Health inspection·July 5, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for physician orders for treatments. Residents Affected - Few The facility failed to follow physician orders and perform wound treatments as ordered for Resident #1. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident #1's face sheet, printed 07/05/2024 revealed a [AGE] year-old male. Resident #1's MDS, dated [DATE] revealed a BIMS of 14 indicating no cognitive impairment. His functionality per his last MDS revealed he required extensive 2-person assistance to complete bathing, toileting, and lower body dressing. Resident #1 needed partial/moderate assistance with upper body dressing, and supervision or touch assistance with eating and oral hygiene. He was admitted originally on 03/01/2024 and readmitted on [DATE] with the following diagnoses: peripheral vascular disease, unspecified, type 2 diabetes mellitus with hyperglycemia, acquired absence of left leg below knee, other lack of coordination, need for assistance with personal care, weakness, depression, non-pressure chronic ulcer of left heel and midfoot with fat layer exposed, end stage renal disease, acquired absence of right leg below knee. Record review of physician's orders dated 07/05/2024, for Resident #1's 4th finger wound treatment revealed the following: Right 4th finger: clean with wound cleanser or normal saline, pat dry with gauze, apply Mupirocin to Aguacel AG cut to fit the wound, cover with gauze, and secure with tape. every day shift every Mon, Wed, Fri for 4th finger Order start date was 06/07/2024 with no discontinue date. Record review of wound administration record for May 2024 and June 2024 revealed that Resident #1 did not receive wound care to his right 4th finger on the following day(s): Monday May 6th and Friday May 10th, 2024, and Friday June 21, 2024. Record review of physician's orders dated 07/05/2024, for Resident #1's left below knee amputation (BKA) wound treatment revealed the following: Left BKA. Clean wounds with normal saline or wound cleanser and gauze. Skin prep to peri-wound and with vac drape. Pace Cuticerin into wound bed then pack (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 455480 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Convalescent Center 1009 Clyde St Amarillo, TX 79106 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)