Health inspection·February 27, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 (Resident #4) residents reviewed for pressure ulcers. Residents Affected - Few The facility failed to provide care as ordered to bilateral heel pressure ulcers. The facility failed to assess pressure ulcers weekly. The facility failed to provide interventions to prevent development or worsening of Resident #4's heel pressure ulcers. These failures could place residents at risk of infections and worsening of wounds. Findings include: Record review of Resident #4's electronic face sheet dated 02/27/2024 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: rhabdomyolysis (muscle deterioration), insomnia, gout (inflammation in joint), muscle weakness, and protein-calorie malnutrition (low protein levels and calorie intake). Record review of Resident #4's admission MDS assessment dated [DATE] revealed resident had a BIMS score of 11 meaning moderate cognitive impairment; helper performed more than half the effort with dressing and putting on footwear; helper performed less than half the effort with bed mobility, sitting to lying, sitting to standing, and bed to chair transferring; resident had 1 unhealed pressure ulcer and received pressure ulcer care with pressure reducing device for bed. Record review of Resident #4's orders dated 02/27/2024 revealed: Order with start date of 01/26/2024 resident may have pressure relieving mattress; Order with start date of 01/26/2024 cleanse stage 1 to left buttocks with wound cleanser pat dry apply collagen and cover with bordered dressing one time a day every Mon, Wed, Fri for pressure area; Order with start date of 02/08/2024 resident may have Prevalon Boot (heel protection boot) to right Page 1 of 7 455570 455570 02/27/2024 Mineral Wells Nursing & Rehabilitation 316 SW 25th Ave Mineral Wells, TX 76067

F 0686 and left foot for pressure area two times a day for pressure area; Level of Harm - Minimal harm or potential for actual harm Order with start date of 02/08/2024 cleanse left heel ruptured blister with normal saline pat dry apply iodine skin prep and cover with dressing one time a day for blister; Residents Affected - Few Order with start date of 02/08/2024 cleanse right heel ruptured blister with normal saline pat dry apply iodine skin prep and cover with dressing one time a day for blister. Record review of Resident #4's care plan dated 02/27/2024 reflected it does not address resident's non-compliance with pressure relieving interventions: Avoid positioning the resident on the location of the pressure ulcer right and left heel date initiated: 01/26/2024 revision on: 02/09/2024 . Ensure heels are floated (not touching another surface) with the use of pillows date initiated: 01/26/2024 .Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Record review of Resident #4's treatment administration record on 02/27/2024 revealed wound care was not documented for either the left or right heel on Sunday 02/11/2024 with no rationale why treatment was not performed. Record review of pressure ulcer assessments on 02/27/2024 revealed: Left heel stage 2 pressure ulcer measured 3.0cm(L) by 3.0cm(W) by 0cm(D) on 02/08/2023. Left heel stage 2 pressure ulcer measured 5.0cm(L) by 5.0cm(W) by 0cm(D) on 02/13/2024. Left heel stage 2 pressure ulcer measured 4.5cm(L) by 3.0cm(W) by 0cm(D) on 02/23/2024. Left heel stage 2 pressure ulcer measured 3.0cm(L) by 4.5cm(W) by 0cm(D) on 02/26/2024. Right heel stage 2 pressure ulcer measured 2.0cm(L) by 2.0cm(W) by 0cm(D) on 02/08/2024. Right heel stage 2 pressure ulcer measured 5.0cm(L) by 4.0cm(W) by 0cm(D) on 02/13/2024. Right heel stage 2 pressure ulcer measured 2.5cm(L) by 3.5cm(W) by 0cm(D) on 02/23/2024. Right heel stage 2 pressure ulcer measured 3.0cm(L) by 4.0cm(W) by 0cm(D) on 02/26/2024. Weekly pressure ulcer assessment was not performed on February 20th 2024. During on observation and interview on 02/26/2024 at 3:10 p.m., Resident #4 was sitting in his wheelchair in his room. Resident's bed had a standard mattress. The wheelchair had feet pedals on it and Prevalon boots (heel protection boots) were being worn. Resident #4 said that he did not like wearing Prevalon boots (heel protection boots) in the bed and he wished staff would allow him to not wear them. He stated Prevalon boots (heel protection boots) were used to help wounds on his feet heal. The resident said his heel wounds were getting better. During an interview on 02/27/2024 at 2:34 p.m., LVN C stated she performed treatments and assessments on Resident #4 when she worked. She stated that Resident #4 had a pressure ulcer to his buttocks 455570 Page 2 of 7 455570 02/27/2024 Mineral Wells Nursing & Rehabilitation 316 SW 25th Ave Mineral Wells, TX 76067

