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 residents receive treatment and care in
accordance with professional standards of practice and the comprehensive person-centered care plan for 1
of 2 residents reviewed for quality of care (Resident #1).
Residents Affected - Few
The facility failed to ensure the nurses initialed and dated wound dressings when wound care was
performed on Resident #1.
This failure could result in residents with wounds of not having their treatments performed as ordered,
wounds becoming infected wounds, and decreased wound healing.
Findings include:
Record review of face sheet dated 5/29/24 indicated Resident #1 was a [AGE] year-old female admitted
initially to the facility on 5/4/17 and re-admitted on [DATE] with diagnoses including TYPE 1 Diabetes (an
autoimmune disease that originates when cells that make insulin are destroyed by the immune system),
TYPE 2 Diabetes (high blood sugar, insulin resistance, and lack relative lack of insulin), Anemia (blood
disorder in which the blood has reduced ability to carry oxygen), protein-calorie malnutrition (lack of energy
due to the deficiency of all the macronutrients and many micronutrients), Hyperlipidemia (high levels of any
or all lipids in the blood), Hypokalemia (low level of potassium in the blood serum), Cerebrovascular
disease (arteries supplying oxygen to the brain are damaged).
Record review of the physician orders dated 5/29/24 indicated Resident #1 had an order to cleanse right
great toe with normal saline, pat dry, apply layer of hydrogel to wound bed followed by collagen sheet cut to
fit wound bed. Cover with calcium alginate cut to fit wound bed, cover with non-adherent dressing, and
secure with tape. Frequency: every day.
Record review of the MDS dated [DATE] indicated Resident #1 had a BIMS of 8 and was moderately
cognitive impaired.
Record review of the care plan revised 5/13/24 indicated Resident #1 had a diabetic foot ulcer of the left
great toe related to poor circulation with interventions including wound care as ordered.
Record review of the TAR dated 5/24/24 through 5/28/24 indicated Resident #1 wound care treatment to
the right great toe was being performed daily by facility.
Interview on 5/29/24 at 1:35 am Resident #1 stated she received wound care daily and did not have any
pain while care was being performed.
(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 2
Event ID:
455611
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
455611
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Grace Care Center of Olney
1402 W Elm
Olney, TX 76374
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an observation and interview on 5/29/24 at 1:40pm, LVN A performed wound care on Resident #1.
The wound dressing on the right great toe was not dated or initialed. LVN A stated she performed wound
care yesterday and forgot to date and initial. LVN A removed the dressing and performed wound care
following physician orders. LVN A stated the importance of performing wound care daily as ordered was
because Resident #1's wound had been infected and would easily become infected again especially with
her diagnoses of diabetes. LVN A stated it is important to date and initial wound care bandage because, if
different nurses were working the hall, or the nurse was not going to be there the next day the dressing
should be initialed and dated to show wound care has been performed.
During an interview on 5/30/24 at 3:40 p.m. the DON stated she expected staff to date and initial wound
dressings. The DON stated dating and initialing wound dressing verified the wound care was performed.
The DON stated she expected staff to sign off on the TAR when wound care was completed. The DON
stated if the TAR was not signed off and bandage was not dated and initialed there was no way to prove
wound care had been performed as ordered.
Record review of the facility's undated Dressing Change Procedure indicated Document date, time dressing
changed, and initials on a piece of tape and place on dressing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455611
If continuation sheet
Page 2 of 2
