Health inspection·April 12, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure 1 of 6 residents (Resident #1) received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing. Residents Affected - Few The facility failed to ensure Resident #1's four wound dressings were dated and initialed per facility policy. This deficient practice could affect residents who received pressure ulcer preventative treatments and place them at risk for skin breakdown, infection, pain, and a decline in health. The findings include: Record review of Resident #1's face sheet, dated 04/11/24, revealed an [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses included Urinary Tract Infection (bladder infection), Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar), and Congestive Heart Failure (the heart cannot supply enough blood to meet your body's needs). Record review of Resident #1's Order Summary Report, dated 04/11/24, revealed a physician order: Treatment to skin tears to bilateral elbows and shoulders - Cleanse with normal saline and 4x4 and pat dry, apply dressing daily and PRN, one time a day for wound healing. Record review of Resident #1's Care Plan, dated as revised on 04/07/24, revealed the care plan: Focus: Resident has current skin conditions: 1. Abrasions to rear bilateral shoulders. 2. Skin tears to bilateral elbows. Interventions: 1. Perform treatments per MD orders. 2. Monitor areas for increased breakdown. In an observation and skin assessment of Resident #1, on 04/11/24 at 1:25 pm, with the ADON and CNA A, revealed Resident #1 had bandages on his right and left elbows and on his right and left rear shoulders. The bandages were not dated or initialed. The resident was not interviewable. In an interview on 04/12/24 at 9:10 am, the DON said Resident #1's four wound dressings should have been dated and initialed by the nurse performing the wound care per facility policy. She did not know why the dressings were not dated or initialed, stating she would have to in-service her nurses. The DON said a potential negative outcome would be you wouldn't know when it was last changed and who changed it. Record review of the facility policy Skin Management: Prevention and Treatment of Wounds, effective Page 1 of 2 675751 675751 04/12/2024 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0684 Level of Harm - Minimal harm or potential for actual harm 11/01/19, revealed the following [in part]: Policy: The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injures, diabetic ulcers, arterial ulcers, and skin wounds. Procedure: 4. Treatment: Wound care dressings are dated and initialed. Residents Affected - Few 675751 Page 2 of 2