Health inspection·February 14, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 11 residents (Resident # 1) reviewed for MDS assessment accuracy. Residents Affected - Few The facility failed to accurately reflect Resident #1 had pressure ulcers, wounds, or skin problems on his admission MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #1's face sheet dated 2/12/24 revealed Resident #1 was admitted to the facility initially on 12/28/23 with diagnoses including malignant neoplasm of pancreas (pancreatic cancer-type of cancer often detected late, spreads rapidly, and poor prognosis), muscle weakness, anemia in chronic disease (blood does not have enough healthy red blood cells), abnormality of gait and mobility, lack of coordination, heart failure, and hypertension (high blood pressure). Record review of Resident #1's admission MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated a BIMS score of 14 which indicated Resident #1 was cognitively intact. Resident #1 was dependent or required substantial/maximal assistance for most ADLs. Resident #1 was always incontinent of urine and bowel. The MDS said Resident #1 was at risk for pressure ulcers/injuries, but it said he did not have pressure ulcers. The MDS said Resident #1 did not have any other ulcers, wounds, or skin problems. Record review of Resident #1's 12/28/23 base line care plan revealed his current skin integrity status included wound (pressure, diabetic, or stasis) and bruises/discoloration. Resident #1 had a goal of open area would improve or heal and interventions included a pressure reducing mattress, frequent turning and repositioning, and barrier cream. The base line care plan revealed Resident #1 was high risk for pressure ulcers. Record review of Resident #1's undated care plan revealed he was at risk for/actual skin breakdown as evidenced by wound (pressure, diabetic, or stasis) yes with onset of 12/28/23. Resident #1 had a goal of open area would be healed over the next 90 days. Record review of Resident #1's Order Summary Report printed 2/13/24 revealed there were no orders for wound care from 12/28/23 through 1/2/24. There were orders dated 1/3/24 for treatment one time per day to cleanse buttocks with wound cleanser, apply calcium alginate with silver, apply bordered dressing daily. Page 1 of 7 675561 675561 02/14/2024 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's eMAR date 12/28/23-1/07/24 revealed there were no treatments for wound care from 12/28/23 through 1/2/24. There were treatment orders dated 1/3/24 for treatment one time per day to cleanse buttocks with wound cleanser, apply calcium alginate with silver, apply bordered dressing daily. Record review of Resident #1's nurses' notes revealed LVN A documented on 12/28/23 Resident #1 had an open area to his sacrum (triangular bone in the lower back at the bottom of the spine between the two hip bones) that measured 1 cm x 0.5 cm and had redness and shearing to his scrotum/peri area (area between the anus and the scrotum in a male). Record review of Resident #1's skin data assessment dated [DATE] and documented by LVN A revealed the wound (pressure, diabetic, or stasis) section was answered yes and in the location of wound section was answered arm right, abdomen lower, sacrum, coccyx, and groin. Record review of Resident #1's skin data assessment dated [DATE] and documented by RN B revealed the wound (pressure, diabetic, or stasis) section was answered yes and in the location of wound section was answered buttocks, 9 cm wound right buttocks, 9 cm wound left buttocks. Record review of Resident #1's nurses' notes revealed on 1/3/24, RN B documented Resident #1 was seen by the wound care doctor and new orders were received to cleanse buttocks with wound cleanser, pat dry, apply calcium alginate (create and maintain a moist wound environment for moderate to heavy draining wounds), and apply bordered dressing. During an interview on 2/14/24 at 2:30 PM, LVN G said she was the MDS Coordinator. LVN G said she builds the MDS by reviewing documentation and doing interviews with the Resident, CNAs, charge nurses, social worker, interdisciplinary team, nutritionist, and therapy. LVN G said wounds and pressure ulcers should be captured on the MDS. LVN G said she also utilized the wound report. LVN G said the DON keeps up with the wound report. LVN G said there was a skin assessment completed on admission within the first 24-48 hours. LVN G said she would have to look back at documentation of why she would have put Resident #1 as having no pressure ulcers or wounds on his MDS. LVN G said she did not recall seeing anything in Resident #1's hospital records that indicated he had pressure ulcers or wounds. LVN G said the purpose of capturing everything on the MDS was to give an accurate picture of what was going on with the resident. LVN G said if pressure ulcers or wounds were not captured on the MDS, it would be an inaccurate