Health inspection·April 9, 2023

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 3 residents (Residents #1) whose records were reviewed for assessments. Residents Affected - Few The facility failed to recognize and assess Resident #1 after a significant weight loss and pressure ulcers were identified. This failure placed residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments. The findings included: Review of Resident #1's Face Sheet generated 4/09/2023, reflected Resident #1 was a [AGE] year-old female who was initially admitted to the facility on [DATE]. The resident had the following diagnosis: Aftercare following joint replacement surgery, other disorders of bone density and structure and age-related cognitive decline. Review of Resident #1's Nursing Notes noted the following: 1) On 3/16/2023 at 6:56 AM- During brief change and peri care resident states to be careful as she has a tear down there. Assessment performed noted 2 ulcers to the left inner groin area where foley catheter wraps under leg. Foley repositioned; wound care performed. Admin notified to notify Dr. and DON. 2) On 3/18/2023 at 4:56 PM- Resident has dark purple areas to sacrum related to resident having edema and not changing position frequently enough to circulation area. Dark purple area with red wound edges not open but tissue is delicate. Unable to determine depth and a suspected DTI from sheering and pressure and edema. Resident will be turning reposition every two hours around the clock by staff with pillows to support position. 3) Page 1 of 3 675021 675021 04/09/2023 Electra Healthcare Center 511 S Bailey St Electra, TX 76360

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/24/2023 at 3:30 PM- Low air loss mattress supplied to bed for pressure relief intervention due to saw right down. Resident has an unstageable pressure friction ulcer to sacrum. Resident had a two days when resident stayed in bed with a windswept to the left positioning refused to be assisted or to get out of bed. The discoloration to the sacrum was evident upon allowing staff to assist her in her care. Resident was immediately placed on cue to our turn and reposition as intervention. Resident and family are in agreement that resident needs to be more compliant with allowing care and get out of bed every day. 4) On 3/27/2023 at 4:22 PM- Resident up in wheelchair more alert and interactive. Close monitoring of food and fluid intake due to weight loss and need for good nutrition and hydration to prevent infections and ate and wound healing. Resident has been taking food and snacks in the room and family suspicious that she is not eating the food or snacks and request that we take her to the table for two meals a day as add an intervention. Dietitian to see resident tomorrow. Review of Resident #1's MDS Schedule reflected last assessment as a Quarterly assessment on 3/16/2023. Review of Resident #1's weight Variance report reflected the following dates and weight: 1) Date: 11/07/2022- Weight: 126.00 2) Date: 11/14/2022- Weight: 122.60 3) Date: 11/22/2022- Weight: 120.80 4) Date: 12/31/2022- Weight: 116.40 5) Date: 1/02/2023- Weight: 116.40 6) Date: 1/30/2023- Weight: 116.30 7) Date: 2/27/2023- Weight: 111.00 675021 Page 2 of 3 675021 04/09/2023 Electra Healthcare Center 511 S Bailey St Electra, TX 76360

F 0637 8) Level of Harm - Minimal harm or potential for actual harm Date: 3/27/2023- Weight: 100.00 9) Residents Affected - Few Date: 4/2/2023- Weight: 92.60 Interview with the DON on 4/09/2023 at 7:00 PM revealed that the MDS Coordinator was responsible for creating and completing Significant Change Assessments. She said that the resident did have a significant decline since she started the beginning of March and that she was unsure why a Comprehensive Assessment was not completed. She said that she had updated the care plan and care areas to make sure the resident received her treatments that reflected her current health status. Interview with the MDS Coordinator on 4/09/2023 at 7:05 PM revealed that she was responsible for completing an accurate resident assessment. She stated that she should have completed a Significant Change assessment once she saw the resident had a significant weight loss on February 27, 2023. She said this failure could place the resident at risk for not receiving the care they needed. She said that she was going to complete the assessment, but they had her covering two additional buildings. She stated she was behind on all assessments while she was going to another facility, she said she was trying to catch up, but she is the only one. Review of the facility's policy and procedure for Resident Assessments and/or Significant Changes was not provided at the time of exit. 675021 Page 3 of 3