Health inspection·November 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 observation, interview, and record reviews the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 6 residents (Resident #43, Resident #45, and Resident #7) reviewed for pressure ulcers. Residents Affected - Some The facility failed to provide daily wound care for Resident #43 on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24, resulting in worsening of his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers. The facility failed to receive Resident #43's biopsy/culture results for his R heel that was performed 9/30/24, until 10/24/24. The facility failed to start Resident 43's antibiotic for MRSA and osteomyelitis (bone infection) to his R heel until 10/31/24, when results were received on 10/24/24. The facility failed to have the Wound Care MD see Resident #43 after 10/7/24 due to not having staff to assist him. The facility failed to measure Resident #43's wounds throughout October 2024. The facility failed to prevent a Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer to Resident #45's toe while at the Page 1 of 11 455725 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 facility between 9/9/24 and 10/1/24. Level of Harm - Immediate jeopardy to resident health or safety The facility failed to provide daily wound care to Resident #45's R middle toe on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24. Residents Affected - Some The facility failed to provide daily wound care to Resident #7's Left Lateral Forefoot and Left Sacrum on 10/1/24, 10/6/24, 10/11/24, 10/12/24, 10/13/24, 10/17/24, 10/24/24, 10/27/24, 10/28/24, and 10/29/24, which resulted in worsening of the Sacrum pressure ulcer. An Immediate Jeopardy (IJ) was identified on 10/31/2024. The IJ Template was provided to the facility on [DATE] at 4:15pm. While the IJ was removed on 11/2/2024, the facility remained out of compliance at a level of more than minimal harm and a severity of no actual harm with potential for more than minimal harm that not Immediate Jeopardy and a scope of pattern due to the need for implementation of corrective measures and the effectiveness of its corrective plan. Findings included: 1.Record review of Resident #43's undated face sheet revealed he was a [AGE] year-old male admitted originally on 3/3/22, with the most recent admission being 8/30/23. His diagnoses included pressure ulcer of the sacrum (buttocks), type 2 diabetes (body does not produce insulin or is resistant to it), quadriplegia (complete or severe loss of motor function in all four limbs), muscle spasms (involuntary muscle contractions), muscle wasting and atrophy (muscle shrinkage/contraction due to not using), and neuromuscular dysfunction of the bladder (bladder does not work due to nerve issues). Record review of Resident #43's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. He had impairment on both sides of his upper and lower extremities and used an electric wheelchair. The resident was dependent with all ADLs and had a suprapubic catheter (a hole from the bladder through the abdomen to the outside to drain urine) and a colostomy (a hole through the abdomen from the colon to the outside to drain stool). The MDS revealed Resident #43 had 5 Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it ) pressure ulcers, and only 1 was present on admission. Record review of Resident #43's care plan dated 3/10/22 revealed a Focus: The resident has pressure ulcers: L heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) Reopened, R heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R lower leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R ischium (R side of buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), L ischium (L side of buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R lateral leg Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) Resident refuses visits from wound care doctor and refuses treatments frequently. (Initiated: 8/10/24, Revised: 10/29/24) Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 3/30/22, Revised: 9/29/22, Target: 11/26/24). Interventions: Assess/record/monitor wound healing at lease weekly. Measure length, width and depth. Obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated. Refer to wound care MD. Turn/reposition every 2 hours. Focus: Resident is on antibiotic 455725 Page 2 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some therapy r/t diagnosis of osteomyelitis (Initiated: 11/12/23, Revised: 10/31/24). Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date (Initiated: 11/12/23, Revised: 2/5/24, Target: 11/26/24). Interventions: Administer medication as ordered. Report pertinent lab results to MD. Focus: The resident has IV access (Initiated: 10/31/24). The resident will not have any complications related to IV therapy through the review date (Initiated: 10/31/24, Target: 11/26/24). Interventions: Administer IV medications as ordered. The resident has PICC line IV access to right upper arm. Record review of Resident #43's Physician Orders revealed the following orders from MD A: Calcium Alginate-Silver External Pad 2, Cleanse wound to R Heel with wound cleanser/ns, pat dry, apply calcium alginate w/ silver and santyl (wound care medications), cover with dry dressing. Every day for wound care. Ordered on 6/3/24. Calcium Alginate, Cleanse wound to R Posterior leg with wound cleanser/ns, pat dry, apply calcium alginate and santyl, cover with dry dressing. Every day for wound care. Ordered on 6/17/24. Calcium Alginate-Silver External Pad 2'x2', Cleanse wound to R Heel with wound cleanser/ns, pat dry, apply calcium alginate w/ silver (wound care medications), and cover with dry dressing. Every day for wound care. Ordered on 8/19/24. Cleanse wound to L Ischium with wound cleanser/ns, pat dry, apply Dakins 125% (wound care medication) and cover with dry dressing. Every day for wound care. Ordered on 10/9/24. Cleanse wound to R Ischium with wound cleanser/ns, pat dry, apply Dakins 125% (wound care medication) and cover with dry dressing. Every day for wound care. Ordered on 10/9/24. 455725 Page 3 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Santyl External Ointment 250U/gm (Collagenase) (wound care medication), Apply to R Heel/Lateral Leg, Every day for wound care. Ordered on 10/9/24. No orders for any antibiotics were found for his MRSA/osteomyelitis. Residents Affected - Some Record review of Resident #43's Wound Care Note dated 9/30/24, revealed a L Ischium (L side buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer that was 5.6cm x 1.9cm x 0.1cm, a R Ischium (R side buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer that was 3.5cm x 3.9cm x 0.1cm, L Heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.2cm x 1.2cm x 0.1cm, R Heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 6.1cm x 5.2cm x 0.4cm, and a R Lateral Lower Leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 2.8cm x 1.9cm x 0.1cm. Debridement (removal of dead tissue) was performed on the L Ischium (L buttock), R Ischium (R buttock), R Heel, and a biopsy (tissue sent to the lab) was taken from the R Heel d/t suspicion of osteomyelitis (bone infection). Wound orders were entered for daily wound care. Record review of Resident #43's October 2024 MAR-TAR revealed blank spots where wound care was not provided to his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers, for the following dates: 10/1/24, 10/6/24, 10/12/24, 10/13/24, and 10/26/24. Record review of Resident #43's Wound Care Note dated 10/7/24, revealed a L Ischium (L buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 5.6cm x 2cm x 0.1cm, a R Ischium (R buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 3.7cm x 3cm x 0.1cm, a L Heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.2cm x 2.2cm x 0.1cm, a R Heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 5.3cm x 3.9cm x 0.2cm, a R Lateral Lower Leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 2.6cm x 1.5cm x 0.1cm, and a new R Proximal Lateral Lower Leg Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 4.5cm x 1.6cm x 0.1cm. Debridement (removal of dead tissue) was performed on the R Heel and the R Proximal Lateral Lower leg. Record review of Resident #43's medical record, revealed a final report from [lab] dated 10/9/24 was faxed from the Wound Care MD's office to the nursing facility on 10/10/24, with results of acute osteomyelitis (bone infection) that was found during the biopsy (tissue removal sent to lab) on 9/30/24. Record review of Resident #43's Weekly Ulcer Assessments for 10/14/24 and 10/28/24, were the same as the last measurements from the Wound Care MD on 10/7/24. Record review of Resident #43's medical record, revealed culture results from [lab] dated 10/24/24 was faxed from the Wound Care MD's office to the nursing facility on 10/24/24, with results of high amounts of MRSA (a drug resistant bacteria) and multiple other bacteria that was found during the culture on 9/30/24. 