Health inspection·November 10, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to ensure that the comprehensive care plan was developed and implemented describing services to be furnished to maintain the resident's highest practicable physical well-being, including services that are not provided due to the resident's exercise of the right to refuse care for 1 of 2 residents (Resident #1) reviewed for care plan revisions The facility failed to ensure Resident #1's care plan was revised to indicate the preference to keep socks on during skin assessment. These failures could place residents at risk of receiving inappropriate care. The findings include: Record review of Resident #1's face sheet dated 11/08/2023 revealed an admission date of 8/28/2023 with diagnoses which included: Type 2 diabetes mellitus, muscle weakness, and dementia. Record review of Resident #1's Care Plan, initiated on 8/29/23, had not been revised to include Resident #1's refusal to have shoes/socks taken off during skin assessments. During an interview on 11/7/23 at 2:45 PM RN A stated that to complete a full skin assessment, resident #1's socks would have to be removed, for the weekly skin assessment. He stated Resident #1 refused a lot, she never liked to have her socks taken off. During an interview on 11/7/23 at 3:30 PM CNA B stated that the resident really did not like to go without her socks or shoes. She stated in general she really did not like her socks removed. She stated that this happened often. During an interview on 11/7/23 at 3:50 PM CNA C stated that Resident #1 rarely had her socks off. She stated there were multiple times that she can remember that Resident #1 refused to take her socks off. During an interview on 11/07/2023 at 10:42 a.m. the MDS Coordinator stated that a change in condition is anything that has a pattern. She stated that if a resident or employee notices of a issue even it's a few times then it should be care planned. She stated it was not communicated to her that Resident #1 refused to take her socks off. She stated now that she knows this will be care planned. During an interview on 11/07/2023 at 12:41 p.m. the DON stated that she did go and talk with RN A, Page 1 of 6 676068 676068 11/10/2023 Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA B, and CNA C about Resident #1's refusal to take off her socks. She stated that all of them confirmed that Resident #1 did refuse to take socks off or shoes off. She stated now that she knows this information then it will be care planned, but it should have been care planned a few weeks ago. During an interview on 11/07/2023 at 12:41 p.m., Administrator stated that the care plan should have been done for refusal, but she and the DON did not know this was something stated by Resident #1 until 2 days ago. She stated it should have been care planned earlier, this puts the resident at risk for safety. Record review of a facility policy, titled Care Plan, Comprehensive Person-Centered change in condition should be care planned. 676068 Page 2 of 6 676068 11/10/2023 Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to accurately document Resident #1's ulcer assessment for new wounds to her left foot. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #1's face sheet, dated 11/08/2023, revealed an admission date of 8/28/2023 with diagnoses which included: Type 2 diabetes mellitus, muscle weakness, and dementia. Record review of weekly skin assessment, dated 10/10/23, indicated a skin tear posterior Left Upper extremity and question marked yes for does the resident have a pressure, venous arterial or diabetic ulcer? If yes complete the ulcer assessment. Signed by RN A Record review of weekly ulcer assessment, dated 10/10/23, indicated medial distal L foot Arterial L 2cm W 1.4cm, unable to measure depth, entire wound covered by necrotic tissue (slough and/or eschar) and unable to determine. Approximate necrotic tissue 76-100%. Currant wound treatment clean, hydro active dsg, q 3 days. Turning and repositioning q2h. PoA N/A wound is not a pressure injury. Signed by RN A Record review of weekly skin assessment, dated 10/17/23, indicated bruise LFA 12.6x15.2 and skin tear LFA 5.6, signed by RN D No documentation of weekly ulcer assessment provided for 10/17/23. Record review of weekly skin assessment, dated 10/24/23, indicated posterior L hand posterior to Ad R elbow hand distal lateral RLE. Signed by RN A Record review of weekly ulcer assessment, dated 10/24/23, indicated medial Left distal foot 2cm W1.4, 0 if unable to measure depth. Entire wound covered by necrotic tissue (slough and/or eschar) and unable to determine. Approximate necrotic tissue 76-100%. Currant wound treatment clean, hydro active dsg, q 3 days. PoA N/A wound is not a pressure injury. During a phone interview, on 11/10/23 at 12:45 p.m., RN D stated yes, it was absolutely her fault that there is no documentation of the Weekly ulcer assessment for 10/17/23. She stated she gets so busy sometimes she forgets to click things in the system. She stated that the ulcer assessment was physically done on 10/17/23 but the paperwork was not completed. She stated that the weekly ulcer assessment was necessary for the new wounds to track the improvement of healing. During an interview, on 11/10/23 at 1:05 p.m., CNA C stated she had her own written notes of each day she works and little things she observes while on shift. Her notes for the 17th of October stated 676068 Page 3 of 6 676068 11/10/2023 Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that RN D did go and access the wound and clean the wound. She stated that she knows that RN D did come and accessed the wound. During an interview on 11/8/23 at 11:15 a.m., the DON stated that she did speak with RN D and confirmed that the assessment was done but no documentation was complete. She stated the assessment is key to the progress of the healing of the wounds for the resident. She stated that all wounds in the facility are to be monitored and accessed weekly by the charge nurse. 