Health inspection·August 10, 2024

F 0583 Keep residents' personal and medical records private and confidential. 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 protect the personal privacy rights of the resident during medical treatment for 1 (Resident #1) of 6 residents observed for dignity. Residents Affected - Few The facility failed to ensure ADON A provided Resident #1 with privacy during wound care on 08/09/24. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: Record review of Resident #1's face sheet, printed on 08/10/24, reflected an [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of Encephalopathy (an alteration in consciousness caused due to brain dysfunction), Pressure ulcer of right heel(area of damaged skin and tissue caused by sustained pressure that reduces blood flow), Type 2 diabetes mellitus (high blood glucose), Peripheral vascular disease (a systemic disorder that occurs when blood vessels outside of the brain or heart become narrowed, blocked, or spasmed, reducing blood circulation to a body part), and End stage renal disease ( the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). Record review of Resident #1's admission MDS, dated [DATE], reflected Resident #1 had a BIMS score of 08, which indicated a moderate cognitive impairment. Section GG - Functional Abilities and Goals indicated Resident #1 substantial or maximum assistance in ADLs of dressing, toileting, and bathing. Record review of Resident #1's care plan, revised on 07/16/24, reflected the following: I HAVE AN UNSTAGEABLE WOUND ON MY RIGHT HEEL 4/25/2024: UNSTAGEABLE TO RIGHT HEEL IS NOW A STAGE 4, with interventions to include, WOUND TREATMENT CHANGED: CLEANSE AREA WITH NS/WOUND CLEANSER, PAT DRY, APPLY BETADINE AND WRAP WITH KERLIX QD. In an observation on 08/09/24 at 8:39 a.m. reflected ADON A gathered needed supplies, entered Resident #1's room. ADON A pulled the treatment cart in the door of Resident #1's room, performed hand hygiene and provided wound care to Resident #1 heel. The door and the curtain were not closed during wound care. 4 staff members, 3 residents and 3 visitors passed Resident #1's door, as he received wound care. Page 1 of 8 455748 455748 08/10/2024 Ashford Hall 2021 Shoaf Dr Irving, TX 75061

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 08/09/24 at 9:00 a.m., ADON A stated she should have closed the door or pulled the curtain to provide Resident #1 with privacy during care. ADON A stated she normally would close the door and she could not say why she had not. ADON A stated providing care without privacy could embarrass the resident which was a dignity issue and could expose health issues to passersby. In an interview on 08/09/24 at 9:05 a.m., Resident #1 stated he was well. Resident #1 stated the door was sometimes left open when the nurse came to help him with his foot. Resident #1 stated he did not care if the door was closed during his wound care, as long as they checked his foot when that were supposed to. In an interview on 08/09/24 at 12:23 p.m., the IDON stated the ADON A had notified her of the wound care observation, prior to the interview with the surveyor. The IDON stated staff are expected to provide all residents with privacy while they provide care. The IDON stated not doing so could expose the resident. The IDON stated she will start an in-service with all nursing staff, regarding dignity, to ensure privacy was provided in the future. In an interview on 08/09/24 at 12:39 p.m., ADMIN stated all residents should be provided with privacy when they receive care. The ADMIN stated the blinds should be closed, door closed, and the privacy curtain should be pulled if a resident roommate were in the room as well, as not doing so would violate the residents right. The ADMIN stated an in-service n privacy and resident rights was started and facility leadership will monitor the halls to ensure privacy was provided during care. Record review of the facility's policy entitled Dignity, revised February of 2021, read in part: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . 455748 Page 2 of 8 455748 08/10/2024 Ashford Hall 2021 Shoaf Dr Irving, TX 75061