455725 Page 4 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In an interview and observation with Resident #43 on 10/29/24 at 11:15am, the resident was observed laying on his back receiving wound care by the floor nurse, directed by the ADON. The resident said the facility no longer had a Wound Care Nurse, so the floor nurses had to perform wound care and they did not come every day. He said they were only doing it because State was there and the last time he had received wound care was on 10/27/24. In an interview with Resident #43 on 10/30/24 at 12:15pm, he said the Wound Care MD would not see him because the facility did not have a Wound Care Nurse to help him. He said the Wound Care MD wanted someone to help him position and take orders and the floor nurses were too busy to come help, so the doctor did not have time to wait around and would not see him. The resident also said the staff would get him into his chair and then want him to get back to bed for wound care and then get back into his chair and that was too much work, so a couple times he refused. He said he felt like they would wait for him to get in his chair on purpose so they could offer it then and they know he would refuse. Resident #43 stated he felt like his pressure ulcers had worsened since the Wound Care MD had not seen him since 10/7/24. In an interview with a family member of Resident #43 on 10/30/24 at 1:45pm, who said the facility had a big problem with performing wound care daily since they did not have a wound care nurse. She said Resident #43 may have refused a few times, but he did not refuse often because he has become septic in the past and knew how important wound care was. She said the problem was staff would get him into his chair and then wanted him to get back into bed for wound care, and then get back into his chair. She said that was a lot of work for him and he would not want to do it. She said she did not understand why they would not do his wound care first and then put him in his chair. In an interview with the Wound Care MD on 10/30/24 at 1:48pm, he said he came every Monday to see residents. He said Resident #43 was complex, had a lot of wounds, and needed help getting ready before he arrived. He said he would call the facility and give them an hour notice before he arrived, but the resident still would not be ready when he arrived, and he would not have time to sit around and wait when he had other residents to get to. He said it was hard for nursing staff to keep up with wound care when there was not a dedicated wound care nurse, so it frequently did not get done or fell through the cracks. He said they had not had a wound care nurse in about a month. The Wound Care MD said he received the labs, he thought on 10/24/24 but was not sure when, and the resident had osteomyelitis before. He said he talked to NP B on Monday (10/28/24) and told her to order the antibiotics for the resident. He said he wanted to make sure she ordered the antibiotics, and they did not get missed. In an interview with NP B on 10/30/24 at 2:40pm, she said the Wound Care MD called her to inform her Resident #43 would be on Cipro/Vancomycin (antibiotics for wound infection) but did not tell her to order them. She said the Wound Care MD would inform the nurse at the facility and they would enter the orders. She said she did not enter orders for the Wound Care MD. She said she saw labs come in for the resident but if the Wound Care MD ordered them, he would be responsible for following up on them. In an interview with the DON on 10/30/24 at 3:05pm, she said she was kind of familiar with Resident #43's wounds. She was not sure if the wounds were getting better or worse. She said the floor nurse was the one responsible for measuring the wounds. She said [username] was her and that was who logged all the measurements of Resident #43's wounds for October 2024, so she must have performed the measurements. She said she thought the wounds had not changed. She did not know if the resident had had any labs/biopsies (tissue removal and sent to lab) on any of his wounds. The DON said the Wound 455725 Page 5 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Care MD did not give any orders to NP B because she did not work for him. She said the Wound Care MD would tell a nurse at the facility and they would enter the orders, or he would slide the orders under her door, and she would enter them. She said she did not know anything about the antibiotic orders for Resident #43 and she was going to go call the Wound Care MD. In an interview and observation of Resident #43 on 10/30/24 at 4:00pm, he said the DON never measured his wounds and that he had never even seen her face before. Measurements were performed with the DON and the Clinical Resource Nurse and were as follows: L Heel: 