Health inspection·September 18, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (CR#1 and Resident #2) reviewed for clinical records. -The facility failed to ensure staff documented wound care treatments on CR#1 and Resident #2's MAR/TAR. This failure could affect residents that received wound care and place them at risk of inaccurate or incomplete clinical records. Findings include: CR#1 Record review of the admission sheet (undated) for CR #1 revealed an [AGE] year-old female admitted to the facility on [DATE] and discharged on 08/31/2023. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of CR #1's Quarterly MDS assessment, dated 08/07/2023, revealed the BIMS score 05 out of 15 indicating severely impaired cognitively. She required total dependence from staff physical assist for personal hygiene, toilet and transfer. Resident was always incontinent of bowel and bladder. Further review of the MDS Section M: Skin Conditions. Risk for Pressure Ulcers/Injuries- Is this resident at risk of developing pressure ulcers/injuries coded Yes Unhealed pressure ulcers/injuries- Does this resident have one or more unhealed pressure ulcers/injuries coded No Number of Venous and Arterial Ulcers -Enter the total number of venous and arterial ulcer present was coded-0. Record review of CR #1's care plan initiated 07/21/23 and revised on 8/24/23 revealed the following: Focus: Resident has current skin concerns: DTI to right heel. Change to Arterial wound. DTI to left heel. Change to Arterial Wound. Vascular Consult. Goal: Areas will resolve without complications within the review date. Interventions/Task: 1. Perform treatments per MD orders. 2. Monitor areas for increase breakdown, s/s of infection and report to MD. 3. Monitor for pain, give med per order, Page 1 of 4 675000 675000 09/18/2023 Focused Care at Beechnut 12777 Beechnut St Houston, TX 77072

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some monitor for relief. 4. Encourage PO and fluid intake within dietary limits. 5. Keep MD and RP informed of resident's progress.6. Assess skin weekly and record findings in clinical record. Record review of CR#1's physician order dated 07/24/23 revealed an order to Clean right heel with wound cleanser, pat dry, apply skin prep daily. Leave open to air. Every day shift for Skin integrity. The order was discontinued on 08/14/23. Record review of CR#1's physician order dated 08/24/23 revealed an order to clean left heel Arterial wound with wound cleanser. Pat dry apply Betadine solution cover with dry dressing everyday. Every day shift for Wound care. Record review of CR#1's physician order dated 08/24/23 revealed an order to clean right heel arterial wound with wound cleanser. Pat dry apply Betadine cover with dry dressing everyday. Every day shift for Wound care. Record review of CR #1's MAR/TAR for the month of August 2023 revealed Left heel and Right heel had blanks on the TAR indicating the treatment did not occur on 08/06/23, 08/10/23 and 08/29/23. Record review of CR #1's nurses note for the month of August 2023 revealed there was no documentation of CR#1's treatments not being done, notification to the MD or a Nurse Practitioner of treatment not being done, or of CR#1's refusing treatment. There was no documentation indicating why the scheduled treatment was withheld or not administered as ordered. Resident #2 Record review of the admission sheet (undated) for Resident #2 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), type 1 diabetes mellitus without complications (a chronic condition in which the pancreas produces little or no insulin) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #2's Quarterly MDS assessment, dated 07/19/2023, revealed the BIMS score was 00. Assessment for mental status was conducted resident was unable to complete interview. Resident#2 has short term memory problem, long term memory problem, and cognitive skills for daily decision making is severely impaired never/rarely made decision. Further review of the MDS revealed she required supervision from staff for personal hygiene, toilet and transfer. Further review of Section M Skin Conditions F. Unstageable- Slough and/or eschar: Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar was coded-1. Record review of Resident #2's Care plan initiated 06/14/2021 and revised on 08/01/2023 revealed the following: Focus: Resident has current skin concerns: DTI to left heel. Goal: Areas will resolve without complications within the review date. Interventions/Task: 1. Perform treatments per MD orders. 2. Monitor areas for increase breakdown, s/s of infection and report to MD. 3. Monitor for pain, give med per order, monitor for relief. 4. Encourage PO and fluid intake within dietary limits. 5. Keep MD and RP informed of resident's progress. 6. Assess skin weekly and record findings in clinical record. 675000 Page 2 of 4 675000 09/18/2023 Focused Care at Beechnut 12777 Beechnut St Houston, TX 77072

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident#2's physician order dated 08/24/23 revealed an order to clean stage 4 left heel wound with wound cleanser. Pat dry apply hydrogel cover with dry dressing Every day. every day shift for Wound care. Record review of Resident#2's MAR/TAR for the month of September 2023 revealed stage 4 left heel had blanks on the TAR indicating the treatment did not occur on 09/08/2023 and 09/09/2023. Record review of Resident #2's nurses note for the month of September 2023 revealed there was no documentation of Resident#2's treatments not being done, notification to the MD or a Nurse Practitioner of treatment not being done, or of Resident#2's refusing treatment. There was no documentation indicating why the scheduled treatment was withheld or not administered as ordered. In an interview on 09/18/2023 at 1:10p.m., with RN A, she said Wound Care Nurse performed wound care Monday to Friday. She said the floor nurses were responsible to perform wound care on the weekends and PRN dressing changes and to document on the TAR. In an interview and record review on 09/18/2023 at 1:50p.m., Surveyor reviewed CR#1's and Resident #2's TAR/MAR, physician order and nurses note with the Wound Care Nurse. The Wound Care Nurse said for CR#1 Right heel and Left heel for 8/6/23, 8/10/23 and 8/29/23 and Resident#2's Left heel stage 4 treatment on 09/08/23 and 09/09/2023 the orders on the PCC (electronic medical record) were showing red indicating the treatment was not completed on those dates. She said once the treatment was completed, and the nurse signed off on the TAR the order would turn green. She said, maybe the system was down, and I forgot to go back and sign it. She said she worked Monday through Friday at this facility as a wound care nurse and was responsible for performing the facility's wound care and skin assessments. She said the floor nurses were responsible for completing the wound care on the weekends. She said one of the dates mentioned above was on a Saturday (09/09/2023). The Wound Care Nurse said she would go back and make a nurses notes that the treatment was performed for the open/blank spaces in TAR. In an interview and record review on 09/18/2023 at 2:01p.m., Surveyor reviewed CR#1's and Resident #2's TAR, physician order and nurses note with the DON. The DON confirmed the Wound Care Nurse, and the floor nurses did not document on the TAR after performing the treatments in August/September 2023. She said there should not be any open/blank spaces in the MAR/TAR and that if it was not documented it means it was not completed. The DON said, there was no explanation for the holes in the MAR. The DON said she went over MAR/TAR once a week. She said there was an issue with PCC and the corporate had to send an email with issues. The DON said she could not recall the date when the PCC was having issues. In an interview on 09/18/2023 at 2:09p.m., with the Administrator and the DON, the Administrator said PCC was having a glitch and some people's documentation were affected as it was shooting out multiple charting/documentation entries. The Administrator said he could not recall the dates when the PCC had a glitch and said he would email the Surveyor a copy of the email that was sent from corporate to PCC with the issues. As of 09/25/23 Surveyor had not received any correspondence from the Administrator or the DON. Record review of facility's Skin Management Policy (last revised: 10/06/2022) revealed read in part: .4. Treatment: Residents who decide not to comply with physician orders or nursing interventions will be educated on risk, physician and responsible party notified, and documentation will be 675000 Page 3 of 4 675000 09/18/2023 Focused Care at Beechnut 12777 Beechnut St Houston, TX 77072

F 0842 completed in resident's chart. Nursing staff will provide ongoing education and documentation as needed . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 675000 Page 4 of 4