assessment and could possibly impact the resident's care. During an interview on 2/14/24 at 3:30 PM, the ADM said the MDS Coordinator was responsible for the MDS assessments. The ADM said she expected staff to ensure the MDS was coded accurately. The ADM said if Resident #1 had pressure ulcers or wounds at the time of the MDS assessment, then she would have expected them to be on the MDS assessment, but she said she talked to Resident #1 and he asked her about getting handrails for positioning and asked when therapy was coming, but he did not mention having wounds to her. The ADM said the NP said the areas to his bottom was moisture related, but she did not know the NP had not actually looked at his wounds. Record review of the facility's policy titled Documentation of Wounds Related to MDS 3.0 dated July 2018 indicated . the purpose was to promote consistency in nursing, therapy, and CAA/RAI documentation . Section M (skin conditions) of the MDS would be completed within CMS guidelines . information presented on Section M of the MDS would reflect data obtained through observation, data collection, and documentation by members of the interdisciplinary team . the coding of MDS, section M would follow CMS RAI criteria . the MDS reflects the stage of a pressure ulcer based on the appearance of the 675561 Page 2 of 7 675561 02/14/2024 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0641 Level of Harm - Minimal harm or potential for actual harm ulcer/injury during the assessment reference data collection period . section M on the MDS would reflect the current appearance reflecting the stage of the pressure ulcers/injuries for items on Section M using professional practice guidelines within the assessment reference data collection period . Residents Affected - Few 675561 Page 3 of 7 675561 02/14/2024 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure injury. Residents Affected - Few The facility failed to adequately document Resident #1's wounds upon admission. The facility failed to measure Resident #1's wounds upon admission. The facility failed to obtain initial wound care orders for Resident #1's wounds. The facility failed to provide appropriate wound care for Resident #1 from admission [DATE] until seen by wound care specialist 1/3/24. These failures could place residents at risk for deterioration of wounds. Findings included: Record review of Resident #1's face sheet dated 2/12/24 revealed Resident #1 was admitted to the facility initially on 12/28/23 with diagnoses including malignant neoplasm of pancreas (pancreatic cancer-type of cancer often detected late, spreads rapidly, and poor prognosis), muscle weakness, anemia in chronic disease (blood does not have enough healthy red blood cells), abnormality of gait and mobility, lack of coordination, heart failure, and hypertension (high blood pressure). Record review of Resident #1's admission MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated a BIMS score of 14 which indicated Resident #1 was cognitively intact. Resident #1 was dependent or required substantial/maximal assistance for most ADLs. Resident #1 was always incontinent of urine and bowel. The MDS said Resident #1 was at risk for pressure ulcers/injuries, but it said he did not have pressure ulcers. The MDS said Resident #1 did not have any other ulcers, wounds, or skin problems. Record review of Resident #1's 12/28/23 base line care plan revealed his current skin integrity status included wound (pressure, diabetic, or stasis) and bruises/discoloration. Resident #1 had a goal of open area would improve or heal and interventions included a pressure reducing mattress, frequent turning and repositioning, and barrier cream. The base line care plan revealed Resident #1 was high risk for pressure ulcers. Record review of Resident #1's undated care plan revealed he was at risk for/actual skin breakdown as evidenced by wound (pressure, diabetic, or stasis) yes with onset of 12/28/23. Resident #1 had a goal of open area would be healed over the next 90 days. Record review of Resident #1's order summary report printed 2/13/24 revealed there were no orders for wound care from 12/28/23 through 1/2/24. There were orders dated 1/3/24 for treatment one time per day to cleanse buttocks with wound cleanser, apply calcium alginate with silver, apply bordered dressing daily. 