs, oatmeal, or muffins.

In an interview on 02/07/2025 at 7:25 AM, DC K stated she did not wash or sanitize her hands in between tasks and during the entire process of pureeing food. She stated she touched her clothes, recipe manual, plastic bag that was garbage and the top of a cardboard box. DC K stated her clothes, surveyor clothes, cardboard box, plastic bag, and the recipe manual would be considered contaminated. She stated after she touched those items, she did not sanitize or wash her hands and did not wash her hands during the process of puree the muffins, eggs, and oatmeal. DC K stated there was a possibility she contaminated the food. She stated a resident may become ill such as stomach issues such as vomiting if the residents ate food with bacteria. DC K stated she received an in-service on hand hygiene. She stated she did not recall the date or time of in-service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0812 In an interview on 02/07/2025 at 7:35 AM, the Dietary Manager stated all staff was expected to wash hands

in between tasks and during preparation of food. She stated the menu binder, a box, clothes, and a plastic Level of Harm - Minimal harm or bag would be considered contaminated. She stated there was a possibility the food may become potential for actual harm contaminated with some type of bacteria. The Dietary Manager stated it would be difficult to determine what type of illness a resident may obtain until knew what type of bacteria was transferred from DK C hands to the Residents Affected - Some food. She stated all dietary staff was in-service on hand hygiene. She did not recall the date of the in-service.

The in-service was requested and was not provided at the time of exit.

2. Observation on 02/05/2025 at 1:15 PM, revealed DC L entered the kitchen and his beard guard was located under his chin. He was standing over a food prep table and he did not cover his beard with the beard guard. He had approximately 8 inches of hair growth around his chin and jaw area.

Interview on 02/05/2025 at 1:20 PM, DC L stated he was not wearing a beard guard correctly it was located under his chin. He stated there was a potential hair may fall from his face onto the food he was placing on

the meal trays. DC L stated if there was hair on the food preparation table there was a potential hair may transfer to a resident plate or food. He stated a resident may become physically ill with stomach issues. DC L stated hair was considered contaminated. DC L stated he was trained to wear beard guards and hair nets when in the kitchen. He did not recall the date or time of the in-service.

Interview on 02/07/2025 at 10:55 AM, Dietary Manager stated all male staff with facial hair growth was expected to wear a beard guard. She stated when DC L entered the kitchen, he was not wearing his beard guard correctly. His beard was not covered with the beard guard. She stated there was a possibility hair may fall on food or food preparation table. She stated it depended if there were bacteria on the hair if a resident may become physically ill if a resident had hair on their food and the resident ingested the hair. She stated

she was not a nurse and could not determine if a resident may become physically ill from hair being on their food. Dietary Manager stated staff had been in-service on wearing hair nets and beard guards when in the kitchen. She did not recall the date of the hair net and beard guard in-service. Requested copy of the in-service of hair net and beard guard and this was not provided at the time of exit.

Interview on 02/07/2025 at 1:45 PM, the Administrator stated anyone who entered the kitchen with a beard was expected to wear a beard net. She stated hair was considered contaminated. She stated the Dietary Manager was responsible to monitor the kitchen and she was over the Dietary Manager. The Administrator also stated she expected the dietary staff to wash their hands in between tasks or when they touched any contaminated item. The

Administrator stated if the staff was not washing their hands after touching contaminated items there was a potential the food may become cross contaminated. She stated without knowing the type of bacteria from the hands and from hair it would be difficult to determine if a resident may become physically ill.

Review of Facility's Employee Sanitation Policy, not dated, reflected Employee Cleanliness Requirements: Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Hand Washing: Employees must wash their hands and exposed portions of their arms at the designated hand washing facilities at the following times:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0812 1. After touching bare human body parts other than clean hands and clean, exposed portions of arms.

Level of Harm - Minimal harm or 2. Immediately before engaging in food preparation including working with exposed food, clean equipment potential for actual harm and utensils, and unwrapped single-service and single-use articles

Residents Affected - Some 3. When switching between working with raw foods and working with ready-to-eat foods

4. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks.