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when he admitted to the facility on [DATE]. LVN C stated that on 02/08/2024 she was called to evaluate Resident #4's heels and she observed new skin issues at that time. She received physician's orders and treated the pressure ulcers that day. LVN C stated that on 02/11/2024 she did not work since it was a Sunday. She stated charge nurses were to perform wound care on the days that she did not work, and she did not know why wound care was missed. She stated Resident #4 was non-compliant with letting staff offload his heels with pillows and would kick the pillows out from under his legs. She stated Resident #4 said the Prevalon boots (heel protection boots) the facility used for offloading the area at this time caused his claustrophobia to worsen and he would kick them off at times. She stated he refused to allow the facility to put on foot pedals to his wheelchair until recently and would plant his heels on the hard floor when sitting in the wheelchair. She stated he had started allowing staff to assist more since he had been at facility longer. LVN C stated she was out on personal leave between 02/14/2024 and 02/23/2024 and did not know why pressure ulcer assessments were not performed in her absence. She stated that charge nurses should have performed the assessments. She stated the DON monitors that assessments and treatments are performed. She stated that Resident #4 was on the list for the wound care physician to assess him on 03/01/2024 due to pressure ulcer worsening. She stated that when Resident #4 was admitted , the air mattress was not available. The facility was working on getting him one at this time and she felt that the facility would be able to rent a low air loss mattress to help relieve pressure areas while in bed. During an interview on 02/27/2024 at 2:42 p.m., the DON stated pressure ulcers were preventable. She stated her expectation was for pressure ulcer assessments to be performed weekly and weekly meant every 7 days. She stated her expectation would be for the charge nurses to perform assessments and treatments on days when the treatment nurse was not working in the facility. On 02/11/2024 she expected for the charge nurse or the weekend supervisor to perform treatment. She did not know what led to the failure. She stated that if treatment was not documented then it was not done. The DON stated she did not know the assessment was missed on 02/20/2024 and that treatment was missed on 02/11/2024 therefore did not follow up. She stated that missing treatments and assessments could cause wounds to worsen. She voiced that she was responsible for monitoring treatments and assessments were performed. Review of facility policy titled Comprehensive Care Planning that is not dated revealed In situations where a resident's choice to decline care or treatment (e.g. due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan. Review of facility policy titled Skin Assessment dated 08/15/16 revealed It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to ensure appropriate intervention are initiated in a timely manner .All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed by the Treatment Nurse/designee within four (4) hours of the resident's arrival at the facility. If the Treatment Nurse/designee is not available, then the charge nurse should complete the skin assessment within four (4) hours of the resident's arrival at the facility. The charge nurse will then notify the Treatment Nurse/designee of any skin concerns noted and complete the appropriate attachments/assessments. The DON (Director of Nursing) or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations. Any pressure ulcer should also be care planned. Any alterations in skin integrity will be treated according to physician orders. Notify DON and 455570 Page 3 of 7 455570 02/27/2024 Mineral Wells Nursing & Rehabilitation 316 SW 25th Ave Mineral Wells, TX 76067

F 0686 Level of Harm - Minimal harm or potential for actual harm responsible family member. Documentation will then be entered into the resident's chart with the following information. All residents should have a skin assessment on a weekly basis completed in PCC (electronic medical record). If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly. Residents Affected - Few 455570 Page 4 of 7 455570 02/27/2024 Mineral Wells Nursing & Rehabilitation 316 SW 25th Ave Mineral Wells, TX 76067

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for oxygen administration. Residents Affected - Few The facility failed to place nebulizer mask and tubing in a bag and date when replaced. The facility failed to obtain physician's order prior to supplying oxygen to resident. The facility failed to monitor oxygen concentrator tubing connected appropriately. The facility failed to date humidifier on oxygen concentrator when replaced. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection. The findings include: Record review of Resident #5's electronic face sheet dated 02/27/2024 revealed a [AGE] year-old female who was admitted to the facility most recently on 11/10/2023 with diagnoses that included: dementia, gastrointestinal hemorrhage (stomach bleed), heart failure (heart disease that affects how much blood the heart can pump), muscle wasting, and COVID 19. Record review of Resident #5's significant change MDS assessment dated [DATE] revealed a BIMS score of 9 meaning moderate cognitive impairment; no oxygen treatment was coded on admission or while a resident. Record review of Resident #5's orders dated 02/27/2024 revealed order with start date of 12/13/2023 furosemide solution 10mg/ml (furosemide) 4mL (milliliter) inhale orally via nebulizer every 6 hours as needed for SOB (shortness of breath) and no order for oxygen therapy . Record review of Resident #5's care plan dated 02/27/2024 revealed no mention of oxygen therapy or nebulizer use on the care plan. During an observation and interview on 02/25/2024 at 1:25 p.m., Resident #5 stated she used oxygen as needed. She stated facility staff helped her when she needed oxygen. There was an oxygen concentrator and tubing with humidifier not connected to the concentrator. The humidifier tubing had a different electronic machine plug prong inserted into the end of it instead of being connected to the concentrator. The oxygen concentrator turned on, and no air bubbles were rising up to the top of water observed in the humidifier canister and the end of the tubing was placed in the top drawer of the nightstand. During an observation on 02/26/2024 at 11:41 a.m., Resident #5 had the oxygen concentrator sitting to the left of her bed. The oxygen tubing with humidifier was not connected to the concentrator and had a different electronic machine plug prong inserted into the end of the tubing that should have been connected to the concentrator. The oxygen concentrator was turned on with no bubbles forming in the humidifier canister and the end of the tubing was placed in the top drawer of the nightstand. 455570 Page 5 of 7 455570 02/27/2024 Mineral Wells Nursing & Rehabilitation 316 SW 25th Ave Mineral Wells, TX 76067