3.5 x 2.5 = 8.89cm x 6.35cm R Heel: 6.5 x 5 = 16.51cm x 12.7cm R Distal Leg: 2.5 x 1 = 6.35cm x 2.54 R Proximal Leg: 6 x 1 = 15.24cm x 2.54cm In an observation of Resident #43 on 10/31/24 at 10:00am with the ADON, DON, and the Clinical Resource Nurse the resident's L Ischium (L buttock) and R Ischium (R buttock) were measured as follows: L Ischium (L buttock): 6.5 x 2.5 x .1 = 16.51cm x 6.35cm R Ischium (R buttock): 6 x 3 x .2. = 15.24cm x 7.62cm There was also new maceration (skin breakdown due to moisture) to both sides. The resident was observed with a right upper arm PICC line. In an interview with the DON on 10/31/24 at 10:40am, she said she copied the last measurements the Wound Care MD entered on 10/7/24 and entered those measurements throughout October, because she did not want to enter the wrong information or the wrong staging. She said the wound care nurse left about 3 weeks ago and then before that they had another wound care nurse that was there that left. She said she expected her floor nurses to provide wound care but not touch anything having to do with measurements. She said she would know if the wounds got worse without measuring by noting the smell, drainage, and pain. In an interview with RN C on 10/31/24 at 12:51pm, she said she did not know of any labs/biopsies (tissue removed and sent to lab) that Resident #43 had to his wounds. She looked in his chart and said she did not see anything. She said when cultures/biopsies (tissue removed and sent to lab) are done, they put it on the 24hr report so they can keep track of it. She said the other nurses did not have enough time to perform wound care and that they really need a wound care nurse, but she makes time. She said Resident #43's wound care was mainly done at night, and she did not know of him refusing, maybe once or twice. In an interview with the ADON on 10/31/24 at 1:00pm, she said she did not know anything about the culture/biopsy (tissue removed and sent to lab) results for Resident #43 until the results were recently brought to her attention. She said the Wound Care MD did not communicate well and only communicated with the wound care nurse when they had one. If they did not have a wound care nurse, he kept to himself. She was not sure how it was ordered because there were no orders in the system. She said the results were always sent to the Wound Care MD's office and then they would fax them to the 455725 Page 6 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 nursing facility. Level of Harm - Immediate jeopardy to resident health or safety In an interview with the Administrator on 10/31/24 at 1:40pm, she said the ADON, and the floor nurses were assigned to handle the wound care treatment for the residents since they no longer had a wound care nurse. She said the floor nurses were aware they would be providing treatment and if they were not able to round with the Wound Care MD, then the ADON was responsible for rounding and entering orders. She said the ADON, and the DON were responsible for following up on the orders. The Administrator said when the last wound care nurse left there were no loose ends, or anything left outstanding that she was aware of. She said only the Wound Care MD measures the wounds and then the nurse enters the measurements in the system. She said if the Wound Care MD had not seen the resident in a while, like Resident #43, then the DON/ADON should have seen the resident and taken measurements. Residents Affected - Some In an interview with the Wound Care MD on 10/31/24 at 3:15pm, he said he did his own biopsies (tissue removed and sent to lab)/cultures and took them to the lab himself. He said he left a copy of his handwritten notes and a copy of the order at the facility. He said he usually gave it to the wound care nurse but if the wound care nurse was not there, he would give it to the floor nurse. If the floor nurse was not available or he could not find anyone, then he would give it to the DON or slide it under her door. He said he gave it to a floor nurse, but he did not remember who it was. He said the results were faxed to the facility. He said he got a biopsy/culture because the wound was deteriorating, and it appeared to look like it had osteomyelitis. 