Health inspection·December 31, 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 that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 3 residents (Resident #1) reviewed for quality of care. Residents Affected - Few -The facility failed to ensure Resident #1's treatment orders for left distal/medial foot were followed as ordered by the NP (Nurse Practitioner) on 11/11/24. -The Wound Care Nurse failed to cover Resident #1's left distal/medial foot with kerlix bandage on 12/31/24 after applying betadine (topical antiseptic and germicide that contains povidone iodine). This failure could affect all residents and place them at risk of decline in health and well-being. Findings included: Record review of Resident #1's Face Sheet, dated 12/31/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included type 2 diabetes mellitus (high levels of sugar in the blood), local infection of the skin and subcutaneous (inner most layer of the skin that contains fat and connective tissues) tissue, and pressure induced deep tissue damage of left heel. Record review of Resident #1's comprehensive MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment. She was dependent on staff (assistance of 2 or more helpers was required for the resident to complete the activity) for toileting hygiene, personal hygiene, and upper/lower body dressing. Resident #1 was always incontinent of bowel and urinary. Further review of Section M, Skin Conditions, revealed she was at risk for developing pressure ulcers/injuries and had 1 unstageable venous and arterial ulcer present. Record review of Resident #1's Care Plan, dated 03/22/16-present and updated on 10/17/24, revealed she had impaired skin integrity and was at risk for continual decline. Further review revealed she had extremely dry skin, arterial left lateral foot, and left foot. Goal was areas would heal without complications over the next 90 days and intervention was to perform treatment per orders. Record review of Resident #1's Physician Order Sheet, dated 12/31/24, revealed an order for apply betadine to the left distal/medial foot and cover with kerlix bandage one time daily. Record review of Resident #1's TAR (Treatment Administration Record) for the month of December 2024 Page 1 of 2 676207 676207 12/31/2024 The Colonnades at Reflection Bay 12001 Shadow Creek Parkway Pearland, TX 77584

F 0684 revealed an order for betadine to the left distal/medial foot and cover with kerlix bandage. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 12/23/24 at 5:13 p.m. with Resident #1, revealed she was sitting in her wheelchair near the kitchenette area for residents on the second floor. Resident was wearing a pressure relieving boot on her left leg and the dressing was clean and dated. She said she was doing okay. She said her foot was healing fine. She said she likes the facility and said yes, ma'am everyone treats me well. She said she did not have any concerns about her care. Residents Affected - Few Observation on 12/31/24 at 9:37 a.m., revealed Wound Care Nurse, with the assistance of CNA (Certified Nursing Assistant) A, providing wound care for Resident #1. Wound Care Nurse referred to the treatment order on a printed sheet. Continued observation revealed the second wound was at the left medial distal foot. The nurse with a clean pair of gloves applied betadine and left open to air. For this wound, the nurse failed to follow the doctor's order. The order stated: Apply betadine one time daily to the left medial distal foot and cover with kerlix bandage. During an interview on 12/31/24 at 11:41 a.m., the Wound Care Nurse said not following doctor's order, which stated: Apply betadine one time daily to the left medial distal foot and cover with kerlix bandage, said the consequences of not following Doctor's order for Resident #1, was if the resident gets up, she could cause damage to the arterial wound because it was exposed. 676207 Page 2 of 2