Health inspection·January 2, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (Resident #1) of 1 resident reviewed for an in-house acquired pressure ulcer. Residents Affected - Some The facility failed to ensure Resident #1 did not develop two avoidable facility acquired pressure injuries. The facility failed to initiate new orders for Resident #1. The facility failed to remove the immoblizer boot (a medical device worn during treatment and recovery of a variety of foot injuries - it is a form of immoblizing and weight bearing for injuries to foot areas) and accurately assess Resident #1's right lower leg during weekly skin assessments from 10/02/2023 10/18/2023. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/02/2023 and ended on 10/26/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for developing new pressure wounds, inconsistent care resulting in the deterioration of existing wounds, a decline in health, pain, and hospitalization. Findings included: Record review of Resident #1's face sheet dated January 2, 2024, indicated she was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis of Displaced Tri malleolar Fracture of Right Lower Leg (fracture at the ankle joint), Subsequent Encounter For Closed Fracture with Routine Healing, Chronic Obstructive Pulmonary Disease (a group of lung diseases that block air flow and makes it difficult to breathe), Muscle weakness, Senile Degeneration of Brain (a loss of intellectual ability). Record review of Resident #1's physician's order summary dated 10/18/2023 indicated Resident #1 had no wound care orders for her right lower extremity. Record review of the MDS Resident Assessment and care screening Nursing Home Comprehensive Item Set dated September 1, 2023, indicated Resident #1 was cognitively impaired with BIMS score of 07. She was at risk for pressure injuries, and none were noted on this assessment. Resident #1 had no issues with her skin. Page 1 of 5 455532 455532 01/02/2024 Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Record review of the care plan updated on 10/25/2023, indicated Resident #1 had the potential for impairment to skin integrity related to hard case from fracture with a focus of 10/19/2023 pressure ulcer to right lateral calf, 10/19/2023 trauma wound to right medial calf and 10/19/2023 trauma wound to right medial ankle - resolved 10/25/2023. Interventions included 10/19/2023 resident to receive weekly wound care by wound care physician. Monitor and document location, size and treatment of skin injury, Report abnormalities, failure to heal, signs and symptoms infection, maceration etc. to MD. Residents Affected - Some Record review of Resident #1's weekly body skin assessments dated 10/05/2023, LVN B indicated Resident #1 did not have issues with her skin. Record review of Resident #1's weekly body skin assessments dated 10/12/2023, LVN C indicated Resident #1 did not have issues with her skin. Record review of Resident #1's weekly body skin assessments dated 10/19/2023, LVN C indicated Resident #1 did not have issues with her skin. Record review of Resident #1's progress notes dated 10/02/2023, LVN A indicated Resident #1 had returned from a follow-up physician's appointments after removal of the hard cast from right lower extremity with new orders for range of motion to right ankle out of boot, continue with non- weight bearing to right lower extremity, clean ankle once daily with saline and follow-up in four weeks. Record review of Resident #1's progress note dated 10/18/2023, indicated Resident #1 had developed two avoidable pressure injuries on her right lower leg resulting in surgical debridement and infection. On 10/18/2023, the wound care MD was notified of the areas and new treatments were initiated. The resident had a full thickness (the damage extends below the epidermis and dermis - all layers of the skin) wound to her right medial (middle) calf and an unstageable (the depth of the ulcer is obscured by slough - yellow, gray, green or brown substance in the wound bed) full thickness wound to her right lateral - (side) calf. During an interview on 12/27/2023 at 11:15 AM, Resident #1's Responsible Party said Resident #1 was brought home on or about 11/22/2023. Resident #1 Responsible Party said the wounds are almost healed. During an interview on 12/27/2023 at 01:05 PM, RN D said on 10/18/2023, Resident #1 complained of pain to her right lower leg. RN D removed the immobilizer boot and found the three ulcerated areas. RN D said she contacted the wound care physician, DON, and resident's family. RN D said she was the treatment nurse but had not received any notifications to treat Resident #1. RN D said it was the duty of the night charge nurse assigned to Resident' #1's room to do a weekly skin assessment. Attempted telephone call at 12/27/2023 at 11:15 AM, unable to reach LVN B and left a request for return call. Attempted telephone call at 12/27/2023 at 11:18 AM, unable to reach or leave a message for LVN C. During an interview on 12/28/2023 at 1:18 PM, LVN A said Resident #1 returned from her physician's appointment on 10/02/2023 with the boot immobilizer on her right foot. LVN A said the transportation aide handed her the physician's