Senior Care Of Weston Inn

F-F686 - The facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Statement of Deficient Practice: All residents who require wound care could be at risk for potential negative effects.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0686 1. Upon learning the facility failed to ensure residents with pressure ulcers received necessary treatment and services facility had wound physician complete rounds on resident who have consented. All other wound Level of Harm - Immediate treatments not ref erred or consented to wound care physician will be directed by primary care until jeopardy to resident health or otherwise directed by primary physician. Nurse Consultant and Director of Clinical Services have conducted safety an audit to ensure all wounds identified have a current treatment in place.

Residents Affected - Some Responsible Party: DON/ADON,

Target date: 2/11/2025

Follow up: Monitor for completion through morning meeting process.

2. Nurse Consultant and Director of Clinical Services provided in- service education to all nursing staff currently on shift regarding following physician ordered wound care and documentation of wound care.

Responsible Party: DON/ADON,

Target date: 2/11/2025

Follow up: Provide ongoing education to all new hires, agency, prn leave of absence prior to first shift worked and Follow WE CARE meeting process to ensure compliance.

3. All nursing staff will be provided with in-service following physician ordered wound care and documentation of wound care prior to next shift worked, including new hires, PRN, Vacation, Agency and Leave of Absence staff.

Responsible Party: DON/ADON or Designee

Target date: 2/11/2025 and ongoing

Follow-up: Follow WE CARE meeting process to ensure compliance.

4. Identify any new wounds through orders, weekly skin assessments and admission assessments review completed during clinical morning meeting will be referred to primary care physician and wound care physician if ordered by primary care physician.

Responsible Party: IDT Team

Target date: 2/11/2025 and ongoing

Follow-up: Follow WE CARE meeting process to ensure compliance.

5. Wound care physician will be notified via telephone by DON or designee when wound care consultation is ordered.

Responsible Party: IDT Team

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0686 Target date: 2/11/2025 and ongoing

Level of Harm - Immediate Follow-up: Follow WE CARE meeting process to ensure compliance. jeopardy to resident health or safety 6. AD HOC QAPI meeting conducted to discuss plan of correction for compliance.

Residents Affected - Some Responsible Party: IDT Team

Target date: 2/11/2025 and ongoing

Follow-up: Review any compliance issues in QAPI meeting for 3 months

7. Medical Director notified of alleged deficient practice.

Responsible Party: Administrator

Target date: 2/11/2025

The investigator monitored the Plan of Removal on 02/12/2025 as follows:

During interviews conducted on 02/12/2025 between 12:00 noon through 3:30 PM, LVN F, LVN K, RN B, LVN A, LVN L, the MDS Nurse stated they were in-serviced by the ADON and the Administrator on 2/11/2025 and 2/12/2025 prior to their shifts. They stated they were in-serviced on wound care policy, notifying the DON of new wound care orders, implementing new wound care orders immediately after the Wound Doctor's visit. They stated they knew where to find the Wound Doctor's contact number at the nurse's station and in the Resident's chart in Point click Care, the system the facility use to document electronically.

They stated they were in-serviced on documenting that treatments were done. They also stated, for new admission current residents, they were in-serviced to ensure skin assessments were done, if there were skin issues, document the color, size, odor and notify the primary care physician, DON and all parties. They stated they were told to follow up with referrals.

During an interview on 2/12/2025 at 2:23 PM, the ADON stated she was in-serviced by the Nurse Consultant

on 02/11/2025 on the process of new and current residents with wounds, skin assessments weekly as indicated. The ADON stated she was told to get a complete description of the wound, and notify the NP, transcribe orders immediately, communicate with the Wound Doctor if there were referrals, carry out orders from the Wound Doctor immediately. The ADON stated all Residents seen by the wound Doctor had his number in their chart where the nurses can look to contact him. The ADON stated she was to ensure the floor nurses are putting in orders immediately, completing wound care orders as ordered, following up with referrals. The ADON stated she was trained by the Administrator on 2/12/2025 on how to monitor PCC dashboard for missed treatment and follow up with the nurses why the treatments were missed. The ADON stated, she was to ensure after the wound Doctor's visits that all new orders were put in the Resident's charts. She stated the Nurse Consultant rechecked the Wound Doctor's orders from 02/11/2025 to ensure all orders from the Wound Doctor's visit were in the resident's charts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0686 During an interview on 02/12/2025 at 2:54 PM the Administrator stated she was in-serviced by the Nurse Consultant on 02/12/2025 and she was in-servicing nurses at the beginning of their shifts on treatment Level of Harm - Immediate orders, what to do if they identify new wounds. The Administrator stated the facility already identified all the jeopardy to resident health or wounds in the facility, they made sure the new wounds identified by the facility staff were seen by the Wound safety Doctor on 2/11/2025, made sure there were treatments in place and accurate, was verified by the Nurse Consultant and the Regional Director. The Administrator stated the facility would monitor through their daily Residents Affected - Some morning meeting and the weekly WE Care meeting . The DON stated part of the morning meeting process,

they would check the clinical dashboard to make sure treatment had been completed. The Administrator stated the Wound Doctor's contact was in PCC in the Resident's chart. The Administrator stated the DON was responsible to ensure treatments were done and she would designate someone in her absence of the DON.

Review of Wound Doctor's visit orders dated 2/11/2025 reflected all new orders were in the Residents charts.

Review of facility's in-services reflected in-services were initiated on 02/11/2025 at 5:35 PM with attached documents of: Medication orders, Pressure Ulcers/Skin breakdown-clinical Protocols:

Receiving and Transcribing physician orders-Treatment Orders

Physician Referrals-Wound assessment and Management

Wound treatment documentation-Complete documentation and monitoring

Review of facility's Quality Assurance Performance Improvement Committee document reflected QAPI had a meeting on 02/11/2025 to discuss IJ regarding wound care treatment orders.

