Health inspection·February 21, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 17 residents reviewed for PASRR (Residents #17). Residents Affected - Few The facility did not have an accurate PASRR level 1 screening for Residents #17 upon admission therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability, or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 02/20/24 indicated Resident #17 was an [AGE] year-old female admitted [DATE], and readmitted [DATE], with diagnoses of major depressive disorder (mental disorder characterized by persistent hopelessness, disinterest in and lack of enjoyment of normal activities, and prolonged sadness that affects people on a daily basis and can be recurring) as of 07/03/23, cerebral infarct (stroke/ disruption of blood flow to the brain), dementia (loss of cognitive function) and anxiety (a feeling of fear, dread, and uneasiness). Record review of PASRR level 1 screening completed by the transferring facility dated 07/06/23 indicated Resident #17 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record from 07/06/23 through 02/19/24. Record review of an admission MDS dated [DATE] indicated Resident #17 had a BIMS score of 15 indicating cognitively intact, was negative for PASRR, and had a diagnosis of depression and received medication for depression during the look back period. Record review of a care plan revised 01/26/24 indicated Resident #17 was currently taking psychotropic medication including an antidepressant medication and required monitoring for side effects and effectiveness. Record Review of physician's orders dated 02/19/24 indicated Resident #17 was prescribed Remeron (an antidepressant medication) 15 mg daily for major depressive disorder with a start date of 1/18/24. During an interview on 02/19/24 at 4:00 p.m. the MDS nurse said she was responsible for completing Page 1 of 13 675964 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0645 Level of Harm - Minimal harm or potential for actual harm all PASRR forms including the PL1. She said she had worked at the facility for 8 years. She said she did not have a backup with the PASRR process. She said she had been educated on the PASRR process and had been updated at times. The MDS nurse said the DON and the ADON look at the resident diagnoses on admission for PASRR positive diagnoses. She said she was unaware that the diagnosis of major depressive disorder should have been a positive MI diagnosis for PASRR. Residents Affected - Few During an interview on 02/20/24 at 3:30 p.m. the MDS nurse said Resident #17's PL1 was incorrect. She had completed a 1012 form after the state surveyor intervention on 02/20/24 and was waiting for the physician signature, but she should have completed one sooner. The MDS nurse said the risk of an incorrect PL1 was not a risk to the resident. She said the risk was having an incorrect form, she said she rarely saw residents receive services regardless of diagnosis. During an interview on 02/20/24 at 4:50 p.m., the ADON said she had received no education on PASRR forms. She said the MDS nurse was responsible for PASRR forms. The ADON said her expectation was for all PASRR forms to be completed accurately and timely. During an interview 02/20/24 at 4:53p.m., the Administrator said his expectation was for all PASRR forms to be completed accurately and timely. He said the MDS nurse was responsible for PASRR forms, and the DON and Corporate Clinical Reimbursement Nurse were the back up. During an interview on 02/21/24 at 2:30 p.m., the DON said his expectation was all PASRR forms to be completed accurately and timely. He said the MDS nurse was responsible for PASRR forms, and the Corporate Clinical Reimbursement Nurse was the backup. He said Resident #17's PASRR form should have been completed accurately and timely or a resident may miss out on services. During an interview on 02/21/24 at 3:27 p.m., the Corporate Clinical Reimbursement Nurse said she could be the backup if the facility needed help, but she had never had to do it. She said she did biweekly Medicaid triple checks on MDS, she looks at LTCMI, and PASRR but she did not double check the MDS nurse's work. She said she did train on PASRR as needed. The Corporate Clinical Reimbursement Nurse said major depressive disorder diagnosis was a diagnosis positive for PASRR and she would do training with her other buildings to make sure they were all aware of it. Record review of a facility policy, revised March 2019, titled, admission Criteria indicated, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. b. If the level 1 screen indicated that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR represented for the Level II (evaluation and determination screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. 