675561 Page 4 of 7 675561 02/14/2024 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's eMAR/eTAR dated 12/28/23 - 1/07/24 revealed there were no treatments for wound care from 12/28/23 through 1/2/24. There were treatment orders dated 1/3/24 for treatment one time per day to cleanse buttocks with wound cleanser, apply calcium alginate with silver, apply bordered dressing daily. Record review of Resident #1's nurses' notes revealed LVN A documented on 12/28/23 Resident #1 had an open area to his sacrum (triangular bone in the lower back at the bottom of the spine between the two hip bones) that measured 1 cm x 0.5 cm and had redness and shearing to his scrotum/peri area (area between the anus and the scrotum in a male). Record review of Resident #1's skin data assessment dated [DATE] and documented by LVN A revealed the wound (pressure, diabetic, or stasis) section was answered yes and in the location of wound section was answered arm right, abdomen lower, sacrum, coccyx, and groin. Record review of Resident #1's skin data assessment dated [DATE] and documented by RN B revealed the wound (pressure, diabetic, or stasis) section was answered yes and in the location of wound section was answered buttocks, 9 cm wound right buttocks, 9 cm wound left buttocks. Record review of Resident #1's hospital records dated 12/16/23 through 12/28/23 did not mention Resident #1 having pressure ulcers or other wounds. Record review of Resident #1's visit note dated 12/28/23 completed by NP D revealed Resident #1 had wounds, but he refused assessment at that time. Record review of Resident #1's wound evaluation and management summary dated 1/3/24 performed by MD C revealed Resident #1 had a Stage 3 pressure wound (sore caused by pressure that has gone through all layers of skin) of the right buttock full thickness measuring 6.5 by 2.5 by 0.1 cm with a duration of greater than 30 days. Resident #1 had a Stage 3 pressure wound of the left buttock full thickness measuring 2 by 1 by 0.1 cm covered by 100% slough (form of necrotic or dead, non-healing tissue) with a duration greater than 30 days. MD C surgically removed the slough from the wound. MD C documented Resident #1 had anemia that complicated his wound healing. Record review of Resident #1's nurses' notes dated 1/3/24, revealed RN B documented Resident #1 was seen by the wound care doctor and new orders were received to cleanse buttocks with wound cleanser, pat dry, apply calcium alginate (create and maintain a moist wound environment for moderate to heavy draining wounds), and apply bordered dressing. During an interview on 2/13/24 at 9:30 AM, Resident #1's RP said Resident #1 had one sore on his coccyx (tailbone) when he was admitted to the nursing facility from always sitting in his chair at home. Resident #1's RP said the sore on his coccyx got much worse during his stay at the nursing facility. Resident #1's RP said he was re-admitted to the hospital on [DATE] with respiratory issues and passed away 1/19/24 at an inpatient hospice facility and one of the sores on his bottom was so deep, you could put your pinky finger in it. During an interview on 2/13/24 at 1:30 PM, LVN A said she had worked at the facility since April 2023. She said she admitted Resident #1. LVN A said she did a full skin assessment on Resident #1. LVN A said the family wanted every dot documented. LVN A said Resident #1 had bruises everywhere, he had a tegaderm (transparent medical dressing) on his right arm and it had a scabbed area (hardened crust over a wound). LVN A said Resident #1 had a tegaderm on his lower back area and he refused to let 675561 Page 5 of 7 675561 02/14/2024 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her take it off due to the hospital had just placed the dressing that day. LVN A said Resident #1 did not like being laid down flat during the incontinent/wound care. LVN A said she saw Resident #1 had a wound on his coccyx (tailbone) area and she cleaned it and covered it with a dressing. LVN A said she did not remember if the wounds had any depth. LVN A said if a resident did not have wound care orders upon admission, then she would call the NP to obtain orders until a wound consult could be completed. LVN A said she did not remember if she called the NP for wound care orders. During an interview on 2/14/24 at 10:15 AM, MD C said he visits residents weekly on Wednesdays for wound consults and gives his recommendations for wound care. MD C said he was notified of Resident #1 needing a wound consult and added him to his 1/3/24 visit schedule for evaluation. MD C said Resident #1 had a non-pressure wound to his lower back, a Stage 3 pressure ulcer to his right buttock measuring 6.5 by 2.5 by 0.1 cm, a Stage 3 pressure ulcer to his left buttock measuring 2.0 by 1.0 by 0.1 cm, and a MASD area measuring 4.3 by 1.2 by 0.3 cm. MD C said all the wounds appeared to be chronic of more than 2 weeks old when he saw them. MD C said he was unable to determine if the wounds had declined or improved with only seeing him the one time. MD C said if the wounds were not being cared for from admission of 12/28/23 until he saw him on 1/3/24, the wounds could have declined, but he would have no way to determine that. During an interview on 2/14/24 at 11:30 AM, RN B said Resident #1 had 2 spots on his bottom and the Wound Consult MD saw him. RN B said Resident #1 stayed in the bed and only got up with therapy. RN B said they encouraged Resident #1 to turn/reposition himself. RN B said he could turn himself, but