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #2) of 6 residents reviewed for quality of care. Residents Affected - Some The facility failed to identify and treat a wound to Resident #2's left great toe, prior to his visit to a local hospital on [DATE], where Resident #2 was found to have wound to his left great toe with osteomyelitis . Resident #2's left great toe was amputated on 06/18/24. An Immediate Jeopardy (IJ) situation was identified on 08/09/24. While the IJ was removed on 08/10/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. This failure could place residents at risk for delay in needed treatment and diminished quality of care. The findings included: Record review of Resident #2's face sheet, printed on 08/10/24, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (conditions that affect blood flow to the brain), Partial traumatic amputation of left great toe, Osteomyelitis (bone infection), End stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), Essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause), and Type 2 diabetes mellitus(high blood glucose). Record review of Resident #2's quarterly MDS assessment, dated 05/24/24 reflected Resident #2 had a BIMS score of 03, which indicated a severe cognitive impairment. Section GG - Functional Abilities and Goals of the assessment indicated Resident #2 required substantial or maximal assistance with ADLs of Toileting, personal hygiene, bathing, and lower body dressing. Record review of Resident #2's care plan, dated 05/31/24, reflected the following: - Problem start date: 03/05/24 - I am a diabetic and is at risk for complications from disease process., with approaches to include Approach Start Date: 03/05/2024 - MONITOR SKIN FOR CHANGES--REDNESS, CIRCULATORY PROBLEMS, BREAKDOWN, REPORT TO M.D., R.P. and Approach Start Date: 03/05/2024 WEEKLY SKIN ASSESSMENTS. Record review of the progress notes tab of Resident #2's electronic health record reflected the following notes: - Documented by RN B on 06/13/24 at 2:55 p.m., Resident went to the dialysis, dialysis nurse called to me said he has a pus like drainage from the cvc catheter and he is confusion little bit he need to go to hospital for checkup, talked to the NP, AND DON, and try to make him ready, he said after lunch, and he refuse again, give handover to the incoming nurse . continue on plan of care. - Documented by RN B on 06/13/24 at 3:18 p.m., Resident went hospital with facility transport at 455748 Page 3 of 8 455748 08/10/2024 Ashford Hall 2021 Shoaf Dr Irving, TX 75061

F 0684 3pm. Level of Harm - Immediate jeopardy to resident health or safety - Documented by LVN C on 06/22/24 at 7:25 p.m., Resident was readmitted to [facility] at around [5:30 p.m.] from [hospital]. Patient was brought in via stretcher and placed in room [number]. Resident is alert and verbally responsive to care. Respirations are even and unlabored. No SOB noted or s/sx of respiratory distress. Vitals are stable. BP:121/67, 83, Residents Affected - Some 97.5, o2 sat 98% @ RA. Afebrile. Resident will continue to be under the care of [PCP]. All orders clarified with [PCP]. Covid test done, negative results. Current weight is 75.7 kg and height 170.2 cm. Upon head-to-toe assessment, this nurse noted patient to have a laceration on his right groin. Scabs on left knee and left thigh. Discoloration on left thigh was noted as well. A pustule noted on on left lateral thigh. Bruising on left elbow and low abdomen. Black hard tissue on right ankle was also noted. Upon report via telephone per [hospital RN], she stated that doctor from [hospital] ordered to not remove dressing on left great toe until 6/28/24 due to his amputation . Record review of the Plan of Care History, Skin tab of Resident #2's electronic health record, dated 06/01/24 through 06/13/24 and documented by CNAs C, D, E, F, G, and H reflected Resident #2's skin was clear and free of any skin problems. Record review of Resident #2's skin assessment documentation, documented by RN I on 05/27/24 at 11:39 a.m., on 06/03/24 at 12:15 p.m., and on 6/11/24 at 1:39 p.m., reflected Resident #2's skin was warm, dry, normal in color and no alteration to the skin was observed. Record review of Resident #2's local hospital records, service date of 06/13/24 reflected the following: Documented by hospitalist on 06/13/24 at 7:23 p.m., Assessment & Plan . Leukocytosis, Left great toe wound POA . Will do Xray, wound cultures, wound care consulted; Wound Evaluation Note documented by hospital physician on 06/14/24 at 8:11a.m., 06/14 Evaluation and Assessment: Pt presents with a chronic necrotic ulcer present at the tip of the L great toe wound. Wound initially covered with lifting dry necrotic tissue. Performed selective sharp excisional debridement with scissors to remove lifted non adherent necrotic tissue to level of necrotic tissue. After initial debridement, bone became palpable differed any further debridement. After sharp debridement, the wound measures 1.5cmx3.0cm with unknown depth. Toe nail is separating from the nail 455748 Page 4 of 8 455748 08/10/2024 Ashford Hall 2021 Shoaf Dr Irving, TX 75061