676068 Page 4 of 6 676068 11/10/2023 Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to ensure communication with hospice representatives in the provision of care for 1 (Resident #1) of 2 residents reviewed for hospice coordination of care,: The facility did not keep written documentation of communication between hospice and facility per hospice contract. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #1's face sheet, dated 11/08/2023, revealed an admission date of 8/28/2023, with diagnoses which included: Type 2 diabetes mellitus, muscle weakness, and dementia. Record review of Resident #1's care plan, initiated 8/29/23, revealed the resident had a terminal prognosis and/or was receiving hospice services, constipation, dehydration, skin integrity issues, decreased PO intake, weight loss, mental and physical decline in function may be unavoidable due to end-of-life issues from his terminal illness. Interventions to avoid these issues will be initiated but may be unavoidable r/t end stage disease processes. Interventions/tasks stated: If receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Record review of Progress Note dated 10/8/23, order details that were sent to physician state: Resident #1 exhibits arterial ulcers to posterior, superior, and distal medial Lfoot, physician notified, new orders received to clean apply hydro active 3 days. Entered by RN A. Record review of Order Details dated 10/8/23, by phone, ordered by physician, Description: clean arterial ulcers to posterior, superior, and distal medial L food, apply hypoactive, every-day shift, every 3 days, related to other specified peripheral vascular diseases. During an interview, on 11/7/23 at 11:15 am, RN A stated Resident #1 left the facility, with family, on October 7th and returned to the facility on October 8th. He stated new wounds were observed on top of the left foot and back of the heel. He stated all wounds were roughly the same, round little pieces of eschar (dead tissue that forms over healthy skin and then, over time, falls off (sheds). He stated that the heel wound was the worst. He stated he is not sure how the wound got this bad, his only guess is when they did the wound care on it, the eschar was removed, and the open wound was exposed. He stated he never noticed the wound or anything to the left foot until 10/8/23. He stated that he called the physician and put in an order for wound care due to the new wounds. He stated he did not call hospice because he figured he let the Hospice Nurse know next time she came to the facility which was twice a week. He stated he did not feel it was a big enough concern to contact Hospice immediately only to contact the physician immediately. He stated he verbally let hospice know about the new wounds on 10/10/23. He stated even though that was two days after the discovery of the new wounds and that this was a change in condition, it was not life threatening so he waited to communicate with the Hospice Nurse. He stated he had no idea he needed to keep written documentation of all 676068 Page 5 of 6 676068 11/10/2023 Cedar Manor Nursing and Rehabilitation Center 1915 Greenwood St San Angelo, TX 76901

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communication with the hospice aids/nurses. He stated he communicated with them in person and never documented their conversation, he stated he did not know this documentation was required, per the facility contract. During an interview, on 11/10/23 at 11:15 am, DON- stated the newly identified wounds formed only after the resident went on a day pass, with her family, and she believed that the wound was formed because the resident was wearing a sock with shoes, that were too tight. She stated that she confirmed with the nurse and all 3 wounds were discovered on 10/8/23, after Resident #1 returned to the facility. She stated that communication with hospice was done in person. She stated that when she spoke with RN A, he stated that he just communicated in person with hospice and did not know it needed to be documented. She stated from this point on all communication will be either paper documented for the facility or in the progress notes of the resident. During an interview, on 11/10/23 at 11:15 am, Administrator stated that the lack of documented communications puts the resident at risk to know what is happening with the resident or what has been done. She stated informing the hospice company of a change in condition should have been done, immediately, on 10/8/23. Record review of Hospice-Nursing Facility Services Agreement revised 5/2020 stated: Hospice and facility shall communicate with one another regularly and as needed for each hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of hospice patients are met 24 hours per day. Record review of Hospice-Nursing Facility Services Agreement revised 5/2020 stated: Facility shall immediately inform hospice of any change in the condition of a hospice patient. This includes, without limitation, a significant change in a hospice patients physical, mental, social or emotional status, clinical complications that suggest a need to alter the hospice plan of care, a need to transfer a hospice patient to another facility, or the death of an hospice patient. 676068 Page 6 of 6