The Administrator was notified on 02/12/2025 at 3:36 PM that the IJ had been removed. While the IJ was removed on 02/12/25 at 3:36 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

3. Review of Resident #1's face sheet printed on 01/28/25 reflected a [AGE] year-old female initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] after an overnight stay in the emergency room . Her diagnoses included pressure ulcer of sacral region (between the buttocks) - stage 4, chronic pain, neuromuscular dysfunction of bladder (lack of bladder control due to a nerve problem), paraplegia (paralysis), and type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar).

Review of Resident #1's quarterly MDS assessment dated [DATE REDACTED], Section C (Cognitive Patterns) reflected a BIMS score of 11 indicating moderately impaired cognition. Section GG (Functional Abilities) reflected she required substantial/maximal assistance with bed mobility. Section M (Skin Conditions) reflected she had an unhealed stage 4 pressure ulcer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0686 Review of Resident #1's current clinical physician orders reflected an order dated 07/29/24, Change wound vac dressing every MWF and as needed. After removing dressing, apply [cleanser] soaked gauze for 3 Level of Harm - Immediate minutes, apply topical iodine over wound bed, apply adaptic dressing to wound bed then apply wound vac jeopardy to resident health or foam at 150mmHg continuous. Apply Eakin ring around peri wound to prevent stool into wound. Use skin safety prep to protect skin from dressing. Another order dated 07/29/24 reflected, If wound vac is unable to hold a seal or turned off for 2 hours, remove entire dressing and replace with alginate packing. Residents Affected - Some

Review of Resident #1's January 2025 MAR and TAR reflected the wound vac dressing was not changed on 01/13/25 and 01/17/25 .

Review of Resident #1's comprehensive care plan reflected in part:

Problem - Last revised 10/18/24 - The resident has a pressure ulcer stage four to buttocks. NPWT wound vac is in place (continuous 150mm Hg) to promote healing process. Goal - The residents pressure ulcer will show signs of healing and remain free from infection. Interventions - Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. The care plan was not revised to reflect the current order for 125mmHg.

Review of Resident #1's Wound Care Progress note, from the wound clinic physician, dated 01/22/25, reflected in part, Resident #1 stated that her wound vac had been changed once weekly. I contacted the ADON at the facility. Resident had a wound vac change that was not done on Friday 01/18/25 but otherwise had her dressing changed 3x/week . Initial sacral wound began April 2022 .She was off NPWT from 06/13/24-07/26/24 . Continue NPWT 125mmHg.

During a brief interview on 01/27/25 at 3:30 PM with the ADM, a policy for wound vacs and nursing competencies for wound vacs were requested.

A policy for wound vacs was not received prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42949 jeopardy to resident health or safety Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive Residents Affected - Some person-centered care plan, and the residents' goals and preferences for one (Resident #5) of six residents reviewed for pain.

The facility failed to provide effective pain management for Resident #5 while she resided at the facility from 01/17/25 - 01/27/25. She had a recently acquired amputation that caused her to be in excruciating pain. The facility did not adjust her pain medication or notify her NP.

This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/29/25 at 4:04 PM and an IJ template was given. While the IJ was removed on 01/30/25 at 6:15 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

This failure placed residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life.

Findings included:

Review of Resident #5's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE REDACTED] with diagnoses including type II diabetes, major depressive disorder, chronic pain, and acquired absence of left leg above the knee.

Review of Resident #5's EMR, on 01/29/25, reflected her Admission MDS assessment had not been completed.

Review of Resident #5's admission care plan, dated 01/17/25, reflected she had acute pain related to left AKA and sacroiliitis (a painful condition which affects both sacral joints ) with an intervention of monitoring/documenting for side effects of pain medication and notifying the physician if interventions were unsuccessful.

Review of Resident #5's physician order, dated 01/17/25, reflected Hydrocodone-Acetaminophen Oral Tablet-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain.

Review of Resident #5's MAR , dated January 2025, reflected she was administered the medication (Hydrocodone-Acetaminophen) on the following days with the pain level (numerical) and effectiveness documented (pain level from 1-10):

01/17/25 at 10:36 PM - Pain Level 7 - Ineffective

01/18/25 at 4:30 AM - Pain Level 6 - Effective

01/18/25 at 10:03 PM - Pain Level 10 - Unknown if effective

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0697 01/19/25 at 8:40 AM - Pain Level 8 - Ineffective

Level of Harm - Immediate 01/19/25 at 4:40 PM - Pain Level 10 - Effective jeopardy to resident health or safety 01/20/25 at 10:50 PM - Pain Level 7 - Effective

Residents Affected - Some 01/21/25 at 11:25 AM - Pain Level 8 - Effective

01/22/25 at 10:15 AM - Pain Level 6 - Effective

01/26/25 at 3:47 AM - Pain Level 8 - Effective

01/26/25 at 5:55 PM - Pain Level 9 - Effective

Review of Resident #5's physician order, dated 01/17/25, reflected Tylenol Oral Tablet - 325 MG - Give 2 tablets by mouth every 6 hours as needed for pain.

Review of Resident #5's MAR, dated January 2025, reflected she was administered the medication (Tylenol)

on the following days with the pain level (numerical) and effectiveness documented:

01/19/25 at 7:18 PM - Pain Level 8 - Effective

01/20/25 at 7:48 AM - Pain Level 4 - Effective

01/21/25 at 2:07 PM - Pain Level 3 - Effective

Review of Resident #5's physician order, dated 01/18/25, reflected Buprenorphine Transdermal Patch Weekly 10 MCG/HR - Apply 1 patch transdermally one time a day every 7 day(s) for pain.