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/27/2024 at 10:33 a.m., LVN B stated a physician's order was needed for oxygen to be administered to a resident. She stated she would change the oxygen tubing as needed when the oxygen tubing was visibly soiled and that she checked the oxygen concentrator / tubing once a shift. During an interview on 02/27/2024 at 10:47 a.m., the DON stated if oxygen was used, there was to be a physician's order obtained. The DON stated there should not be an oxygen tank or concentrator in a resident's room if they did not use oxygen. She stated she expected the charge nurses to assess the oxygen tubing and concentrator once a day to make sure they are all functioning well. She stated oxygen tubing was replaced as needed when visibly soiled per facility policy. The DON stated if a resident used humidified oxygen, the humidifier canister should be replaced weekly and dated when replaced. She stated when a resident was on hospice services, the nursing facility staff were responsible to make sure oxygen tubing was replaced when needed. She stated she did not know why the oxygen concentrator and nebulizer were not monitored by the charge nurse daily. During an observation and interview on 02/27/2024 at 10:55 a.m., Resident #5 had the oxygen concentrator in her room that was turned on. The humidifier canister was not connected to the concentrator and no bubbles were observed in the humidifier canister. The end of the humidifier canister's tube had an electric prong inserted into the end that should have been attached to the concentrator. The humidifier canister was not dated when it was last replaced. The nebulizer mask was lying on the floor without a date on it and not covered. The DON stated she expected the charge nurses to monitor oxygen equipment and replace tubing when appropriate. She stated not monitoring that oxygen equipment was set up correctly could cause the resident to sustain harm from attempting to use oxygen that was not set up properly and could cause infection when the tubing and nebulizer mask were not changed appropriately. She stated that she was responsible to monitor that charge nurses were monitoring oxygen and nebulizer equipment and tubing. Review of facility policy titled oxygen administration dated February 13, 2007, revealed: Assemble the concentrator .Fill the humidifier container to the marked level with distilled water. Turn on the flow and set the desired rate. Note that the water in the humidifier is bubbling and hold hand near the device to feel the flow .Place nasal cannula, usually used for flow rate under 6L/min, in the nares with the prongs straight or curving downward and around the ear and under the chin .Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. Review of facility policy titled breathing therapy devices dated February 13, 2007, revealed: Attach the oxygen delivery equipment to the bubble diffusion humidifier and turn the oxygen gauge to the ordered rate. Note the bubbles in the water when the oxygen is turned on and flowing. 455570 Page 6 of 7 455570 02/27/2024 Mineral Wells Nursing & Rehabilitation 316 SW 25th Ave Mineral Wells, TX 76067

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure 5 pies were covered when being stored in the refrigerator. This failure could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 02/25/2024 between at 8:30 AM to 9:00 a.m. of the kitchen's refrigerator revealed: Two metal trays with 5 pies sitting on them uncovered surrounded by food. Above the uncovered pies were boxes and plastic containers with liquid food. Three kitchen staff were present in the kitchen that did not include the DM. During an interview on 02/25/2024 at 8:43 a.m., the DA stated she was unsure if pies stored in the refrigerator needed to be covered. She stated that the pies had been cooked and placed in the refrigerator on the night of 02/24/2024. During an interview on 02/26/2024 at 10:10 a.m., the DM stated she did not see a failure from pies being uncovered in the refrigerator. She stated the pies had been cooked on 02/25/2024 and that they were stored in the refrigerator to cool down. She stated she believed that the pies had only been in the refrigerator for several minutes. She stated the facility used the FDA Food Code 2022 for cooling methods. She denied any negative effect that pies being in refrigerator uncovered could have on residents. She stated since the foods over the pies and foods that surrounded the pies in the refrigerator were covered and there was no observable condensation then cross contamination could not occur. She stated that she was responsible for monitoring kitchen staff stored foods properly. During an interview on 02/27/2024 at 3:00 p.m., the ADMIN stated his expectation would be for kitchen staff to follow the facility's policy. He stated that the policy stated open packages of food should be stored in closed containers with covers or in sealed bags. He stated improper training and understanding of facility's policy and expectations led to the failure. The ADMN stated DM was to monitor dietary staff are storing food appropriately and that he was responsible for monitoring the DM. He stated the effect of storing food uncovered could lead to food borne illnesses in the residents. Record review of facility's policy titled, Food Storage and Supplies dated 2012 revealed: Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. 455570 Page 7 of 7