Health inspection·February 19, 2026

F 0687 Provide appropriate foot care. 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 review, the facility failed to ensure that residents receive proper treatment and care to maintain mobility and good foot health by providing foot care and treatment, in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for foot care.The facility failed to follow physician orders for Resident #1's wound care on her toe.This failure could place residents with wounds to their feet at risk of not receiving proper foot care and developing infections in their wounds. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 12/11/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses which included a stroke that affected the left side of her body, pressure ulcers, and morbid obesity. Record review of Resident #1's care plan, dated 09/23/25, reflected she had skin concerns related to mobility issues, and ADL self-care deficit related to her stroke. Record review of physician orders revealed an order dated 02/09/26 for Mupirocin Ointment 2% (an antibiotic ointment used to treat bacterial skin infections) to be applied to the left great toe two times a day. Cleanse with antimicrobial solution, apply mupirocin, and cover with dry dressing or band aid.Record review of Resident #1's February 2026 Treatment Administration Record reflected there was no documentation by the nursing staff showing that wound care was provided twice a day on February 11th, 12th, 13th, 14th, 16th, and 18th. Record review of progress notes indicate on 02/09/26 Resident #1's left great toenail was removed due to ingrown toenail. During an observation on 02/19/26 at 10:20 AM, Resident #1 was observed to have a dressing on her left great toe dated 2/18. The dressing was clean, dry and intact. Interview attempt on 2/19/26 at 10:20 AM with Resident #1 was unsuccessful, resident was non-verbal. Observation on 2/19/26 at 12:20 PM, revealed Resident #1's dressing remained unchanged. During an observation and interview on 02/19/26 at 2:30 PM, Resident #1's dressing remained unchanged. The Treatment Nurse stated she provided wound care for major wounds (pressure ulcers) and minor (cuts, and abrasions) wound care was done by the bedside nurse. She stated Resident #1's wound care was to be done once a day. She stated she did not know why the wound care had not been done on 02/19/26. During an observation Resident #1's dressing was removed by the Treatment Nurse, left great toe toenail was missing, the wound bed was observed to have pink healthy tissue present in the nailbed, and no redness or indication of infection was observed. The Treatment Nurse stated the risk of not providing wound care twice a day was the wound getting infected. Interview on 02/19/26 at 2:35 PM, LVN A stated she normally did wound care at the end of her shift (6:00 AM-2:00 PM) and she had not provided Resident #1's wound care. LVN-A stated wound care was once a day. She stated she was not aware Resident #1's order was for twice a day wound care. She stated the risk of not following the physician's order for twice a day wound care was the wound getting infected. Interview on 02/19/26 at 2:49 PM, the Regional Nurse Consultant stated staff followed physician orders for wound care. She stated the risk of not following the physician's order was the physician would be upset. Record review of the facility's policy Wound Care, dated October 2010, Residents Affected - Few Page 1 of 2 675270 675270 02/19/2026 Avir at Kennedale 413 E Mansfield Cardinal Kennedale, TX 76060

F 0687 reflected: Preparation:1. Verify the physician's order for the procedure.Documentation:1. The date the wound care was given2. The initials of the individual performing the wound care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675270 Page 2 of 2