Review of Resident #5's MAR, dated January 2025, reflected she only received the patch on 01/18/25.

Review of an intake reported to HHSC, dated 01/24/25, reflected the following regarding Resident #5:

RP and [Resident #5] report that at night when the CNAs [CNA G and CNA H] come in to provide care that

they are rough with her and when she tells them she is hurting they will say we are not hurting you.

Review of Resident #5's ER paperwork, dated 01/27/25, reflected the following:

Reason for Admission: s/p Lt AKA pain . Left AKA stump wrapped, [Resident #5] intolerable of pain and refused exam on leg .

. On exam, [Resident #5] has intractable pain . Patient uncomfortable and histrionic on exam per documentation. Left AKA stump with purulent drainage, mild skin necrosis .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0697 . [Resident #5] was discharged on the 17th to a skilled nursing facility and had increasing pain in her AKA site. [Resident #5] gets dialyzed Monday Wednesday Friday but apparently missed Friday's dialysis due to Level of Harm - Immediate the pain . jeopardy to resident health or safety During a telephone interview on 01/29/25 at 1:12 PM, CNA G stated if a resident was complaining of pain,

she would tell the nurse. She stated she remembered providing care to Resident #5 (on 01/23/25) and knew Residents Affected - Some she had a fresh amputation so she understood she would be in pain. She stated she was swinging at us (she and CNA H) because of the pain she was in during peri care . She stated RN J knew how much pain she was in because she had gone in and out of the room. She stated she was not sure if RN J gave her medication or what medication could have been given because she was just a CNA and did not know about medications. She stated it took CNA H and herself at least 30 minutes to provide the care due to the amount of pain Resident #5 was in. She stated they were not purposely trying to hurt her but had to get her clean.

Review of Resident #5's progress notes, on 01/29/25, reflected no documentation regarding the pain during peri care on 01/23/25 . Pain medication was not administered to Resident #5 until 01/26/25.

During a telephone interview on 01/29/25 at 1:34 PM, Resident #5's NP stated she had never expressed pain to her. She stated she would expect nursing staff to notify her if pain was not being managed or if pain medications were not effective. She stated she could have done something about it. She stated Buprenorphine patch orders should be followed. She stated if the order was for every seven days, it should be changed every seven days as it would no longer be effective. She stated a negative outcome of being in uncontrolled pain could be high blood pressure, heavy breathing, or anxiety. She stated Resident #5 was always anxious.

During a telephone interview on 01/29/25 at 2:46 PM, Resident #5's RP stated he believed the staff agreed

the pain medication was not sufficient while she was at the facility, but they were just following the orders given. He stated her severe pain never subsided the whole time she was at the facility. He stated she recently (01/28/25) had to have a procedure where they put a tube in her wound (incision site) to drain it due to an infection. He stated the infection had been causing her even more pain.

An attempt was made to interview RN J on 01/29/25 at 3:04 PM. A returned call was not received prior to exiting.

Review of the facility's Pain Policy, Revised October 2022, reflected the following:

. The staff will assess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain.

. If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support.

The ADM was notified on 01/29/25 at 4:04 PM that an IJ had been identified and an IJ template was provided.

The following POR was approved on 01/30/25 at 10:47 AM:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0697 The notification of Immediate Jeopardy states as follows:

Level of Harm - Immediate

F-F697 jeopardy to resident health or safety The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the Residents Affected - Some residents' goals and preferences.

Statement of Deficient Practice:

The facility failed to provide effective pain interventions for Resident #5.

CORRECTIVE ACTION: 1. Upon learning of the deficient practice the Regional Director of Clinical Services and Nurse Consultant began a review of residents charts for pain assessment orders .

RESPONSIBLE PARTY: RDCS

TARGET DATE: 1/29/25

FOLLOW-UP: Monitor for completion through morning meeting process.

CORRECTIVE ACTION: 2. DON began inservice education for all nurses currently on shift regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place and how to conduct

a pain assessment properly. Nursing Administration will complete a second pain assessment on 5 residents twice weekly for 3 months to ensure proper assessment of resident pain and level of nurse proficiency. Regional Director of Clinical Services and Nurse Consultant have conducted a pain assessment on each resident currently in the facility and residents will be continued to be assessed q shift ongoing. No residents have been identified at this time for uncontrolled pain.

RESPONSIBLE PARTY: DON

TARGET DATE: 1/29/25

FOLLOW-UP: Provide ongoing education to all new hires, agency, prn, leave of absence prior to first shift worked.

CORRECTIVE ACTION: 3. All licensed nursing staff will be provided with in-service education on regarding pain assessments for all resident each shift to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by current regimen prior to next shift worked, including new hires, PRN, Vacation, Agency and Leave of Absence staff.

RESPONSIBLE PARTY: DON/ADON or Designee.

TARGET DATE: 1/29/25 and ongoing.

FOLLOW-UP: Review daily staffing to ensure compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0697 CORRECTIVE ACTION: 4. Confirm that pain assessment order was placed on the resident chart for all new admissions, readmissions or new complaints Level of Harm - Immediate jeopardy to resident health or RESPONSIBLE PARTY: DON/ADON or Designee safety TARGET DATE: 1/29/25 and ongoing. Residents Affected - Some FOLLOW-UP: Follow morning meeting process to ensure compliance

CORRECTIVE ACTION: 5. Review all residents currently identified for increased or change in pain weekly

during WE CARE clinical meeting to confirm ongoing interventions and physician notification.

RESPONSIBLE PARTY: IDT Team

TARGET DATE: 1/29/25 and ongoing.

FOLLOW-UP: Follow WE CARE meeting process to ensure compliance.