F 0684 bed as well. With palpation of the wound and surrounding area able to express thick purulent drainage as Level of Harm - Immediate jeopardy to resident health or safety well as mild foul odor present. Peri wound is dry and slightly dusky. Tissue composition is dark purple with Residents Affected - Some Treatment: Wound cleansed with normal saline, patted dry with sterile gauze. Applied xeroform double layer yellow necrotic tissue, overall viability of wound is questionable. to the wound bed to assist with maintaining appropriate level of moisture and antimicrobial properties. Covered with dry gauze and secured with tape. Provided education about wound clinical presentation and plan of care while patient is admitted . Continued skilled PT wound care services are indicated for dressing changes, selective debridement as needed, management of drainage/edema, patient education and to assess progression of advanced wound products. Messaged attending MD due to clinical presentation of purulence, bone palpable and necrotic tissue present. At time of documentation, Xray suggestive of OM. MRI and podiatry consult pending. PT wound to continue monitor plan of care and assist with dressing management as appropriate. Documented by hospitalist on 06/21/24 at 12:05 p.m., Assessment & Plan: Acute Problems: . Acute osteomyelitis of left foot . Resolved problems: *no resolved hospital problems. * Leukocytosis: Left great toe wound POA . Xray/MRI foot positive for great tie osteomyelitis . angiogram followed by left great toe amputation by podiatry on 06/18. Follow biopsy results for final determination for antibiotics. Podiatry recommends dressings to stay intact till next evaluation in 1 week to 10 days. In a telephone interview on 08/08/24 at 12:37 p.m., Resident #2's primary care physician stated he became Resident #2's facility physician on 07/02/24, which was after the amputation of his toe. The physician stated he ordered an arterial of the lower extremities on 08/02/24 and found ischemia and Peripheral Vascular Disease, which affected the blood circulation to Resident #2's foot. The physician stated without proper circulation and oxygen to the area, the wound would never heal. The physician stated he was not aware of any change of condition or skin issues prior to Resident #2's amputation, but he would have to double check the records provided to him by Resident #2's previous physician. In an interview on 08/08/24 at 2:01 p.m. with WCN J and the IDON when WCN J stated she was the facility's wound care nurse since February of 2024. WCN J stated Resident #2 had two amputations after 455748 Page 5 of 8 455748 08/10/2024 Ashford Hall 2021 Shoaf Dr Irving, TX 75061

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some being sent to a local hospital in June and July. WCN J stated After Resident #2's amputation of his left great toe, he had to be sent to the hospital because his surgical wound had dehisced (a surgical complication that occurs when a wound incision reopens after being stitched or stapled closed) after the sutures were removed. WCN J stated Resident #2 returned to the facility on or around 7/30/24 with the remainder of his toes amputated. WCN J stated the resident returned to the facility with what appeared to be necrotic tissue around the wound. She stated the wound was monitored, per physician orders and the resident was sent back to the hospital on [DATE], when the surgical wound declined. WCN J stated she was not aware of any skin integrity issues or wounds to Resident #2 left great toe prior to his amputations. In an interview on 08/08/24 at 4:02 p.m., Resident #2 stated he was well, but he did not want to go back to the facility. Resident #2 stated he had a wound on his toe before it was amputation and that he had told facility staff about his toe, but he could not recall how long the wound was there or who he reported his toe to. Resident #2 was unable to verbalize what happened to his foot. Resident #2 was seen and interviewed in his room at a local hospital. Telephone interviews were attempted on 08/09/24 from 9:12 a.m. through 9:22 