675964 Page 2 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible for 1 of 17 (Resident #12) residents reviewed for hazards. The facility failed to ensure an oxygen cylinder (a tank that contains oxygen) in Resident #12's room was properly stored. This failure could place the residents at risk of accidents or injury. The findings included: Record review of an admission sheet dated 02/19/24 indicated Resident #12 was admitted on [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (COPD -a lung disease) and dementia. Record review of the annual MDS assessment dated [DATE] indicated Resident #12 had severely impaired cognition and required assistance of 1 staff for bed mobility and transfer. She received oxygen therapy while at this facility and during the last 14 days. Record review of care plan dated 01/28/23 indicated Resident #12 had COPD interventions included 02 via nasal cannula as needed. Record review of physician orders dated February 2024 indicated Resident #12 orders included an order for 02 at 2 LPM, 3LPM, 4 LPM or 5LPM as needed for shortness of breath. During an observation on 02/19/24 at 10:00 a.m., Resident #12's room had an 02 cylinder under the bed. The 02 cylinder was between the wheels of the bed and the wall, positioned horizontally. The 02 cylinder was not in a cart or secured. The cylinder was about 4 inches by about 30 inches. During an observation on 02/20/24 at 11:25 a.m., Resident #12 was in bed with 02 in progress per the concentrator. The portable 02 cylinder was still on the floor, under Resident #12's bed, between the wall and the wheels of the bed. During an observation and interview on 02/20/24 at 11:27 a.m., Unit Manager B said all tanks/cylinders should be secured and not on the floor as she removed the O2 cylinder from Resident #12's room. She stated, all of the staff were responsible to remove any hazardous items from the resident's room. The Unit Manager said the nurse was responsible for ensuring the 02 cylinder, when brought to the room on a cart, or in a bag on the wheelchair. She said all nurses are trained on hire about oxygen. During an interview on 02/20/24 at 11:30 a.m., the ADON said all the nurses were trained on hire to secure 02 on wheelchair carts or in the 02 closet in the rack. She said the cylinder could be damaged by the wheels of the bed and for fire safety 02 cylinder must be stored properly. During an interview on 02/20/24 at 11:45 a.m., LVN C said she was unaware the 02 cylinder was under Resident #12's bed and should have been in the 02 closet when not in use. 675964 Page 3 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/21/24 at 10:30 a.m., the DON said the 02 cylinder should not be under the beds in the residents' rooms and he said his expectation was for the 02 cylinders to be stored in the 02 closet. Record review of the policy titled Fire Safety and Prevention dated May 2011 indicated All personnel must learn methods of fire prevention and must report condition (s) that could result in a potential fire hazard. Oxygen Safety: . f. Store oxygen cylinders in racks with chains. Sturdy carts or approved stands. Do not store oxygen cylinders in any resident room or living area. 675964 Page 4 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 17 residents (Resident #256) reviewed for unnecessary medication. Residents Affected - Few The facility failed to monitor Resident #256 for side effects from 02/05/24 to 02/20/24 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication. Findings included: Record review of Resident #256's face sheet, dated 02/20/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included an intertrochanteric fracture of left femur (left sided hip fracture). Record review of an admission MDS assessment, dated 02/09/24, indicated Resident #256 had a BIMS score of 12, which indicated moderately impaired cognition. Resident #256 had a diagnosis of hip fracture and received an anticoagulant medication during the look back period. Record review of a care plan, initiated 02/16/24, indicated Resident #256 received an anticoagulant medication, with interventions which included medications administered as ordered and monitored for side effects and effectiveness. Record review of physician orders dated February 2024, indicated Resident #256 was prescribed Eliquis 2.5 mg two times a day for deep vein thrombosis prophylaxis (blood clot in a deep vein usually legs preventive) with a start date of 02/05/24. The orders did not address monitoring the anticoagulant medication. Record review of a MAR, dated 02/1/23, indicated Resident #256 received Eliquis 2.5 mg two times a day from 02/05/24 to 02/20/24 with a start date of 02/05/24. Record review of the electronic record for Resident #256 from 02/02/24 to 02/20/24 indicated the nurses did not document monitoring of side effects of the anticoagulant medication daily with medication administration. During an interview and observation on 02/19/24 at 11:00 a.m., Resident #256 said she gets a blood thinner, Eliquis, but had no bleeding or bruising issues. During an interview on 02/21/24 at 11:10 a.m., LVN A said she was assigned to provide care for Resident #256. She said Resident #256 was on an anticoagulant and should be monitored but was not. She said the admission nurse was responsible for ensuring the monitoring was added into the computer system. She said it was overlooked. LVN A said the ADON, and the DON were the backup to double check physician orders for monitoring and accuracy. She said she was educated on monitoring of anticoagulants. LVN A said the risk of not monitoring an anticoagulant was potential bleeding or too much coagulant. 