CORRECTIVE ACTION: 6. AD HOC QAPI meeting conducted to discuss plan of correction for compliance.

RESPONSIBLE PARTY: IDT Team

TARGET DATE: 1/29/25

FOLLOW-UP: Review any compliance issues in QAPI meetings for 3 months

CORRECTIVE ACTION: 7. Medical Director notified of alleged deficient practice.

RESPONSIBLE PARTY: Administrator

TARGET DATE: 1/29/25

The Investigator monitored the Plan of Removal on 01/30/25 as followed:

During interviews conducted on 01/30/25 between 11:13 AM and 6:06 PM, 3 rehab therapists, 2 RNs, 6 LVNs, and 11 CNAs from both shifts stated they were in-serviced on pain. They all stated that if any resident complained of pain during care, they would stop immediately. The CNAs and therapists said they would notify the nurse immediately. The CNAs said they would tell the nurse and give the nurse a written note as a reminder. The nurses stated they would assess the resident every shift and with every complaint of pain. The nurses stated they would provide pain medication and follow up to ensure effectiveness. They stated if the medication was not effective, they would notify the doctor or nurse practitioner.

Review of the facility's QAPI agenda, dated 01/29/25, reflected the MD, ADM, DON, ADON , MDS Nurse, SW, and Licensed Nursing Staff were in attendance.

Review of an in-serviced entitled Pain, dated 01/29/25, reflected all nursing staff were in-serviced on their pain policy and the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0697 Monitor for pain every shift. Document pain/pain levels. Complete pain assessment if resident has pain. Provide medication if needed. If resident does not have pain meds notify MD/NP and document in EMR. Level of Harm - Immediate CNA and Nurse will stop ADL, wound care, etc. and resident must be assessed and medication for pain. jeopardy to resident health or Activity resume with medication. safety

Review of the WE CARE documentation form, revised 04/2023, reflected the form identified the procedure Residents Affected - Some for conducting the meeting and the information to be reviewed. The information included pain and how the ADON or designee would review PRN pain medication documentation in [EMR system] for residents taking pain medications consistently. The facility had not had their weekly WE CARE meeting prior to exit.

The ADM was notified the IJ was lowered on 01/30/25 at 6:15 PM. However, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42949

Residents Affected - Some Based on interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #10 and Resident #11) of 6 residents reviewed for medications and pharmacy services.

The facility failed to ensure Resident #10's Calcium, Fluorometholone Ophthalmic Suspension, Lidoderm Patch 5%, Valacyclovir, Carvedilol, Revatio, and levothyroxine were administered according to the physician's orders.

The facility failed to ensure Resident #11's Atorvastatin, Latanoprost Ophthalmic Solution, and Levothyroxine were administered according to the physician's orders.

These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life.

Findings included:

Review of Resident #10's face sheet printed on 01/28/25, reflected a [AGE] year-old female admitted to the facility on [DATE REDACTED]. Her diagnoses included effusion left knee (swelling of the tissues around a joint due to extra fluid), Chronic respiratory failure with hypoxia (not enough oxygen in the blood), chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), and heart disease.

Review of Resident #10's EMR on 01/27/25, reflected an admission MDS assessment had not been created.

Review of Resident #10's BIMS assessment dated [DATE REDACTED], reflected a score of 15 indicating intact cognition.

Review of Resident #10's current clinical physician orders reflected:

01/19/25 Calcium 600 mg oral tablet by mouth one time a day with meal

01/19/25 Fluorometholone Ophthalmic suspension 0.1% Instill 1 drop in left eye one time a day for Ophthalmic agent.

01/18/25 Lidoderm Patch 5% Apply to left knee topically in the morning for left knee pain.

01/18/25 Valacyclovir HCl tablet 500 mg give two tablets by mouth one time a day for cold sores, shingles, or genital herpes for 7 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 01/24/25 Biofreeze Cool the Pain External gel 4% apply to right thigh topically two times a day for pain.

Level of Harm - Minimal harm or 01/18/25 Carvedilol tablet 3.125mg give one tablet by mouth two times a day for hypertension with meal. potential for actual harm Hold if SBP less than 110 and Heart Rate less than 60.

Residents Affected - Some 01/18/25 Revatio Oral Tablet 20mg Give 20 mg by mouth three times a day for pulmonary atrial hypertension.

01/28/25 Levothyroxine 137 mcg give one tablet by mouth one time a day for low thyroid hormone.

Review of Resident #10's January 2025 MAR reflected missed administration of the following -

Calcium 600mg on 01/19/25.

Fluorometholone Ophthalmic suspension on 01/19/25 and 01/20/25.

Lidoderm Patch 5% on 01/19/25 and 01/20/25.

Valacyclovir HCl on 01/19/25.

Biofreeze gel 4%on 01/24/25 and 01/26/25.

Carvedilol 3.125mg on 01/20/25.

Revatio 20mg twice on 01/19/25 once on 01/20/25 and twice on 01/24/25.

Levothyroxine 137 mcg on 01/19/25 and 01/20/25.

Review of Resident #10's care plan reflected in part,

Problem: Thyroid therapy to treat hypothyroidism is at risk for adverse effects. Date Initiated: 01/28/25.

Goal: Will have no adverse side effects related to thyroid therapy until next review date. Date Initiated: 01/28/25. Target Date: 04/28/25.

Interventions: Administer medication per physician orders. Date Initiated: 01/28/25. Monitor for signs and symptoms of adverse effects and report any changes to physician. Date Initiated: 01/28/25. Obtain labs as ordered, notify physician of results. Date Initiated: 01/28/25.

Problem: The resident has altered respiratory status/difficulty breathing r/t obstructive sleep apnea. Date Initiated: 01/28/25.

