Health inspection·August 21, 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, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (Resident #1) of six residents reviewed for quality of care Residents Affected - Few The facility failed to ensure WCN A treated Resident #1's wound on her left buttock per doctor's order. This failure had the potential to affect residents receiving wound care could experience infection, worsening of the wounds, and pain. The findings included: Record review of Resident #1's Face Sheet, dated 08/19/2024, revealed a [AGE] year old female admitted on [DATE] with the diagnoses of: Diverticulosis of large intestine (a medical condition that causes small pouches, called diverticula, to form in the walls of the gastrointestinal tract, usually in the large intestine), Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), dementia (a group of thinking and social symptoms that interferes with daily functioning such as forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning). Record review of Resident #1's Minimum Data Set assessment dated [DATE] revealed she: -had unclear speech -usually understood self and usually understood others -had a brief interview of mental status score of 00-severly impaired cognition -was always incontinent of bowel and bladder -had Diabetes Mellitus Record review of Resident #1's comprehensive care plan dated 05/24/2024 documented, FOCUS: o [Resident #1] has MASD of the left and right buttocks r/t increased moisture Date Initiated: 12/26/2023 Revision on: 12/28/2023 Page 1 of 4 676125 676125 08/21/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few GOAL: o The resident will have no s/sx of infection of MASD through the review date. Date Initiated: 12/28/2023 Revision on: 12/28/2023 Target Date: 08/22/2024 INTERVENTIONS/TASKS: o Avoid scratching and keep hands and body parts from excessive moisture. Date Initiated: 12/26/2023 CNA LN RN o Increase out of bed activity as tolerated. Date Initiated: 12/26/2023 [CNA LN RN] o Specialty chair in place while out of bed Date Initiated: 08/16/2024 [LN RN CNA] Record review of Resident #1's physician's orders revealed, Start Date: 08/15/24 Order Summary: Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to left buttock topically every day shift for trauma/injury Cleanse wound to left buttock with saline pat dry with gauze skin peri-wound apply Santyl/Calcium Alginate cover with dry protective dressing qd and PRN if soiled or dislodged. AND Apply to left buttock topically as needed for trauma /injury Cleanse wound to left buttock with saline pat dry with gauze skin peri-wound apply Santyl/Calcium Alginate cover with dry protective dressing qd and PRN if soiled or dislodged. Record review of Resident #1's Treatment Administration Record revealed no nurse check off of wound care to left buttock for 08/15/24, 08/16/24, 08/17/24, 08/18/24, 08/19/24, 08/20/24 or 08/21/24. Record review of Resident #1's wound care measurements of the left buttock revealed: -On 08/07/24: Non-Pressure wound of the left buttock full thickness (Site 11): 4.0 x 2.5 x 0.1 cm Surface area: 10.00 cm2 -On 08/14/24: Non-Pressure wound of the left buttock full thickness (Site 11): 7.5 x 4.0 x 0.1 cm Surface area: 30.00 cm2 -On 08/20/24: Non-Pressure wound of the left buttock full thickness (Site 11): 2.0 x 1.9 x 0.3 cm Surface area: 3.80 cm2 Record review of Progress Note on 08/14/24 at 05:22 PM revealed, NURSING - Skin/Wound Note written by WCN A: Late Entry: Note Text: Patient seen per WCD wound to right and left buttock has deteriorated due to infection, generalized decline of patient, also self-inflicts scratches to buttock area and all over body, new orders received and carried out, Covid positive visiting made aware of change of wound status and new orders, verbalized understanding. Record review of Progress Note on 08/14/24 05:40 PM Change of Condition Note written by [WCN]: Late Entry: Signs/Symptoms Details: wounds to right and lt (left) buttock exacerbated, started 08/14/2024, since started it has gotten: Stayed the same Things that make the condition worse: patient causes self-inflicted scratches to bilateral buttocks and generalized body . Record review of Progress Note on 08/19/24 at 11:30 AM Nurse Note written by [WCN]: Note Text: 676125 Page 2 of 4 676125 08/21/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment performed on wounds which appear to be improving evidenced by decreased drainage, left buttock wound decreased in surface area, call placed to [WCD] and updated on findings stated will be making a follow-up visit this pm. Record review of Progress Note on 08/20/24 at 03:00 AM Nurse Note written by [LVN B]: Note Text: WCD rounded at facility for wound care assessment and treatment for pt. Gave new orders for STAT: -CBC, CMP, Prealbumin, and HGB -New orders for Only up in chair for meals only with gel cushion. [WCD[ also recommended to give pt Tylenol 650 mg PRN for pain to wounds. Orders were input and carried out, pending labs to be drawn in AM. Observation and interview on 08/19/24 at 03:45 PM of wound care on Resident #1 by Wound Care Nurse assisted by CNA C. Obwervation revealed the WCN applied cream to sacral wound and wound on right buttock. Observation revealed no cream was applied on left buttock and left buttock was not cleaned. WCN saw wound on left buttock and she said she thought the doctor said it was healed. WCN