675964 Page 5 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/21/23 at 11:18 a.m., Unit Manager B said the admission nurse was responsible to input monitoring for the anticoagulant medication into the computer system. She said herself, the ADON, and the DON were responsible to double check orders to ensure accuracy. She said Resident #256 should have been monitored for anticoagulant medication and was not. She said the staff were educated on monitoring anticoagulant medication and putting it into the computer system. She said it was overlooked. Unit Manager B said the risk of not monitoring anticoagulant medication was the risk of bleeding. During an interview on 2/21/24 at 11:50 a.m., the ADON said the admitting nurse was responsible to input the monitoring for anticoagulant medication into the computer system. She stated her and the DON were responsible for double checking the orders for accuracy and ensuring anticoagulants were monitored. She said she put Resident #256's anticoagulant order in the computer system and overlooked the monitoring. She said the staff were educated on ensuring anticoagulants were monitored. The ADON said the risk of not monitoring anticoagulants was increased bleeding, black tarry stools, and complications of bleeding with falls. During an interview on 2/21/24 at 2:11 p.m., the DON said his expectation was monitoring to be put in the system when the order was placed into the system. He said they had standing orders for monitoring. The DON said the admission nurse was responsible to input monitoring for anticoagulant medication into the system. He stated that himself and the ADON were responsible for double checking to ensure monitoring was put into the system. He said the ADON had overlooked putting the monitoring in for Resident #256. The DON said the risk of not monitoring anticoagulants was bleeding, complications, scrapes, and bruises. During an interview on 2/21/24 at 2:18 p.m., the Administrator said his expectation was for any medication that required monitoring to be monitored. He said the charge nurse was responsible for monitoring and the DON was ultimately responsible. Record review of a policy revised November 2018, titled, Anticoagulation- Clinical Protocol indicated, .Monitoring and follow up . 5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulant therapy shows signs of excessive bruising, . or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose . Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS® (apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. While taking ELIQUIS, you may bruise more easily, and it may take longer than usual for any bleeding to stop. Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking ELIQUIS: *unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier than normal *bleeding that is severe or you cannot control *red, pink, or brown urine; red or black stools (looks like tar) *coughing up or vomiting blood or vomit that looks like coffee grounds *unexpected pain, swelling, or joint pain *headaches, or feeling dizzy or weak 675964 Page 6 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. Residents Affected - Many *An uncovered and unlabeled personal use cup was stored in refrigerator #1. *Food items were not properly labeled with product and expiration date in refrigerator #2. *Food items were uncovered and exposed to air in the walk-in freezer. These failures could place residents who consumed food prepared by staff in the kitchen at risk of cross contamination and food-borne illnesses. Findings included: During the initial tour of the kitchen on 02/19/24 at 08:25 a.m., the following was observed: *One unlabeled/uncovered personal cup with a straw containing a white slushy substance in refrigerator #1; *One unlabeled single serve container of shredded cheese and one unlabeled single serve container of sour cream in refrigerator #2; *One open plastic bag of link sausages in the walk-in freezer. During an interview on 02/19/24 at 8:54 a.m., the DM said all foods should be properly labeled and dated and no personal food or drinks should be stored in the kitchen refrigerators. He said not labeling and dating food containers could result in serving expired foods to residents. He said storing an uncovered personal cup in the kitchen refrigerator could cause cross contamination of the other foods. He said all food items in the freezer should be tightly closed to prevent the foods from cross contamination and possible spoiling of the food. He said he was a certified dietary manager and all workers in the kitchen had their food handler's certification. During an interview on 02/21/24 at 4:26 p.m., the Administrator said he expected all foods stored in the kitchen to be labeled, dated, and stored appropriately according to the facility's Food and Supply policy. He said the DM's direct supervisor was the Dietary Management Supervisor. During a telephone interview on 02/21/24 at 6:13 p.m., the Dietary Management Supervisor said he was the DM's supervisor. He said he expected all foods stored in the refrigerator to be labeled and dated. He said not labeling and dating foods could result in food being served after the expiration date and could cause food-borne illness. He said no personal items should be stored in the refrigerators. He said all food in the freezer should be tightly closed to avoid freezer burn or changes to the taste and texture of the food. Record review of a Food and Supply Storage policy revised January 2024 indicated All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent 675964 Page 7 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many contamination to maintain the safety and wholesomeness of the food for human consumption. The policy further indicated.Cover, label, and date unused portions and open packages. Record review of the 2022 Food Code dated 01/18/23 indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date. Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections. 675964 Page 8 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