Goal: The resident will maintain formal breathing pattern as evidenced by normal respirations, normal skin color and regular respiratory rate/pattern through the review date. Date Initiated: 01/28/25. Target Date: 04/28/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 Interventions: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Date Initiated: 01/28/25. Monitor for s/sx respiratory distress . Level of Harm - Minimal harm or potential for actual harm Review of Resident #11's face sheet printed on 01/27/25, reflected an [AGE] year-old female admitted to the facility on [DATE REDACTED] and discharged on [DATE REDACTED]. Her diagnoses included other diseases of stomach and Residents Affected - Some duodenum (first part of the small intestine), malnutrition, surgical aftercare following surgery on the digestive system, dry eye syndrome, atherosclerosis of aorta (arteries narrowed and hardened due to buildup of plaque), and osteoporosis (brittle bones).

Review of Resident #11's admission MDS assessment dated [DATE REDACTED] Section C (Cognitive Patterns) reflected a BIMS assessment was not completed. Staff assessed resident as no short-term memory impairment, and independent in decision making.

Review of Resident #11's clinical physician orders reflected:

12/12/24 Atorvastatin Calcium oral Tablet 10mg give one tablet by mouth at bedtime for hyperlipidemia.

12/12/24 Latanoprost Ophthalmic Solution 0.005% Instill 1 drop in both eyes at bedtime for macular degeneration.

12/12/24 Levothyroxine Sodium Tablet 137mcg give one tablet by mouth one time a day for low thyroid hormone.

Review of Resident #11's December 2024 MAR reflected missed administration of the following -

Atorvastatin 10mg on 12/12/24.

Latanoprost Ophthalmic Solution on 12/12/24.

Levothyroxine Sodium 137mcg on 12/13/24.

Review of Resident #11's baseline care plan reflected in part,

Problem: Thyroid therapy to treat (specify), is at risk for adverse effects. Date Initiated 12/13/24. No goal or interventions.

During an observation and interview on 01/27/25 at 10:52 AM, Resident #10 was lying in bed with the HOB elevated. She stated they had a meeting last week and the complaints she had finally got taken care of. She stated she got a new bed, a phone in the room, and little rails to help with turning in bed. She stated she had been getting her meds, but she was not sure if she was getting everything she was supposed to.

During an interview on 01/28/25 at 12:04 PM, the ADON stated she expected medications to be administered as ordered. They do have a supply of common medications available if needed. She stated if a medication was not administered, the resident would not get the intended effect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 During an interview on 01/30/25 at 12:09 PM, the MDS Nurse stated every med given was documented in

the MAR. If the resident had difficulty taking the med the nurse needed to document that in a progress note. Level of Harm - Minimal harm or She stated if a couple times a med was missed, the doctor or nurse practitioner was notified. She expected potential for actual harm effectiveness of prn medications to be documented. She stated missed doses could cause lab levels to be off, or if it were a missed seizure medication, it could cause the resident to have a seizure. She stated if the Residents Affected - Some medication was not documented, it was not given.

During an interview on 01/30/25 at 12:50 PM, the ADON stated it was her expectation that medications were documented when administered. If a medication was not given, the reason for not giving it needed to be documented. She stated if it was not documented, it was not given. She stated negative effects from not receiving a medication would depend on the missed med, such as missing blood thinners could cause blood clots, missed antibiotics could cause infection to linger or build resistance to the med. A policy for medication administration was requested.

During an interview on 01/30/25 at 5:25 PM, the ADM stated she expected medications to be administered as ordered.

Review of the facility's Medication Orders policy revised November 2014, reflected in part, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. The policy did not address administration or documentation of the administration.

A policy on medication administration was requested from the ADM at entrance on 01/27/25. The policy was not received prior to exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42949

Residents Affected - Some Based on interview and record review, the facility failed to ensure that medical records were accurately documented for three (Resident #6, Resident #7, and Resident #8) of six residents reviewed for accurate medical records.

The facility failed to document nursing notes in Residents #6's, #7's, and #8's EMR for multiple days after

they were admitted to the facility.

This deficient practice could result in errors in care and treatment.

Findings included:

Review of Resident #6's undated face sheet reflected a [AGE] year-old male who was admitted to the facility

on [DATE REDACTED] with no documented diagnoses.

Review of Resident #6's EMR, on 01/29/25, reflected an admission MDS assessment had not been created.

Review of Resident #6's EMR, on 01/29/25, reflected an admission/baseline care plan had not been created.

Review of Resident #6's progress notes in his EMR, on 01/29/25, reflected no nursing documentation.

Review of Resident #7's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE REDACTED] with a diagnosis of altered mental status.

Review of Resident #7's EMR, on 01/29/25, reflected an admission MDS assessment had not been created.

Review of Resident #7's EMR, on 01/29/25, reflected an admission/baseline care plan had not been created.

Review of Resident #7's progress notes in his EMR, on 01/29/25, reflected no nursing documentation.

Review of Resident #8's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE REDACTED] with diagnoses including hypotension (low blood pressure), repeated falls, dementia, and acute respiratory failure.

Review of Resident #8's EMR, on 01/29/25, reflected an admission MDS assessment had not been completed.

Review of Resident #8's EMR, on 01/29/25, reflected an admission/baseline care plan had not been created.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 0842 Review of Resident #8's progress notes in his EMR, on 01/29/25, reflected no nursing documentation.

Level of Harm - Minimal harm or During an interview on 01/30/25 at 4:12 PM, LVN A stated residents should have, at the minimum, a daily potential for actual harm skilled note in their EMRs. She stated it would not be okay for there to be no documentation in a resident's chart because the nurses would not know their status, and the resident could go without pertinent care. Residents Affected - Some

During an interview on 01/30/25 at 5:05 PM, the DON stated the residents' progress notes should reflect whatever was going on at that time, any changes in medication or condition. She stated it was important so other staff members could look at their documentation and know what was going on with the resident. She stated a negative outcome could be missing information that would be needed to take care of the resident.