2.Record review of Resident #45's undated face sheet revealed he was a [AGE] year-old male originally admitted on [DATE], with the most recent admission on [DATE]. He had diagnoses of unspecified dementia (decline in cognitive abilities, such as thinking, remembering, and reasoning), pressure induced deep tissue damage of left heel (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces), protein calorie malnutrition (reduced availability of nutrients leads to changes in body), contractures of right and left knees (inelastic fiber-like tissue in the knees preventing normal movement), muscle wasting and atrophy (thinning of your muscle mass), dehydration, type 2 diabetes (body does not produce insulin or resists it), and iron deficiency anemia (body is not producing enough iron). Record review of Resident #45's Annual MDS assessment dated [DATE], revealed a BIMS score was unable to be obtained due to medical issues. The MDS revealed he had severely impaired cognitive skills for daily decision making. He had impairment of both sides of his upper and lower extremities and was dependent with all ADLs. The resident had a nephrostomy (hole into kidney through abdomen to drain urine) and a colostomy (hole from colon through abdomen for stool to collect in bag outside of body). Resident #45 had a Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer that was not present on admission. Record review of Resident #45's care plan dated 4/20/23 revealed a Focus: The resident has a pressure ulcer: R Second toe (Initiated: 4/24/24, Revised: 10/14/24). Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review period (Initiated: 4/24/24, Revised: 4/24/24, Target: 11/17/24). Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing at least weekly. Measure length, width, and depth. Turn every 2 hours. Record review of Resident #45's Physician Orders from MD A revealed the following orders: 455725 Page 7 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Zinc Oxide External Cream 10%, Cleanse abrasion to left buttock with wound cleanser/ns, pat dry, apply zinc oxide (wound medication). Every shift for wound care. Ordered on 10/27/23. - Residents Affected - Some Cleanse right great toe with normal saline or wound cleanser, pat dry, and apply skin prep, leave open to air. Every day for wound care. Ordered on 9/24/24. Calcium Alginate, Cleanse right second toe with NS/Wound cleanser, pat dry, apply calcium alginate/silver (wound medications), cover with dry dressing. Every day for wound care. Ordered on 9/29/24. Skin Prep Spray, Clean posterior left heel with normal saline, pat dry, apply skin prep daily (wound medication), float heels, leave open to air. Every day for deep tissue injury (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces). Ordered on 11/1/24. Record review of Resident #45's October 2024 MAR-TAR revealed blank spots where wound care was not provided for the following dates: 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24. Record review of Resident #45's Wound Care Note dated 10/7/24, revealed R Medial (middle) Second Toe Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.1cm x 1.5cm x 0.3cm with bone exposed (Wound Care MD should have classified it as a Stage 4 since bone was exposed). Record review of Resident #45's progress note from MD A dated 10/9/24, revealed a note that read 9-9-24: Since last evaluation, chronic medical conditions remain stable .No present wound issues. Staff reinforcement done to promote turning, pressure relief, skin care and safety. Another note read 10-9-24 Since last eval, chronic medical issues have been stable .Has developed wound on right second toe, followed by wound care service . In an observation of Resident #45 on 10/29/24 at 9:16am, he was lying on his left side in bed, without his pressure relieving boots on. In an observation of Resident #45 on 10/30/24 at 9:06am, he was asleep on his left side with his pressure relieving boots on his nightstand. In an observation of Resident #45 on 11/1/24 at 10:30am, he was lying on his left side with hand splints on and his bilateral boots on. 455725 Page 8 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of Resident #45's SBAR dated 11/1/24, revealed he had a skin change which was a deep tissue injury to his left heel (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces). 3. Record review of Resident #7's undated face sheet revealed she was a [AGE] year-old female originally admitted on [DATE], with the most recent admission date of 7/18/24. She had diagnoses of Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills), muscle wasting and atrophy (thinning of your muscle mass), protein calorie malnutrition (reduced availability of nutrients leads to changes in body), dementia (decline in cognitive abilities, such as thinking, remembering, and reasoning), and cerebral infarction (stroke). Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed a BIMS score was unable to be performed due to medical concerns. She had impairment on both sides of her lower extremities and was bedbound. She was dependent with all ADLs and was always incontinent of bowel and bladder. The MDS revealed she had 2 Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcers that she was not admitted with. Record review of Resident #7's care plan dated 1/31/20, revealed a Focus: The resident has a pressure ulcer to L Lateral (outside) foot, L Sacrum (buttock) (Initiated: 3/6/24, Revised: 10/14/24). Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 3/6/24, Revised: 4/4/24, Target: 12/30/24). Interventions: Administer medications and treatments as ordered. Assess/record/monitor wound healing at lease weekly. Measure length, width, and depth. Enforce turning/repositioning. Record review of Resident #7's Physician Orders revealed the following orders from MD A: Zinc Oxide External Paste (wound medication), apply to sacrum (buttocks) two times a day. Ordered on 7/18/24. Zinc Oxide External Cream 10%, cleanse sacrum (buttocks) with wound cleanser/ns, pat dry, apply zinc oxide (wound medication), every shift. Ordered on 7/22/24. Skin Prep Wipes, apply to right lateral (outside) ankle every day for wound care. Ordered on 7/29/24. Betadine External Solution, apply to left plantar (bottom) foot every day for wound care. Ordered on 8/26/24. 455725 Page 9 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Cleanse left lateral (outside) foot with normal saline or skin cleanser, apply medi-honey and calcium alginate (wound medications), cover with dry dressing, daily and PRN. Every day for wound care. Ordered on 10/4/24. - Residents Affected - Some Calcium Alginate Powder, cleanse sacrum (buttocks) with normal saline, pat dry, apply calcium alginate (wound medication), cover with dry dressing. Every day for wound care. Ordered on 10/4/24. Cleanse sacrum (buttocks) with normal saline or skin cleanser, pat dry and apply calcium alginate (wound medication), cover with dry dressing, daily and PRN. Every day for wound care. Ordered on 10/8/24. Record review of resident #7's Wound Care MD Note from 9/30/24, revealed a Left Lateral Forefoot (outside front part of foot) arterial ulcer (due to bad circulation) 2.5cm x 1.2cm x 0.3cm, and a Left Sacrum Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.7cm x 1.5cm x 0.1cm. Record review of Resident #7's October 2024 MAR-TAR revealed blank spots where wound care was not provided for the following dates: 10/1/24, 10/6/24, 10/11/24, 10/12/24, 10/13/24, 10/17/24, 10/24/24, 10/27/24, 10/28/24, and 10/29/24. Record review of Resident #7's Weekly Ulcer Assessment performed by the Clinical Resource Nurse on 10/30/24, revealed measurements for the sacrum (buttocks) 9.5cm x 6cm. In an observation of Resident #7 on 10/29/24 at 10:02am, she was asleep on her left side in bed. In an interview with Resident #7's family member on 10/29/24 at 1:48pm, she said she would like to see the resident up in her wheelchair at least once a month. She said the facility never got Resident #7out of bed and into her wheelchair and she laid in bed every day. She said she spoke to the Administrator and DON about it, but still nothing changed. In an observation of Resident #7 on 11/1/24 at 10:35am, she was asleep on her left side in bed. Record review of the facility's policy and procedure on Pressure Injury: Prevention, Assessment and Treatment (Revised 8/12/16) read in part: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone [color], turgor [elasticity of skin] and circulation to prevent breakdown, injury and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems. 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the 455725 Page 10 of 11 455725 11/02/2024 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some physician. 2. Notify family and dietary department. Document Notification . Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 2. Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV). 11. Director of Nursing or designee to inservice nurses and CNA's on above prevention. 2. Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages. Staging definitions are per the guidelines of the National Pressure injury Advisory Panel February 2016 definitions .7. Nursing Care Plan. 1. Identify the problem of pressure injuries on the Nursing Care Plan 2. Under Nursing Intervention, list physician ordered treatments .Assessment of the pressure injury should also include the site, size, and W x L x D, of the injury. Surrounding tissue, color, exudate [drainage], wound edges, sinus tracts [narrow abnormal channel that co[TRUNCATED] 455725 Page 11 of 11