Inspection·August 15, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the charge nurse LVN B on 08/14/23 to change Resident #1s wound dressing on the 2:00 PM to 10:00 PM shift because it was the shift Resident #1 received his shower and the time in which his wound dressing would be changed. LVN A stated she asked LVN B to change the wound dressing for Resident #1 to ensure the resident did not have a wet dressing after his shower. An observation on 08/15/23 at 10:18 AM LVN A obtained permission from Resident #1 to observe the dressing to his right ischium. LVN A and the Director of Rehab entered resident room washed their hands with soap and water and donned gloves. LVN A along with assistance of the Director of Rehab assisted Resident #1 to a side lying position exposing his right hip. The dressing to Resident #1's right hip appeared clean dry and intact, the dressing had no date or initials indicating when or who performed the dressing change. LVN A removed the wound dressing covering Resident #1's right ischium and stated after inspection of the resident's wound there was nothing packed inside the wound. Resident #1 stated every nurse comes to him to provide wound care and placed a sticker on top of his wound and do not pack anything inside of it and because they do not pack anything inside of it his wound will not heal. LVN A disposed of the dressing and her gloves and washed her hands with soap and water, returned to her wound care cart and prepared wound care supplies to provide wound care to Resident #1's right ischium. LVN A verified the wound treatment order for Resident #1, using disinfectant wipe disinfected resident bedside table and allowed it to dry. LVN A sanitized hands her hands with ABHR, placed a wax paper on the bedside table as a barrier between the wound care supplies and bedside table. LVN A then took the bedside table with wound care supplies and placed it near Resident #1's bed. LVN A washed her hands with soap and water, donned gloves, assessed Resident #1's pain, resident stated he was in no pain. LVN A wound care nurse informed Resident #1 of each step of care before the care was provided. LVN A with assistance of Director or Rehab who cleansed her hands with soap and water and donned gloves positioned the resident on his side. LVN A using a measuring device and q-tip applicator measured the resident wound length, width and depth. LVN A disposed of the q-tip applicator measuring device and gloves in biohazard bag, sanitized her hands with ABHR, and donned new gloves. LVN A cleansed resident wound bed with soaked gauze and q-tip applicator, disposed of supplies and gloves, and sanitized her hands with ABHR. LVN A donned new gloves and with saline soaked gauze cleansed the resident's wound outer edges and surrounding skin, disposed of supplies and gloves and washed her hands with soap and water. LVN A donned new gloves, used a q-tip applicator told resident she was going to pack calcium alginate into his wound bed, and then packed a calcium alginate dressing strip into the resident's wound bed. LVN A disposed of supplies and gloves, sanitized her hands with ABHR, and donned new gloves. LVN A applied a dated 08/15/23, initialed, and clean gauze adhesive bordered dressing to cover wound and secure in place the calcium alginate packed into the wound bed. LVN A disposed of gloves and remaining supplies and washed hands with soap and water before leaving the resident's room. In an interview on 08/15/23 at 11:15 AM LVN A stated when she was unavailable to perform wound are facility charge nurses like LVN B are provided access to the wound care supplies and trained in providing wound care to residents. LVN A stated facility nurses were aware of the treatment to be provided a wound by reviewing the physician wound orders and the facility treatment administration record. LVN A stated it was important to follow physician orders related to the treatment of a resident's wound because it could impact the healing of the wound, she stated calcium alginate would be necessary to help with drainage from a wound. LVN A stated following wound treatment orders could help heal the wound and not following wound orders could be detrimental to the healing of the wound. LVN A stated she had been providing wound care for Resident #1 since June of 2022. LVN A stated the wound to Resident #1's right hip had been present on his admission; he has had several skin flap surgeries (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455798 If continuation sheet Page 2 of 4 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 455798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bedford Wellness & Rehabilitation 2001 Forest Ridge Dr Bedford, TX 76021 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 to his sacral area. LVN A stated she this morning she assessed Resident #1's dressing and wound before performing wound care and his wound was clean, the dressing removed had minimal serous drainage, the dressing removed was not initialed or dated, there were no foul odors associated with the drainage noted, and there were no secondary dressings packed into Resident #1's wound. LVN A stated Resident #1 told her it was the charge nurse LVN B on the 2pm-10pm shift who applied the dressing to his right ischium that was not packed with calcium alginate. LVN A stated based upon her assessment of Resident #1's wound was stable, there was no noted deterioration. LVN A stated should she notice deterioration of Resident #'1 wound she would notify his wound care physician. LVN A stated she had not had to report and deterioration of Resident #1's wound to the wound care physician. LVN A stated with previous wound treatments when removing Resident #1's wound dressing she had not noticed any other instance where components of his wound dressing were not present, or the dressing not initialed or dated. LVN A stated the wound care physician sees Resident #1 each Monday when he allows her to visualize his wound the physician had not voiced any concerns regarding the healing of his wound. LVN A stated the wound care physician had commented Resident #1 would potentially have the wound to his ischium for life due to multiple flap surgeries with some failure to completely heal the wound to his right ischium. LVN A stated the risk to Resident #1 should his wound care orders not be followed as prescribed