During an interview on 01/30/25 at 5:25 PM, the ADM stated her expectations were that Medicare residents had nursing documentation in their progress notes every shift as it was best practice, but every 24 hours was

a requirement. She stated if the resident was not a skilled resident, they should have at least three days of post-admission notes charted by exception at that point. She stated it would not be acceptable for a resident to go without any nursing documentation as it was important for anyone who read their chart to know what was going on with the resident. She stated if not documented clearly, issues could be missed.

Review of the facility's Charting and Documentation Policy, revised July 2017, reflected the following:

All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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** 42949 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to establish and maintain an Residents Affected - Some 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 infection for 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #9) of 7 residents reviewed for infection control.

1. The facility failed to wear PPE when providing high contact resident care (dressing, bathing, transfers, wound care, device) to Residents #1, #2, #3, #4, and #9.

2. The facility failed to have signage on resident doors that reflected PPE was required for high contact care for Residents #1, #2, #3, #4, and #9.

3. The facility failed to educate staff on infection control procedures related to Enhanced Barrier Precautions (EBP).

These failures could place residents at risk for infection, hospitalization , or death.

Findings included:

1. Review of Resident #1's face sheet printed on 01/28/25 reflected a [AGE] year-old female initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Her diagnoses included pressure ulcer of sacral region (between the buttocks) - stage 4, chronic pain, neuromuscular dysfunction of bladder (lack of bladder control due to a nerve problem), paraplegia (paralysis), and type 2 diabetes mellitus (a condition that affects the way

the body processes blood sugar).

Review of Resident #1's quarterly MDS assessment dated [DATE REDACTED], Section C (Cognitive Patterns) reflected a BIMS score of 11 indicating moderately impaired cognition. Section H (Bladder and Bowel) reflected she had

an indwelling catheter. Section M (Skin Conditions) reflected she had an unhealed stage 4 pressure ulcer.

Review of Resident #1's comprehensive care plan reflected in part:

Problem - Last revised 10/18/24 - The resident had a pressure ulcer stage four to buttocks. Goal - The residents pressure ulcer will show signs of healing and remain free from infection. Interventions - Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage.

Problem - Resident had suprapubic catheter r/t neuromuscular dysfunction of bladder. Goal - last revised 09/25/24 - The resident will show no s/sx of urinary infection through the review date. Interventions - Position catheter bag and tubing below the level of the bladder. Monitor for s/sx of discomfort on urination and frequency. Monitor/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 Review of Resident #1's January 2025 MAR reflected the resident received Amoxicillin -Pot Clavulanate Tablet 875-125mg (antibiotic) 1 tablet by mouth every 12 hours for bacterial infection 01/17/25 through Level of Harm - Minimal harm or 01/21/25 and Doxycycline Hyclate oral tablet 100mg (antibiotic) 1 tablet by mouth two times a day for UTI potential for actual harm from 01/17/25 through 01/22/25.

Residents Affected - Some Review of Resident #1's Wound Care Progress note dated 01/22/25, reflected she was on two antibiotics, at that time, based on a urine culture that grew P. mirabilis and MRSA. Her sacrum wound culture from 01/13/25 grew E. faecalis.

Review of Resident #1's current clinical physician orders reflected in part, Change wound vac dressing every MWF and as needed. After removing dressing, apply [cleanser] soaked gauze for 3 minutes, apply topical iodine over wound bed, apply [dressing] to wound bed then apply wound vac foam at 150mmHg continuous . dated 07/29/24, and Wound care to suprapubic catheter site twice a day and prn. Cleanse around suprapubic ostomy with NS and pat dry with gauze . dated 07/16/24.

2. Review of Resident #2's face sheet printed on 01/30/25 reflected a [AGE] year-old male admitted to the facility on [DATE REDACTED] His diagnoses included acute osteomyelitis left ankle and foot (infection in the bone), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), cellulitis of left lower limb (skin infection), and non-pressure chronic ulcer of left foot with necrosis (death of cells) of bone.

Review of Resident #2's MDS assessments reflected they were all, in process.

Review of Resident #2's baseline care plan, reviewed by the nurse on 01/18/25 reflected, Problem - The resident has potential/actual impairment to skin integrity of the (specify location) r/t. No goal or interventions reflected. Problem The resident has an AD: self-care performance deficit r/t. No goal or interventions reflected. Problem - The resident has (specify acute/chronic) pain r/t. No goal or interventions reflected. The care plan did not address the wound, the wound vac, or the PICC.

Review of Resident #2's current clinical physician orders reflected in part, Change wound vac dressing every MWF and as needed. After removing dressing apply [cleanser] soaked gauze for 3 minutes, apply topical iodine over wound bed, apply dressing to wound bed, then apply wound vac foam at 150mmHg continuous . dated 01/20/25. Vancomycin HCl in NaCl intravenous solution 1.25-0.9Gm/250ml Use 1500 mg intravenously every 12 hours for osteomyelitis /wound (bone infection) to run at 167 ml per hour dated 01/28/25.

Review of Resident #2's Admission/ReAdmission Evaluation dated 01/16/25 reflected a PICC in the right antecubital (inside of the forearm) and an unknown wound on the left lower leg.

3. Review of Resident #3's face sheet reflected a [AGE] year-old female initially admitted to the facility 01/04/25 and readmitted on [DATE REDACTED]. Her diagnoses included acute cystitis without hematuria, type 2 diabetes mellitus, unspecified open wound on right lower leg, and hypertension (high blood pressure).

