Health inspection·February 15, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #3) reviewed for resident records. The facility failed to ensure the wound administration records (WAR) for Resident #3 accurately reflected the wound care that was provided to her sacrum (large triangular bone at base of the spine) wound and ischium (the curved bone forming the base of the pelvis) wound on 5 different treatment days in November and December 2024. This failure could put residents at risk of inaccurate documentation. The findings were: Record review of Resident #3's admission Record (face sheet), dated 02/12/2025, revealed she was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (kidney failure), high blood pressure, diabetes (long-term condition in which the blood sugar level is too high which can result in damage to many of the body's systems especially the nerves and blood vessels), anemia (low iron stores), Von Willebrand Disease (an inherited blood disorder that keeps the blood from clotting), heart failure (chronic condition in which the heart doesn't pump blood as well as it should), severe protein-calorie malnutrition (inadequate intake of protein and calories resulting in depleted body stores of protein), pressure ulcer (bed sore) of sacral region, and pressure ulcer of other site. Record review of Resident #3's electronic clinical record revealed she was discharged to the hospital on [DATE], readmitted on [DATE], discharged to the hospital on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. Record review of Resident #3's MD Quarterly assessment dated [DATE], revealed a BIMS score of 12 out of 15, which indicated her cognitive skills for daily decision making were intact; and she was admitted with two stage 4 pressure ulcers (the most severe type where the skin is severely damaged and underlying muscles or bone may also be damaged). Record review of Resident #3's care plans for impairment to the skin integrity related to the stage 4 pressure ulcer to the right ischium (the curved bone forming the base of the pelvis on the right side) and sacrum (large triangular bone at base of the spine), revealed under interventions was to Administer treatment as ordered by MD/NP with a start date of 06/24/2024 and was revised on Page 1 of 4 676250 676250 02/15/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0842 09/20/2024. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 6 cm length x 3.5 cm width x 2.7 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5 cm length x 3 cm width x 1.6 cm depth, and interventions included wound care as ordered. Residents Affected - Few Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 7 cm length x 4 cm width x 3.2 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5.2 cm length x 4.2 cm width x 1.5 cm depth, and interventions included wound care as ordered. Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 7.5 cm length x 4 cm width x 2.5 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5.3 cm length x 5 cm width x 3.1 cm depth, and interventions included wound care as ordered. Record review of Resident #3's Weekly Skin Pressure Ulcer assessment dated [DATE], revealed the resident had a stage 4 pressure ulcer on the sacrum which was present upon admission and measured 5.5 cm length x 4.2 cm width x 2 cm depth, a stage 4 pressure ulcer on the right ischium which was present upon admission and measured 5.5 cm length x 3.5 cm width x 1.5 cm depth, and interventions included wound care as ordered. Record review of Resident #3's Physician Order Listing Report, dated 02/15/2025, revealed the following orders: -Wound Care: Stage 4 Pressure Sacrum: Cleanser with wound cleanser, pat dry, skin pre peri-wound, Collagen particles to entire wound bed ., pack entire wound with calcium alginate or gel fiber ribbon and secure with dry absorbent dressing every day shift every other day with a start date of 11/01/2024 and a discontinue date of 11/12/2024. -Wound Care: Stage 4 Pressure Sacrum: Cleanser with wound cleanser, pat dry, skin prep peri-wound, Collagen particles to entire wound bed .pack entire wound with calcium alginate or gel fiber ribbon and secure dry with absorbent dressing every day shift . with a start date of 11/12/2024 and a discontinue date of 12/17/2024. -Wound Care: Stage 4 Pressure Sacrum: Cleanser with wound cleanser, pat dry, skin prep peri-wound, Collagen Sheet to entire wound bed ., pack entire wound with calcium alginate or gel fiber ribbon and secure with dry absorbent dressing every day shift . with a start date of 12/17/2024 and a discontinue date of 01/29/2025. -Wound Care: Stage 4 Pressure RT [right] Ischium: Cleanse with wound cleanser, pat dry, skin prep peri-wound, place collagen particles to entire wound bed and cover with gel fiber ribbon or calcium alginate and secure with dry dressing every day shift every other day . with a start date of 11/01/2024 and a discontinue date of 11/12/2024. 676250 Page 2 of 4 676250 02/15/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Wound Care: Stage 4 Pressure RT Ischium: Cleanse with wound cleanser, pat dry, skin prep peri-wound, place collagen particles to entire .wound bed and cover with gel fiber ribbon or calcium alginate and secure with dry dressing every day shift . with a start date of 11/12/2024 and a discontinue date of 12/17/2024. -Wound Care: Stage 4 Pressure RT Ischium: Cleanse with wound cleanser, pat dry, skin prep peri-wound, place collagen sheet to entire .wound bed and cover with gel fiber ribbon or calcium alginate and secure with dry dressing every day shift . with a start date of 12/17/2024 and a discontinue date of 01/29/2025. Record review of Resident #3's November 2024 WAR revealed wound care for the stage 4 pressure ulcers on the right ischium and sacrum were not documented as provided on 11/02/2024 and 11/04/2024. Record review of Resident #3's December 2024 WAR revealed wound care for the stage 4 pressure ulcers on the right ischium and sacrum were not documented as provided on 12/11/2024, 12/12/2024, and 12/30/2024. In an interview on 02/15/2025 from 10:14 a.m. to 10:37 a.m., Wound Care Nurse LVN A stated she would provide wound care to residents Monday through Friday and the weekend supervisor or floor nurse would provide wound care on the weekends. Wound Care Nurse LVN A stated she provided wound care for Resident #3 on 11/04/2024 since it was a Monday and she probably forgot to check off that she had provided the wound care. LVN A said the wound care provided to Resident #3 on 11/02/2024 would have been done by the nurse or weekend supervisor since it was a Saturday. LVN A stated she provided wound care to Resident #3 on 12/11/2024, 12/12/2024, and 12/30/2024 and she probably forgot to document it was completed. Wound Care Nurse LVN A stated the harm of not documenting the wound care was provided is that it would not show the treatment was done. LVN A said she thought the reasons why it was not documented were because she was moving too fast and because she had clicked it was done and did not sign off in the electronic clinical record before she closed her computer. In an interview on 02/15/2025 at 12:22 p.m., the DON stated RN B was Resident #3's nurse on 11/02/2024. In a telephone interview on 02/15/2025 at 2:33 p.m., RN B stated she was Resident #3's nurse on 11/02/2024 and she provided wound care to the resident but was not certain if she had documented the wound care was completed. RN B said the harm of not documenting that wound care was completed was that it would not show the wound care was completed and it would look like the wound care was not done. In an interview on 02/15/2025 at 3:06 p.m. to 3:18 p.m., the DON stated wound care should be documented in the clinical record after it was provided to the resident and the harm of not documenting could result in other staff not knowing the wound care had been provided. In an interview on 02/15/2025 at 3:21 p.m., the Administrator stated he could not think of any harm that could result from wound care not being documented in the resident's clinical record. Record review of the facility's policy Charting and Documentation, revised 05/2007, revealed The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition .IMPORTANCE AND USE OF THE RECORD .2. To the institution it reflects the quality of care given to the resident. 3. To the physician, it guides him in his treatment, use and effects of drugs and plan for care. 4. In legal defense, it serves as valid 676250 Page 3 of 4 676250 02/15/2025 Pecan Valley Rehabilitation and Healthcare 3838 E Southcross Blvd San Antonio, TX 78222

F 0842 information .6. To the nurse, it provides a multidisciplinary record of the physical and mental status of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676250 Page 4 of 4