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 observation, interview, and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 17 residents (Residents #7 and #28) reviewed for accuracy of clinical records. The facility did not ensure the wound assessments for Residents #7 and #28 were completely and accurately documented. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of physician orders dated February 2024 indicated Resident #7 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (a loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged or scarred), and deep tissue injuries (DTI) (pressure ulcer defined as purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer) to bilateral heels. Orders indicated to paint bilateral heels with betadine daily and leave open to air. Record review of a significant change MDS assessment dated [DATE] indicated Resident #7 had moderate cognitive impairment, required substantial/maximal assistance with ADLs, was at risk for developing pressure injuries, and had been admitted to hospice services. Record review of a care plan dated 12/27/23 indicated Resident #7 had a DTI to her left heel. The care plan was revised on 02/20/24 to indicate the wound was classified as unstageable (a full-thickness pressure injury in which the base is obscured by slough and/or eschar [tissue that is typically dead, dry, black, & firm]). Record review of a wound evaluation dated 02/15/24 indicated Resident #7 had a DTI to her left heel. The picture of the left heel showed an area of blackened tissue. The wound evaluation was revised on 02/20/24 to indicate an unstageable pressure injury to the left heel due to covering of eschar. During an observation and interview on 02/20/24 at 1:43 p.m., the Treatment Nurse painted Resident #7's left heel with betadine and left it open to air to dry. She said she thought the blackened area was eschar tissue, but the ADON assessed and staged wounds. She said she was currently attending training for wound care certification and had been the Treatment Nurse at the facility for 2 months. During an interview on 02/21/24 at 2:29 p.m., the ADON said the Treatment Nurse had notified her of a change to Resident #7's wound on 02/20/24. She said she then assessed the wound, notified the physician of the change, wrote a nurse's note indicating the wound status change, and revised the wound evaluation dated 2/15/24 changing the wound stage from DTI to unstageable. She said she should have written a new wound evaluation dated 02/20/24 instead of revising the evaluation dated 02/15/24 because that note should reflect the assessment of the wound on 02/15/24. She said she was certified in wound care since 2022. She said she assessed wounds weekly and audited wound evaluations weekly for 675964 Page 9 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0842 accuracy after assessments. She said inaccurate wound documentation could result in wound deterioration. Level of Harm - Minimal harm or potential for actual harm 2. Record review of a face sheet indicated Resident #28 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included congestive heart failure (a condition in which the heart's main pumping chamber is weak, becomes stiff, and is unable to fill properly). Residents Affected - Some Record review of the care plan dated 08/14/23 indicated Resident #28 had a Stage 2 pressure injury to the intergluteal cleft (deep [NAME] or groove that lies between the two gluteal regions (commonly known as the buttocks)). Record review of the care plan dated 10/17/23 indicated Resident #28 had a Stage 2 shearing (two surfaces move in the opposite direction) pressure injury to the left gluteal cheek (buttock). Record review of Progress Notes Skin Only Evaluation entries for Resident #28 indicated Skin Issue #001: * on 12/22/23 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 12/29/23 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/05/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/12/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/19/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 01/26/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; * on 02/02/21 had no change and she had a stage 2 pressure ulcer/injury to the right buttock; and * on 02/09/24 had no change and she had a stage 2 pressure ulcer/injury to the right buttock. Record review of Progress Notes with a Wound entry note dated 02/15/24 indicated Resident #28 had a wound to the sacrum, 3.3 cm length by 4.4 cm width by 0.1 cm depth, unstageable, and beefy red color covered with