Review of Resident #3's Discharge/Return Anticipated MDS assessment dated [DATE REDACTED], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 Review of Resident #3's care plan, initiated on 01/04/25 and revised on 01/28/25, reflected in part, Problem -

The resident has actual impairment to skin integrity of the midline upper abdomen and right inner thigh r/t Level of Harm - Minimal harm or surgical procedure. Goal - The resident will have no complications r/t laceration of right medial thigh through potential for actual harm the review date. Interventions - . Wound/dressing:(specify location and type), observe dressing (specify frequency). Change dressing and record observations of site (specify frequency). The care plan did not Residents Affected - Some address the wounds or the wound vac.

Review of Resident #3's current clinical physician orders reflected in part, Change wound vac dressing every T, TH, Sat and as needed. After removing dressing apply [cleanser] soaked gauze for 3 minutes, apply topical iodine over wound bed, apply dressing to wound bed, then apply wound vac foam at 125mmHg continuous . dated 01/23/25, Wound care referral - wound to R thigh dated 01/20/25, and mid abdomen: cleanse with NS, pat dry apply hydrogel, cover with dry adhesive dressing daily and PRN dated 01/09/25.

4. Review of Resident #4's face sheet printed 01/29/25, reflected a [AGE] year-old female admitted to the facility on [DATE REDACTED]. Her diagnoses included atherosclerosis of native arteries of extremities left leg with rest pain (narrowing of the arteries decreasing blood flow causing pain while resting), sacroiliitis (An inflammation of one or both immovable joints formed by the bones of the pelvis called sacrum and the ilium. This causes stiffness or pain in the lower back, hip, and legs), acquired absence of left leg above knee (amputation), and dependence on renal dialysis (a treatment that helps people with kidney failure keep their body's balance of fluids, electrolytes, and blood pressure).

Review of Resident #4's MDS assessments reflected all assessments were in progress.

Review of Resident #4's baseline care plan initiated on 01/17/25, reflected in part, Problem - The resident has potential/actual impairment to skin integrity of the (specify location) r/t. Goal - The resident will maintain or develop clean and intact skin by the review date. Interventions - Educate resident/family/caregivers of causative factors and measures to prevent skin injury .The resident needs (specify: assistance, supervision, reminding) to apply protective garments (specify: Geri-sleeves, bunny boots etc.) . The care plan did not address the surgical incision, the dialysis fistula, or the implanted port in the chest.

Review of Resident #4's clinical physician orders reflected in part, LLE incision - monitor for s/sx infection. Clean daily with NS, pad dry, leave OTA dated 01/23/25. The orders did not address the dialysis port.

Review of Resident #4's Admission/ReAdmission Evaluation, dated 01/17/25, reflected an implanted port in

the right upper chest, a dialysis fistula in the left antecubital (a surgical connection made between an artery and a vein for performing dialysis on the left inner arm), and a surgical incision on the left thigh.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 Review of Resident #4's medical record summary from the acute hospital, printed on 01/28/25, reflected the resident presented on 01/27/25, to the hospital, from the vascular clinic, for uncontrolled pain. The record Level of Harm - Minimal harm or reflected the resident had an above the knee amputation on 01/02/25. The stump had purulent drainage and potential for actual harm mild skin necrosis (dead tissue). The resident was transferred to the ER. Resident #4 was admitted to the hospital with a primary diagnosis of cellulitis (skin infection). The surgical progress note written on 01/28/25 Residents Affected - Some reflected a plan' OR tomorrow 01/29 for wound washout and debridement .

5. Review of Resident #9's admission MDS assessment dated [DATE REDACTED], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE REDACTED]. Section I (Active Diagnoses) reflected diagnoses including aphasia (difficulty using or comprehending language), cerebrovascular accident (stroke), chronic lung disease, and other tracheostomy complications. The MDS reflected the resident received tube feedings but did not reflect a pressure ulcer or indwelling catheter.

Review of Resident #9's comprehensive care plan last revised 01/28/25 reflected in part, The resident requires tube feeding (specify) r/t. Goal - The resident will be free of aspiration through the review date. The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/s of malnutrition or dehydration through review date. The resident's insertion site will be free of s/sx of infection through the

review date. Interventions - The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed. Administer tube feeding formula . Check for tube placement and gastric contents . Monitor/document/report PRN any s/sx of aspiration, fever, tube dislodged, infection at tube site . The care plan did not address the indwelling catheter or the stage 4 pressure ulcer.

Review of Resident #9's clinical physician orders reflected in part, Clean stage 4 to sacrum (large bone at

the bottom end of the spine) with normal saline, apply calcium alginate, then foam adhesive dressing daily, dated 01/22/25, Check gastric residual volume (GRV) every 4 hours and hold feedings if residuals are greater than 250 ml ., dated 12/28/24and Change urinary catheter and drainage bag monthly dated 01/28/25.

During an observation and interview on 01/27/25 at 10:30 AM, Resident #1 was lying in bed with the head of

the bed elevated. She stated she had a bed sore and was supposed to get wound care on Mondays, Wednesdays, and Fridays. The wound vac machine was observed hanging at the bedside. A catheter drain bag was observed at the bedside. The resident moved her sheet and blanket, and an indwelling suprapubic catheter was observed.

During an observation and interview on 01/27/25 at 10:41 AM, Resident #9 was observed lying in bed with

the head of the bed elevated. A urinary catheter drainage bag was observed at the bedside. Cartons of tube feed formula were observed at the bedside. Resident was unable to verbalize, but a family member at the bedside confirmed that the resident received tube feeding and that she had a pressure sore on her back side.