orders for Resident #1. LVN A said she put a progress note into the Resident #1 electronic medical record but failed to enter the new orders she had received. LVN A 455532 Page 2 of 5 455532 01/02/2024 Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some said it had been a very busy day and she forgot. LVN A said she was Resident #1's nurse and she should have assessed Resident #1 upon her return from the appointment. LVN A said she was educated on the facility's policy regarding entering orders. LVN A said she was in serviced on the appropriate way to perform a head-to-toe assessment and received checkoffs weekly on performing skin assessments. LVN A stated she received disciplinary actions regarding her job duties. LVN A said a new system was in place due to the identified failure. LVN A said the new process was as follows: when a resident left the facility for any appointment and no new orders were received, then the DON contacted the physician's office to ensure there were no new orders. LVN A said the importance of orders entered timely and appropriately was to prevent the resident from neglect and a decline in the resident's health by not receiving services and care. During an interview on 12/28/2023 at 1:30 PM, the DON said the charge nurse was responsible for assessing and updating/inputting any new orders upon a resident's return to the facility after any physician appointments. The DON said the weekly skin assessments were assigned by hall and divided out to the day or night nurse per a schedule. The DON said the night nurse was assigned to Resident #1's room. The DON said LVN B and LVN C had failed to perform proper head to toe assessments from 10/02/2023 through 10/19/2023 on Resident #1 by not removing the immobilizer. The DON said there was a failure in the system which had been identified and corrected by in servicing all licensed staff on job duties and responsibilities regarding entering orders and weekly head to toe assessments. The DON said she followed up on orders after all resident physician appointments by contacting that physician's office after each appointment to ensure no new orders were inadvertently not sent to the facility. The DON said all appointments were now discussed in the staff morning meeting. The DON said LVN A failed to enter the orders upon Resident #1 returning from the physician appointment on 10/02/2023. The DON said she expected head to toe assessments to be completed by removing immobilizers per orders and examining for skin integrity issues to prevent a decline in the health and healing of residents. The DON expected all orders to be entered into the system timely and appropriately to ensure the residents getting all the necessary services and care to promote healthy lifestyles. The DON said all licensed staff were educated with one-to-one weekly skills check-off on head-to-toe assessments, in-services were completed on job duties and responsibilities for charge nurses, staff in-services for abuse and neglect, and disciplinary actions were provided on staff involved in Resident #1's care. During an interview on 12/28/2023 at 1:30 PM, the Administrator said there was a failure in the system which was identified and corrected by in servicing all licensed staff on job duties and responsibilities regarding entering orders and weekly head to toe assessments. The Administrator said the DON followed up on orders after all resident physician appointments by contacting that physician's office after each appointment to ensure no new orders had been inadvertently not sent to the facility. The Administrator said all appointments were discussed in the staff morning meeting. The Administrator said all staff was educated and in-serviced on abuse and neglect, and immobilizers. All licensed staff was educated and completed weekly skills check offs on head-to-toe assessments. The Administrator said LVN A, LVN B, LVN C had received disciplinary actions. The Administrator said LVN C was no longer employed at the facility. The Administrator said she expected all orders entered timely. The Administrator said she expected head to toe assessments done appropriately according to policy. The Administrator said entering orders timely and appropriate head to toe assessments were vital to providing and promoting healthy resident care. During an interview on 12/28/2023 at 2:08 PM, LVN B said she was the night charge nurse for Resident #1. LVN B said her job duties included weekly skin assessments for Resident #1. LVN B said she should have removed the immobilizer boot and examined Resident's #1 skin. LVN B said she was not sure why she 455532 Page 3 of 5 455532 01/02/2024 Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455