he would not. RN B said they would usually just cleanse the wounds with wound cleanser, pat dry, and apply bordered dressings to wounds if there were no wound care orders upon admission. RN B said those orders would be put in orders until the Wound Consult MD could evaluate the resident. RN B said she remembered calling and getting orders for the wound cleanser and bordered dressing and thought she put the order in for Resident #1. RN B said she must have forgotten to put the initial wound care orders in, but his wound care was provided and provided more frequently than daily due to his bowel incontinence and the wound dressings had to be changed with almost every incontinent episode. During an interview on 2/14/24 at 2:15 PM, RN F said she was the ADON. RN F said she was on leave during the brief time Resident #1 was admitted to the facility. RN F said in reviewing Resident #1's chart there was a lack of documentation of what wound care was provided to what wounds. RN F said the nurses should be notifying the NP for orders for wound care upon admission unless there were orders from the hospital. RN F said she would hope they were doing some barrier cream at least, but there was no documentation of that either. RN F said if appropriate wound care was not provided, the wound(s) could deteriorate and there was no documentation to prove what was being done. During an interview on 2/14/24 at 2:50 PM, the DON said she was responsible for completing the wound care reports. The DON said Resident #1 was not listed on the December 2023 or January 2024 reports because she had not added him at that time due to the holiday and he was not admitted long before returning to the hospital. The DON said she expected the nurses to do a skin assessment on admission, measure the wounds, and get initial wound orders from NP if needed. The DON said if appropriate wound care was not provided, there was an increased risk to the resident of worsening of the wounds and/or infection. The DON said there was no documentation of wound measurements or wound care being provided to Resident #1 from admission until the Wound Consult MD saw him. The DON said she was told Resident #1 had MASD and questioned whether the Stage 3 pressure ulcers to Resident #1's right & left buttocks were truly Stage 3 pressure ulcers due to the depth that the Wound Consult MD documented. During an interview on 2/14/24 at 3:07 PM, NP D said she saw Resident #1 on the day of his 675561 Page 6 of 7 675561 02/14/2024 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission [DATE]. NP D said he refused a skin assessment at the time of her visit. NP D said the nurse had discussed his wounds to his bottom with her and it sounded like MASD, and she told the nurse to apply zinc barrier cream and get a wound care consult. NP D said she was not able to assess the wounds herself due to the resident refused and she had to go with what was described to her by the nurse. NP D said from what she remembered, Resident #1 had MASD on his bottom and bruise on his back and later had some yeast. NP D said she listened to his heart and lungs on the day of his admission, but she did not assess his skin because he refused. During an interview on 2/14/24 at 3:30 PM, the ADM said she would expect all residents to be treated appropriately to take care of the resident's needs. The ADM said she talked to Resident #1, and he asked her about getting handrails for positioning and asked when therapy was coming, but he did not mention having wounds to her. The ADM said the NP said the areas to his bottom was moisture related. The ADM said she did not know the NP had not actually looked at his wounds. Record review of the facility's wound care reports for December 2023 and January 2024 revealed Resident #1 was not listed on the wound care reports. Record review of the facility's policy titled Documentation and Measurement of Wounds dated July 2018 indicated . wounds were measured and documented within professional guidelines . if resident had more than one wound, each wound was measured individually using a separate tool . wounds were measured upon admission . on a weekly basis . and overall change of condition . wound data collection, treatments and evaluations were documented in the EMR/medical record . wound characteristics terminology . location was anatomical location of the wound(s) . if there was more than one wound present in a specific anatomical area, attach a number to each wound . type of wound was the descriptor of the etiology (cause) of the wound . stage of pressure ulcer/injury was the description of the extent of tissue destruction and injury of the wound . color was the color of the wound base . exudate/drainage was fluid exhibited by the wound that was captured on a primary or secondary dressing . odor was presence or absence of wound drainage odor; abnormal wound odor may be an indication of infection . 675561 Page 7 of 7