a.m., with Resident #2's podiatrist, previous primary care physician, and wound care physician but were unsuccessful. In a telephone interview on 08/09/24 at 9:50 a.m., CNA G stated she was Resident #2's aide prior to the amputation of his toe. CNA G stated she checked Resident #2 every two hours and provided care as needed. CNA G stated she could not recall ever noticing a wound or skin issue to Resident #2's left toes or foot. CNA G state Resident #2 liked to keep his socks on, so she had never changed his socks and focused more on his brief. A telephone interview was attempted on 08/09/24 at 11:06 a.m. with LVN L, who was Resident #2's weekend nurse prior to the amputation of his toe but was unsuccessful. In a telephone interview on 08/09/24 at 11:20 a.m., RN K stated she was Resident #2's weekend nurse from February 2024 until June 2024. RN K stated she did not recall Resident #2 having a wound or skin integrity issue to his feet and she could not recall an aide reporting an issue to her. RN K stated if a skin integrity issue or wound it report by an aide, nurses were to assess the resident, provide first aide as needed, notify the resident physician and responsible party and carry out any orders provided. RN K stated skin assessments were to be documented as a skin progress note and they are to make a skin event if issues are noted. In an interview on 08/09/24 at 11:36 a.m., CNA C stated she was Resident #2's first shift aide in June 2024. CNA C stated Resident #2 received total care from facility staff. CNA C stated she could not recall if Resident #2 had a wound to his left great toe. CNA C stated if she had saw a wound to his toe, she would have reported to a nurse for evaluation. In an interview on 08/09/24 at 11:54 a.m., CNA E stated he was Resident #2's aide briefly when he first started to work for the facility, which was roughly 2 months ago. CNA E stated he did not recall seeing a wound to Resident #2's toes but would have reported to a charge nurse if he did. Telephone interviews were attempted on 08/09/24 at 11:56 a.m. with RN B and at 11:59 a.m. with RN I, who were Resident #2's first and second shift nurses prior to the amputation of his toe, but attempts were unsuccessful. 455748 Page 6 of 8 455748 08/10/2024 Ashford Hall 2021 Shoaf Dr Irving, TX 75061

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In a telephone interview on 08/09/24 at 12:05 p.m., CNA D stated she was Resident #2's aide prior to his first amputation. CNA D stated Resident #1 was a total assist resident but could transfer himself. CNA D stated she gave the resident bed baths instead of showers and had not observed any skin integrity issues to his toes. In a interview on 08/09/24 at 12:23 p.m., the IDON stated to her knowledge Resident #2 was sent to a local hospital on [DATE], after returning from dialysis with pus like discharge coming from his dialysis port. The IDON stated she believed Resident #2's left great toe was black or something and it was amputated prior to his return to the facility on [DATE]. The IDON stated Resident # 2 had to be sent to the hospital two additional times due to wound complications on 07/15/24 and 08/06/24. The IDON stated she had no knowledge of Resident #2 having skin integrity issues to his left foot. The IDON stated she would have to check Resident #2's records to see if his physician was following Resident #2's foot prior to is amputation. The IDON stated if a skin integrity issue or wound is observed on a resident the aide was expected to report to a nurse. She stated the nurse was expected to assess the resident, report to the resident's physician, responsible parties, facility leadership and to carry out any orders given by the physician. The IDON stated Resident #2 had not reported any issues with his feet to her. In an interview on 08/09/24 at 12:39 p.m., the ADMIN stated she was not aware of a wound to Resident #2's left great toe prior to his hospital visit on 06/13/24. The ADMIN stated she normally communicate with hospital staff to check on the residents and no one let her know Resident #2 arrived at the facility with a wound to his left great toe. The ADMIN stated she spoke with Resident #2's primary care physician who ordered a doppler and confirmed the resident had Peripheral Vascular Disease, which was contributed to the healing process of Resident #2's surgical wounds. The ADMIN stated if a nurse identifies a skin issue they should create and event in the