Health inspection·July 15, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (Resident #1) of 6 residents reviewed for medical records. The facility failed to document wound care had been completed on 6 days of the previous 90 days that were reviewed. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury.Findings include: Record review of Resident #1's clinical record revealed a [AGE] year-old-female admitted to the facility originally on 07/23/24 and readmitted on [DATE]. Resident #1's current diagnoses include peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), atherosclerosis of native arteries of extremities (bilateral legs) (a medical condition where plaque builds up in the arteries that supply blood to the limbs), other injury of unspecified body region (graft site from left thigh). Record review of Resident #1's last MDS revealed an annual assessment completed on 07/11/25 with a BIMS of 12 indicating she was moderately cognitively impaired, she had a functional status of being dependent on staff for most of her activities of daily living, and she had 2 venous and arterial ulcers present. Record review of the care plan with admission date of 09/16/24 for Resident #1 revealed the following: Focus:I have Peripheral Vascular DiseaseFocus: Venous/Stasis Ulcer r/t PVD to LLEFocus: Venous/Stasis Ulcer r/t PVD to RLE-Further review revealed there were no interventions related to completion of wound care noted. Record review of Resident #1's physician orders printed 07/15/25 revealed the following orders:- Lt Calf- Cleanse with wound cleanser. Dry. Apply Mupirocin2%, Adaptec, ABD, and cover with ABD. wrap with Kerlix. wrap with Ace bandage. secure with Tetra-Net size 6 very day shift for wound .-Revision Date: 04/23/2025 - Lt Upper Thigh-Cleanse with wound cleanser. Dry. Apply Mupirocin 2%, Adaptec, ABD, and cover with ABD. wrap with Kerlix. secure with tape. every day shift for wound . -Revision Date: 04/23/2025 - Rt Calf- Cleanse with wound cleanser. Dry. Apply Mupirocin2%, Adaptec, ABD, and cover with ABD. wrap with Kerlix. wrap with Ace bandage. secure with Tetra-Net size 6 every day shift for wound . -Revision Date: 04/23/2025 Record review of Resident #1's WAR's from 04/17/2025 through 07/15/2025 (last 90 days) revealed the following: Left calf wound with a revised order for daily wound care started on 04/23/25. Noted no documentation of wound care completed for 04/27.25, 05/02/25, 05/07/25, 05/31/25, 07/04/25, and 07/13/25. Left upper thigh wound with a revised order for daily wound care started on 04/23/25. Noted no documentation of wound care completed for 04/27.25, 05/02/25, 05/07/25, 05/31/25, 07/04/25, and 07/13/25. Right calf wound with a revised order for daily wound care started on 04/23/25. Noted no documentation of wound care completed for 04/27.25, 05/02/25, 05/07/25, 05/31/25, 07/04/25, and 07/13/25. During an observation and interview on 07/15/2025 at 09:03 AM Resident #1 was in her room in her bed. Resident #1 was dressed well and appeared in good Page 1 of 2 455480 455480 07/15/2025 Heritage Convalescent Center 1009 Clyde St Amarillo, TX 79106

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some condition. Resident #1 reported that she had an issue with LVN C but that she had not received any care from LVN C in quite a while. All other staff have been very good at what they have done. Resident #1 reported that all wounds were doing better to include the graft site on her left upper thigh and both lower leg PVI/venous status ulcer wounds. During an interview on 07/15/2025 at 03:05 PM the DON reviewed Resident #1's WAR record and reported that the dates of 4/27/25, 5/2/25, 5/7/25, 5/31/25, 7/4/25, and 7/13/25 were not documented on the WAR that the wound care had been completed for Resident #1's right calf, left calf, and left upper thigh. The DON reported that she knew the wound care had been done because Resident #1 would always tell her if any of her wound care was missed, and Resident #1 did not report any of those dates. During an interview on 07/15/2025 at 03:56 PM the DON reported that she had talked with LVN B, and he reported that he had completed the wound care for Resident #1 on 04/27/25 and reported that he just did not document it. ADON A completed the wound care on 05/02/25 and ADON A reported that Resident #1's wound care was done but she forgot to document it in the resident records. On 05/07/25 Dr [NAME] was in the facility, performed the wound care, and whoever the staff that was with Dr. E did not document the wound care in Resident #1's records and she (the DON) was not able to determine who that was that day. On 05/31/25 Resident #1 refused wound care for LVN C, but LVN C did not document the refusal and LVN C was currently out of town on vacation and unavailable for contact. On 7/04/25 LVN D completed Resident #1's wound care and reported that she (LVN D) forgot to document that she completed the wound care in Resident #1's chart. On 07/13/25 she (the DON) covered the hall Resident #1 was on, and she could not remember what was done that day but she did know she (the DON) did not document that the wound care was completed since she did not mark the WAR. The DON again stated if the wound care had not been completed Resident #1 would have told her about it. During an interview on 07/15/2025 at 04:08 PM ADON A reported that she missed documenting the wound care that she had performed on Resident #1 on 05/02/25 and stated, I just missed it. I had to many things going on that day. ADON A reported that she did not feel this was an issue and would not affect the residents care since Resident #1 had received her wound care. During an interview on 07/15/2025 at 04:11 PM LVN B reported that he did Resident #1's wound care on 04/27/25 but that he did not document that he had completed the wound care in Resident #1's chart. LVN B stated that if you do not document the care was provided then that don't count. He reported that a resident can be affected if their care was not documented. During an interview on 07/15/2025 at 05:00 PM LVN D stated, I thought I did it, I might have missed the documentation, but the care was done. On 07/04/25 for Resident #1. LVN D reported that if the documentation was not completed then nobody knows that it was completed and the wound could get worse if it really wasn't done, but I did mine that day. During an interview on 07/15/2025 at 04:57 PM the DON reported that she could not find a facility policy on the accuracy of documentation. The DON stated, so I guess we do not have one. 455480 Page 2 of 2