5. After engaging in other activities that contaminate the hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50360 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and Residents Affected - Few 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 1 of 3 residents (Resident #57) observed for infection prevention.

The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-G and CNA-J provided perineal and catheter care for Resident #57.

This deficient practice could place residents at-risk for spread of infection.

Findings included:

Record review of Resident #57's face sheet dated 12/09/2023 revealed she was a [AGE] year-old woman, with an initial admitted [DATE REDACTED], with re-admission on 12/09/2023 and with diagnoses which included: Type 2 Diabetes Mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy), Neuromuscular Dysfunction of Bladder (a condition where the nerves controlling bladder function are damaged, leading to impaired bladder control), Indwelling Urethral Catheter (a thin, flexible tube inserted into

the urethra (the tube that carries urine from the bladder to the outside of the body) to collect and drain urine).

Record review of Resident #57's Quarterly MDS assessment dated [DATE REDACTED] revealed a BIMS score of 13, indicating intact cognition. Further review revealed Resident #57 was assessed as having an indwelling catheter.

Record review of Resident #57's Active Orders dated 02/07/2025 revealed orders which included:

- Enhanced Barrier Precautions start date 02/06/2025.

- Foley Catheter care with perineal wipes and/or soap and water q shift and PRN: start date 01/29/2025.

- EBP (Enhanced Barrier Precautions); Foley, colostomy, and wound care (until wound healed) Practice EBP as indicated: start date 11/27/2024 and stop date 11/27/2024.

Record review of Resident #57's Care Plan dated last reviewed 12/13/2024 revealed a Problem which included I require an Indwelling Catheter, r/t Dx of Neurogenic Bladder, initiated 06/13/2024 and revised 02/06/2025. This problem area included the following interventions:

- Catheter Care every shift and as indicated.; initiated 06/13/2024 and

- change catheter per my physician's orders; Initiated 06/13/2024

- Check tubing for kinks each shift & during care encounters; Initiated 06/13/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 675909 Department of Health & Human Services Printed: 09/09/2025 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 675909 B. Wing 02/07/2025

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

Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

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 0880 - EBP (enhanced Barrier Precautions); Initiated 06/13/2024.

Level of Harm - Minimal harm or Observation on 02/06/2025 at 09:16 a.m., revealed there was a sign indicating Enhanced Barrier potential for actual harm Precautions outside the door to Resident #57's room, and there was no supply of PPE available outside the door/room. Further observation revealed CNA-G and CNA-J put on gloves but did not put on or wear a gown Residents Affected - Few while performing peri-care and foley care for Resident #57 .

During an interview with CNA-J on 02/06/2025 at 09:17 a.m., CNA-J stated that she did not think Resident #57 was on Enhanced Barrier Precautions (EBP) because Resident #57's sacral wound had probably healed, and she no longer needed to be on EBP. CNA-J was asked to retrieve the Kardex. CNA-J was able to demonstrate pulling up the Kardex. Record review of the Kardex demonstrated there was no indication of Resident #57 being on EBP.

During an interview with the DON on 02/06/2025 at 9:53 a.m., the DON stated staff should know the type of precautions a resident is on by consulting the Kardex. The DON stated a negative outcome of failure to abide by EBPs would be the spread of infection.

Record review of facility policy titled Infection Prevention and Control revised 4/1/2024 revealed In addition to isolation practices, Enhanced Barrier Precautions (EBP) may be implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. EBP may be indicated as a recommendation by the CDC (when contract Precautions do not otherwise apply) for residents with the following:

Wounds or indwelling medical devices, regardless of MDRO colonization status.

Infection or colonization with an MDRO.

EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer o0f MDROs to staff hands and clothing.

Residents/Patient with the following clinical indication should be under EBP.

Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO Colonization status

EBP should be utilized during high-contact resident care activities.

Device care of use: central line, urinary catheter feeding tube, tracheostomy/ventilator

o Urinary catheters-during incontinent/catheter care activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 675909