slough. Record review of physician orders as of 02/20/23 indicated Resident #28 had an order dated 02/15/24 to clean left sacral/coccyx wound. Record review of a Skin and Wound Evaluation form dated 02/15/24 indicated Resident #28: * had an unstageable (wound with slough (white/yellow stringy or thick substance)/eschar (tan, brown, or black dead tissue) obstructing the wound bed) pressure ulcer; * it was located on the left gluteus (muscle that makes up the buttocks) * with 20% granulation (pink/red, moist, shiny tissue that glistens and is composed of new blood vessels, connective tissue, fibroblasts, and inflammatory cells that fills an open wound when it 675964 Page 10 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0842 begins to heal) Level of Harm - Minimal harm or potential for actual harm * with 80% slough, and * had no eschar. Residents Affected - Some Record review of a Wound Evaluation dated 02/15/24 indicated Resident #28: * had an unstageable pressure ulcer; * was located on the left gluteus; and * with the wound bed having 20% granulation and 80% slough. Record review of a Skin Only Evaluation form dated 02/16/24 indicated Resident #28 on the right buttock. Record review of Progress Notes a Skin Only Evaluation entry for Resident #28 indicated on 02/16/24 Skin Issue #001 had no change and she had a stage 2 pressure ulcer/injury to the right buttock. During an observation and interview on 02/20/24 at 11:45 a.m. the Treatment Nurse provided wound care to Resident #28. The resident only had one wound and it was located on the left upper buttock near the sacral area. When the resident skin was pulled to expose the wound better, it appeared to be on the sacral area. The wound base was partially covered with dull yellow colored stringy tissue but there was a small portion of red beefy looking tissue. There was no presence of eschar. The wound had a small amount of blood coming from it. The Treatment Nurse said with the way Resident #28's skin would move it was not easy to determine the exact location of the wound. During an interview on 02/21/24 at 2:26 p.m., the DON said the wound evaluation dated 02/15/24 should not have been altered and a new wound evaluation should have been completed. He said all wound care notes were audited weekly by he and the ADON. He said the ADON did all wound evaluations because she was wound care certified. He said possible negative outcome of wound stage or status being documented incorrectly could be wound deterioration. Record review of the facility policy titled Charting and Documentation last revised July 2017, indicated All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. According to the National Pressure Ulcer Advisory Panel's Clinical Practice Guideline dated April 2016 accessed at https://npiap.com/page/2019Guideline: Classification of Pressure Injuries: .Pressure injury classification is based on the visual and palpatory identification of tissues including skin, subcutaneous fat, bone, muscle, tendon, and ligament. Necrotic tissue (slough and eschar) appears in full-thickness pressure injuries. Granulation tissue becomes present as a full-thickness pressure injury heals. In contrast, Category/Stage II pressure injuries do not have necrotic tissue and heal with epithelialization rather than granulation tissue. Healing tissues include scar, granulation tissue, and epithelium The description of a pressure 675964 Page 11 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some injury should be supplemented with other findings. Indicating the exact anatomical location of the pressure injury is important, including clearly identifying location over a bony prominence as applicable NPUAP Classification System (April 2016): Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions 675964 Page 12 of 13 675964 02/21/2024 Mrc Creekside 1433 Veterans Memorial Parkway Huntsville, TX 77340

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to ensure that each employee received the required training that at a minimum educated staff on dementia management for 2 of 13 employees (Maintenance Director and Housekeeping Supervisor) reviewed for required annual trainings. The facility did not ensure dementia management training was completed by the Maintenance Director and Housekeeping Supervisor. This failure could place residents with dementia at risk of a poor quality of care by staff with inadequate training when caring for dementia residents. Findings included: Record review of employee file for the Maintenance Director indicated a hire date of 02/21/16. Record review of the training transcript for February 2023 through February 2024 indicated the Maintenance Director had not completed any training for dementia management. Record review of employee file for the Housekeeping Supervisor indicated a hire date of 12/13/94. Record review of the training transcript for February 2023 through February 2024 indicated the Housekeeping Supervisor had not completed any training for dementia management. During an interview on 02/21/24 at 05:30 p.m., the HR staff and Administrator said all staff were to complete required trainings. The HR staff said she tried to keep up with the trainings. They were not able to locate the appropriate training. 675964 Page 13 of 13