went out to cart and brought in Santyl to cover wound. WCN patted wound with normal saline, dried with dry gauze, and applied Santyl. In an interview on 08/19//24 at 04:26 PM, WCN stated she thought the order for the left ischium was the wound on the left side (buttock). WCN stated she had not treated the wound on the left buttock. In a telephone interview on 08/19/24 at 05:30 PM, WCD said it did not matter if that wound were treated or not since the 15th (08/15/24). WCD stated the ischium would be the important wound. He stated Resident #1 was non-compliant and was a scratcher. He said they had all Resident #1's wounds about closed and then she got COVID and deteriorated all over again. He said he was stopping by tonight (08/19/24) or tomorrow (08/20/24) to check on Resident #1. He said WCN was very good and he did not complain to the facility about the care the resident was getting. He was telling the facility of Resident #1's rapid deterioration after getting COVID. He said he came to the facility once or twice and sometimes more, and the facility and the WCN were fantastic. He said that the wound on Resident #1's left buttock started by the resident picked and scratched. In an interview on 08/20/24 at 09:15 AM CNA D stated she first started noticing Resident #1's wounds getting worse around August 9, 2024. CNA D stated she started noticing it get bad when Resident #1 was in isolation for COVID and she reported it to the nurse. CNA D stated she could not remember who the nurse was. CNA D stated Resident #1 scratched a lot. She said the nurses put cream on her that seemed to help. CNA D stated when she noticed a change on a resident, she notified the nurse right away and documented in their computer. CNA D stated she had been caring for Resident #1 since her arrival last year on Halloween (10/31/24). CNA D stated they kept Resident #1's nails short. CNA D stated they were trained on incontinent care at least once a month with hands-on demonstrations. In an interview on 08/20/24 at 09:25 AM, CNA E stated she had worked with Resident #1 for a few months. CNA E stated Resident #1 scratched a lot. CNA E stated nurses would put cream on Resident #1. CNA E stated the cream seemed to work. CNA E stated she noticed Resident #1's wound getting worse around 08/09/24. CNA E stated she was going to give Resident #1 a bed bath and noticed wounds getting worse. CNA E stated they reported wounds to got worse to the nurse . 676125 Page 3 of 4 676125 08/21/2024 Windsor Atrium 1814 Atrium Place Harlingen, TX 78550

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 08/20/24 at 09:45 AM, DON stated both CNA D and CNA E were interviewed and they gave a statement. DON stated she thought the doctor (WCD) was upset because a resident he used to treat, their insurance would no longer pay to have him treat since their wounds had healed. In a telephone interview on 08/20/24 at 02:20 PM with RN F stated she was the weekend wound care nurse at facility. She said the weekend of August 10th - 11th , Resident #1's wounds were worse and she notified during report. RN F stated that past weekend (August 17th and 18th), there were new orders in the computer for Resident #1 and her wounds had improved. RN F stated she did not put any notes in the computer, she only passed information on at report. RN F stated she did wound care on all wounds. In an interview on 08/20/24 at 02:55 PM, WCN stated she had worked with WCD for a long time. She said he was upset about insurance not paying anymore for a resident that he had treated. She said the doctor thought maybe the facility could help out so he could treat the resident, but they could not. In a telephone interview on 08/20/24 at 05:20 PM, WCD stated Resident #1 had deteriorated from having COVID. WCD stated there was no question the facility and the wound care nurse took care of residents. He said the WCN was great and kept him updated on any changes to residents. He said he had been updated on Resident #1's wounds and deterioration while having COVID. WCD stated hewent to the facility at least once a week to assess Resident #1, more if needed. WCD stated with Resident #1 having COVID and her comorbidities, she deteriorated quickly. WCD stated WCN kept him updated on all his residents' conditions. He said since Resident #1 was out of isolation and no longer had COVID, she was starting to improve. WCD said he was the one to let the facility know of interventions. In an interview on 08/21/24 at 01:30 PM, DON stated every morning, they were notified of new orders and the WCN met with the team to go over new orders and measurements of wounds. DON stated if wounds were not treated, there was a possibility of the wound deteriorating and infection. DON stated she may start going on rounds with the WCD and the WCN. In an interview on 08/21/24 at 02:00 PM, ADON A stated before wound care, he would double check the doctor's order and if he needed clarification, he would call the doctor and ask for clarification. ADON A stated if a wound went untreated, it could cause infection or deterioration of the resident. ADON A stated he just started as ADON at the facility. Review of the facility's Physician Visits and Physician Delegation Policy dated 10/24/22 revealed, Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of the residents. The policy did not address the nurse following physician orders. 676125 Page 4 of 4