During an observation and interview on 01/27/25 at 10:48 AM, Resident #2 stated the staff changed his wound vac every MWF. A wound vac was observed on his left lower leg/foot, the dressing partially obstructed by his sock.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 During an observation and interview on 01/28/25 at 9:28 AM, Resident #1 was lying in her bed with her call light on. She stated she was waiting for staff to pull her up in bed so she would be able to eat her breakfast. Level of Harm - Minimal harm or The surveyor stepped out of the room. Two staff members entered the room. There was no signage on the potential for actual harm door and no PPE available outside or inside the room. The two staff members were observed as they left the room. The surveyor re-entered the room and observed the resident sitting up in bed and able to reach her Residents Affected - Some breakfast tray. She stated the staff did not wear PPE except for the one staff wearing a mask. There was no discarded PPE observed in the trash cans.

During an observation and interview on 01/28/25 at 9:33 AM, Resident #3 was observed sitting up in a wheelchair in her room. A wound vac was observed hanging from a strap around her neck. Resident #3 requested a different strap to attach the device to the wheelchair. She stated staff had just changed the dressing on her wound vac. There was no PPE observed in the room or in the trash. There was no signage

on the door, and no PPE available near the room.

During an observation on 10/28/25 from 1:21 PM to 1:24 PM, a walk through the facility was conducted. There were on isolation carts observed in the halls. There were no PPE caddies observed hanging on room doors. There were no isolation or precaution signs observed on any of the room doors.

During a telephone interview on 01/28/25 at 9:56 AM, Resident #1's family member stated the resident had a long history of urinary tract infections. She stated the resident was recently on two different antibiotics at the same time due to a UTI. She stated the resident was recently at a doctor's appointment and the doctor recommended the resident go to the emergency room due to the color of the urine in the drainage bag. Resident #1 went to the emergency room . The suprapubic catheter was replaced during that visit on 01/22/24.

During a telephone interview on 01/28/25 at 1:28 PM, the Medical Director stated he was familiar with EBP.

He stated it was his expectation that the precautions were followed. He stated the staff had all been trained and should have followed the guidelines. He stated there should have been signs on the doors and PPE available. He stated PPE was worn to prevent the spread of infection.

During an interview on 01/28/25 at 2:15 PM, the ADM stated she had talked with the medical director, and

they needed to get the EBP in place. She stated she was not a nurse and she had relied on her clinical team, mostly the DON, to have the precautions in place. She stated she did not know the depth of what should have been done. She stated RN B was the IP, but she stepped down from the ADON position, so the new ADON was the IP. She stated any resident who had a medical device like catheters or PICC lines, or wound vacs should have been on EBP with a sign on the room door and PPE available.

During an interview on 01/28/25 at 2:59 PM, the ADM stated the new ADON did not have her IP certificate but had started the training. She stated she and the administrative team did not find a specific policy that addressed EBP. She stated they were downloading guidance.

During an interview on 01/28/25 at 3:31 PM, the DON stated she had been in the building for 6 days. She stated anyone with anything going into a hole, anything artificial that did not come with the body, should have had EBP. She stated it was her expectation that staff followed EBP guidelines. She stated not wearing proper PPE could have caused infection issues. She stated she had an IP certificate, but she could not be

the person in that role. She stated it was the expectation of the company that all DONs and ADMs had the IP certificate. She stated she was not sure where they kept the PPE competencies but would look for the documents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 675797 Department of Health & Human Services Printed: 09/08/2025 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 675797 B. Wing 02/12/2025

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

Weston Inn Nusring and Rehabilitation 2505 S 37th St Temple, TX 76504

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 During an interview on 01/28/28 at 3:55 PM, LVN F stated she had been at the facility only 2-3 times. She stated she had not had any training at this facility about EBP. She stated there was a sign on the door that Level of Harm - Minimal harm or indicated what PPE to wear. When asked which rooms had the signs, she stated, Oh, there are no signs and potential for actual harm there is no PPE.

Residents Affected - Some During an interview on 01/28/25 at 6:05 PM, CNA G stated she had not had any training on EBP at that facility.

During an interview on 01/28/25 at 6:07 PM, Resident #1 stated staff had worn gloves and sometimes a mask, but never a gown, when they provided wound care or incontinent care.

During an interview on 01/28/25 at 6:10 PM, MA I stated she started working at the facility in December 2024. She stated she had not had any training on EBP.

During an interview on 01/28/25 at 6:11 PM, Resident #3 stated staff wore gloves when they provided wound care. She stated some staff wore a mask, but staff did not wear gowns or any other protective equipment

during care.

Review of the facility's infection control tracking reflected there had been on outbreak.

Review of the facility's Infection Prevention and Control Program policy, revised September 2022, reflected

in part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Policy Interpretation and Implementation 2. The program is based

on accepted national infection prevention and control standards . 6. Policies and Procedures a. Policies and procedures are utilized as the standards of the infection prevention and control program. b. Policies and procedures reflect the current infection prevention and control standards of practice .11. Prevention of Infection a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections;(2) instituting measures to avoid complications or dissemination; (3) educating team members and ensuring that they adhere to proper techniques and procedures .

Review of the facility's guidelines, Virginia Department of Health - Enhanced Barrier Precautions in Nursing Homes Algorithm, dated 06/2024, reflected in part, EBP are indicated for the following residents who are: Known to be colonized or infected with a multidrug-resistant organism (MDRO) when contact precautions do not otherwise apply; At increased risk of MDRO acquisition (e.g., resident has a wound or indwelling medical device) . In addition to standard precautions, gowns and gloves should be worn during the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care . Steps to Implementation: With implementation, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. 1. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. 2. Make PPE, including gowns and gloves, available immediately outside of the resident room .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 35 675797