his wound could become infected or increase in size and or pain. In an interview on 08/15/23 at 12:09 AM LVN B stated she worked the 2:00 PM to 10:00 PM shift on 08/14/23 and provided wound care to Resident #1. LVN B stated as charge nurse she had access to the wound treatment supplies and knew what treatment to provide a resident by reviewing eh physician order for a resident in their electronic chart. LVN B stated after providing wound care for a resident she would document a progress note in the electronic medical record the treatment was done. LVN B stated when she provided wound treatment to Resident # 1's right ischium she dated the dressing. LVN B stated 08/14/23 she could not find the calcium alginate and did not use it to pack his wound. LVN B stated she normally used calcium alginate to treat Resident #1's wound and when she could not find the calcium alginate on the wound cart she did not look anywhere else or called anyone to tell them she could not find the calcium alginate. LVN B stated the risk of not providing wound care and not applying calcium alginate to Resident #1's wound was it could delay his healing. In an interview on 08/15/23 at 11:56 AM Resident #1's wound care physician stated the resident had a chronic wound to his right ischium which she suspected would not heal due to ischemia (inadequate blood flow to that part of the body) and without another plastic surgery it would remain on his right ischium. The wound care physician stated the wound to Resident #1's right ischium had been stable, there had been no note deterioration to his wound and should there be facility staff would communicate any changes to his wound to her. The wound care physician stated Resident # 1 had not communicated to her in the past any concerns with facility staff not providing wound care per her treatment orders. The wound care physician stated when she has removed his dressings and assessed his wounds the dressing she has observed were dated, initialed, his wounds have not macerated (grow thinner or waste away) or deteriorated and she believed Resident #1's wound care had been provided per her physician orders. In an interview on 08/15/23 at 2:06 PM the DON stated in event the wound care nurse LVN A was unable to provide a resident wound care the facility charge nurses like LVN B were to provide resident's wound care. The DON stated wound care supplies are located at each nursing station and should a nurse be unable to find a wound care supply on the treatment cart they should check central supply and or pick up the phone and contact either her or LVN A to be directed where to find supplies. The DON stated she expected a nurse who provided wound care treatments to follow physician orders located in the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455798 If continuation sheet Page 3 of 4 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 455798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bedford Wellness & Rehabilitation 2001 Forest Ridge Dr Bedford, TX 76021 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 electronic medical record and treatment administration record. The DON stated should wound care orders not be followed by staff as prescribed it could risk wound deterioration and infection to a resident. The DON stated when staff perform a wound dressing change, she expected staff to date and initial the dressing to show accountability the treatment was completed as well as document the treatment in the resident's treatment administration record and or resident's electronic progress note. The DON stated LVN B did not call her 08/14/23 to indicate she was not able to find wound care supplies to perform Resident #1's wound treatment and the facility was not out of calcium alginate required to perform the resident's wound treatment. The DON stated LVN B should have initialed and dated the wound dressing she applied to Resident #1's right ischium to indicate it was changed by her. The DON stated LVN B should have also documented in the resident's treatment administration record or nurse progress note the treatment had been provided. The DON stated Resident #1 had a long-standing chronic wound to his right ischium with the wound care physician monitors each week on Mondays. The DON stated the wound care physician with her assessment of his wounds had not voiced to her any concerns regarding infection of Resident #1's wound and his wound had been a chronic stable wound. The DON stated Resident #1 had been to several appointments regarding his wound, but the surgical wound had not completely closed. Review of the wound care physician's progress notes dated 07/27/23 reflected Resident #1's right hip surgical wound was not healed with 0.2cm length, 0.8cm width x 1 cm in depth. Review of facility skin wound noted dated 08/15/23 reflected Resident #1's surgical wound to his right ischium measured 0.3 cm length, 0.8cm width x 1 cm in depth. Review of LVN B's facility Clinical Competency Validation for Wound Dressing: Aseptic dated 06/02/23 reflected critical elements 1. Verifies order and reviews skin Integrity report .30. Documents patient response to treatment, wound evaluation, treatment administration. Review of Resident #1's Treatment Administration Record and progress notes dated 08/14/23 revelaed no record of LVN B provided wound care treatment to Resident #1's right ischium. Review of facility policy titled, Wound Management revised 06/20, reflected Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury. Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing .Procedure: I. Assessment: .B. Upon identification of a new wound the Licensed Nurse will: .ii. Initiate a Wound Monitoring Record sheet; .c. The Wound Monitoring Record is optional for recording skin tears, lacerations, cuts, and abrasion. If the Wound Monitoring Record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans. iii. Implement a wound treatment per physician's order . Review of facility policy titled, Medication Administration not dated, reflected .XIX. Documentation: A. The time and dose of the drug or treatment administered to a resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. B. Recording will include the date, the time and the dosage of the medication and or type of the treatment. C. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455798 If continuation sheet Page 4 of 4