F 0686 Level of Harm - Immediate jeopardy to resident health or safety had not fully removed the immobilizer during 10/02/2023 - 10/18/2023. LVN B said the importance of removing the immobilizer and performing full head to toe assessments was to prevent any skin breakdowns that can lead to infections. LVN B said she was in-serviced on her job duties and responsibilities, abuse and neglect, one to one head to toe check offs with performance weekly. LVN B stated she received disciplinary actions from the facility. Residents Affected - Some Attempted telephone call at 12/27/2023 at 2:18 PM, unable to reach or leave a message for LVN C. Record review of the facility's policy revised on 08/12/16 and titled, . Pressure Injury Prevention Program indicated All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries. 5. If a pressure injury/ skin breakdown is identified, the following will be done- If a pressure injury/ skin breakdown is identified, the following will be done- If new area found-if pressure injury- complete new wound evaluation / assessment if non-pressure area-complete new wound evaluation / assessment must include: Size, Stage (staged by RN or PT), Location, Drainage amount If odor if present Signs and symptoms of infection if present Wound bed description, Wound edge and surrounding tissue description, How the resident tolerated the wound care If pain with dressing change identified, treatment paused to allow for appropriate pain management before resumption. If pain with dressing change previously identified, confirm order for pain management in place and pre-medication completed per order. Any noted changes in condition requiring new or updated interventions Wound status Notify MD-obtain treatment orders Notify RP/ or family if they are RP or Resident has directed family to be updated Update care plan Note on 24-hour report Referrals to therapy, dietician or other consultant as deemed necessary Monitor weekly via weekly wound reporting and skin integrity quality assurance processes . Record review of the facility's policy dated 2015 titled, .Physician's Orders indicated Written Orders by the Physician or Nurse Practitioner . 3. The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the order was received Record review of in service dated 10/26/2023 of sixteen licensed staff with one-to-one education on skin integrity, pressure ulcer (injury) prevention and treatment, and abuse and neglect, and inputting MD orders included LVN A, LVN B, and LVN C. Record Review of inservice dated 10/26/2023 of sixteen licensed staff completed competencies checks for performing skin assessments and inserviced on what to do when a resident was admitted with immobilizer/boot in place without orders to remove, when to remove to assess skin and pulses including LVN A, LVN B, and LVN C. Record Review of the documented facility completed skin sweep dated 10/18/2023 of all residents resulted in no new concerns. Record Review of Disciplinary Actions completed on 10/26/2023 with LVN B and LVN C over incomplete skin assessments and with LVN A who failed to put in the orders. During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 8 CNAs (4 from each shift (CNA E, CNA 455532 Page 4 of 5 455532 01/02/2024 Pleasant Springs Healthcare Center 2003 N Edwards St Mount Pleasant, TX 75455

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some F, CNA G, CNA H, CNA K, CNA L, CNA M, CNA N) were able to identify and define abuse and neglect, state the procedure of skin assessments and who to report to with questions and concerns. During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 6 LVNs (3 from each shift (LVN A, LVN B, LVN O, LVN P, LVN Q, LVN R) all were able to identify and define abuse and neglect, state the procedure of skin assessments and immobilizer removal and care, and who to report to with questions and concerns. All were aware of the expectations of completing proper skin assessments and how to monitor pressure ulcers per protocol and to notify the DON/ADON and the Administrator immediately per procedures. During interviews on 01/02/2024 from 08:00 AM to 05:00 PM., 4 RNs (RN T, DON, RN D, and the Regional Compliance Nurse) all were able to identify and define abuse and neglect, state the procedure of skin assessments and immobilizer removal and care, and who to report to with questions and concerns. All were aware of the expectations of completing proper skin assessments and how to monitor pressure ulcers per protocol and to notify the DON/ADON, physicians and/or the Administrator and family immediately per procedures. During interviews on 01/02/2024 from 08:00 AM to 5:00 PM., the Administrator, DON, Regional Compliance Nurse and LVN A said the DON was responsible for following up on new orders by ensuring all orders were entered into the electronic health system after the residents' physician appointments, and by contacting the physician's office after each appointment to ensure no new orders had been inadvertently not sent to the facility. The Administrator, DON, Regional Compliance Nurse and LVN A said all appointments were discussed in the staff morning meeting. Record review of a QAPI Committee Report dated 10/26/2023 indicated that there was a meeting held consisting of the Administrator, the assistant Administrator, the DON, the ADON, the MDS nurse, the social worker, and the Medical Director. The following interventions were put in place: In-service: re-education to staff on how to maintain skin integrity On 12/28/2023 at 03:46 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/02/2023 and ended on 10/26/2023. The facility had corrected the noncompliance before survey began. 455532 Page 5 of 5