electronic health record, report the issue to the resident's physician and carry out treatment orders until the wound care physician could visit with the resident. The ADMIN stated all residents were to have weekly skin assessments completed and are also completed by aides during showers. The ADMIN stated this information is documented in the resident's electronic health record. The ADMIN stated it was expected for all skin integrity issues to be identified and reported to the appropriate parties, as not doing so could create a delay in needed care. The ADMIN stated she would begin to in-service staff on skin assessments and documentation to ensure all skin integrity issues were addressed as needed. Review of the facility's policy entitled Pressure Injury Risk Assessment, revised in March of 2024, read in part: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs) . Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin . Notify attending MD if new skin alteration noted. 4. Notify family, guardian or resident update if new skin alteration noted . The identified failure was determined to be an Immediate Jeopardy (IJ) on 08/09/24 at 3:38 p.m. The Administrator and the IDON were notified. The Administrator was provided with the IJ template on 08/09/24 at 3:45 p.m. 455748 Page 7 of 8 455748 08/10/2024 Ashford Hall 2021 Shoaf Dr Irving, TX 75061

F 0684 Level of Harm - Immediate jeopardy to resident health or safety In a telephone interview on 08/09/24 at 4:42 p.m., the local hospital charge nurse stated the POA reviewed on Resident #2's hospital records, dated 6/13/24, meant present on arrival or admission. The charge nurse stated if the hospital staff wanted to document the power of attorney was notified, they use 'MPOA', as in Medical Power of Attorney. The following Plan of Removal submitted by the facility was accepted on 08/10/24 at 11:08 a.m.: Residents Affected - Some On 8/9/2024 At 4:40pm Surveyor reported to the Administrator that the facility failed to identify and treat a wound to Resident #1's great toe, which lead to osteomyelitis and amputation of the toe on 6/18/2024. At 4:45pm Nurse Managers started a skin sweep of all residents; any findings will be corrected by notification to PCP for recommendation of wound orders. A referral to Wound Physician will be made. There were no negative findings. - Completion Date: 8/9/2024 On 8/9/2024 At 5:15pm In-service started for Licensed Nurses by DON/ADONS on completing Hospital On 8/09/2024 5:36pm DON/ADON's started an in-service with all Licensed Nurses, Med aides and CNA's regarding skin/wound documentation and notification in their documentation in the [electronic health record system]. Documentation will be monitored daily by DON/ADON's/Weekend Supervisor to ensure all skin On 8/9/2024 at 5:30pm We have added to our current system the ADON's will complete skin sweeps 3X weekly to ensure all wound/skin issues are documented. This will be monitored by the DON/Designee 3X weekly to ensure skin sweeps are completed and all negative findings corrected. Any negative findings will Monitoring of the facility's implementation of the Plan of Removal revealed the following: Record review of skin assessment sheets dated 08/09/24 and 08/10/24, reflected all facility's residents, 94 in total, received a skin assessment and new skin integrity issues were reported to the resident's physician. Record review of in-services dated 08/09/24, regarding Hospital Transfer Form completion, wound documentation and skin assessment completion and documentation, reflected all facility nursing staff were in serviced in person or by phone. Interviews conducted on 08/10/24 from 12:30 p.m. through 4:26 p.m., with the ADMIN, the DON, the IDON, ADON A, ADON M, 10 CNAs, 4 MAs, 4 LVNs, and 4 RNs from various shifts revealed all interviewed staff were in serviced in person or by phone and phone in serviced staff would have to be in serviced again before their next shift. During the interviews staff could explain the facility's skin assessment and documentation and notification policies in their own words. In interviews with facility nursing leadership all staff were aware of the expectation of monitoring for skin sweeps three times a week to ensure all skin integrity issues were identified and treated, as needed in the future. The Administrator was informed the Immediate Jeopardy was removed on 08/10/24 at 5:00 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 455748 Page 8 of 8