Health inspection·March 21, 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 observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 15 residents (Residents #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure Resident #1's physician's orders dated 02/27/25 were updated to include the resident no longer received wound treatment to a stage 2 wound to her sacrum (triangular bone on the lower back) to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. 2. The facility failed to ensure Resident #2's physician's orders dated 01/24/25 were updated to include the resident no longer received wound treatment to DTI area to his left heel to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. These deficient practices could place residents at risk of improper care due to inaccurate medical records. The findings included: 1. Record review of Resident #1's face sheet, dated 03/20/25 reflected a [AGE] year-old female with diagnoses to include need for assistance with personal care, limitation of activities due to disability, and unspecified lack of coordination. Record review of Resident #1's admission MDS assessment, dated 03/02/25, reflected a BIMS score of 12 out of 15, indicating moderately impaired cognition. Record review of Resident #1's March 2025 Physician Order Sheet, dated, 03/20/25, reflected Wound Treatment-Collagen, Notes: Cleanse Stage 2 wound to Sacrum with Normal Saline or Skin Cleanser. Pat Dry. Apply Collagen to wound bed. Cover with Dry Dressing . with order date 02/27/25. Record review of Resident #1's March 2025 Treatments Administration record, dated 03/19/25, reflected Wound Treatment-Collagen One Time Daily Starting 02/27/25 . Cleanse Stage 2 wound to Sacrum with Normal Saline or Skin Cleanser, Pat Dry. Apply Collagen to wound bed. Cover with Dry Dressing . with Day Treatments signed off by nurses from March 1st to March 19th to include LVN A signing off for completing these treatments from March 17th to the 19th. Interview and observation on 03/19/25 at 1:30 PM, Resident #1 revealed there was no treatment done Page 1 of 3 676353 676353 03/21/2025 Coronado at Stone Oak 19638 Stone Oak Parkway San Antonio, TX 78258

F 0842 to her lower back. Resident #1 showed this area and there was no wound nor bandages to this area. Level of Harm - Minimal harm or potential for actual harm Interview on 03/20/25 at 11:15 AM, CNA E revealed she provided care to Resident #1 and Resident #1 did not have any wounds to her sacrum and there was no wound treatment done for this resident. Residents Affected - Few Interview on 03/20/25 at 12:52 PM, LVN A revealed Resident #1 no longer had a stage 2 wound on her sacrum as it was healed and said the physician's order for wound treatment needed to be discontinued. She revealed it was important to follow physician's orders to provide appropriate resident care. She further revealed she did not know when Resident #1's wounds healed. 2. Record review of Resident #2's face sheet, dated 03/20/25 reflected a [AGE] year-old male with diagnoses to include need for assistance with personal care, limitation of activities due to disability, and cognitive communication deficit. Record review of Resident #2's admission MDS assessment, dated 03/02/25, reflected a BIMS score of 06 out of 15, indicating severely impaired cognition. Record review of Resident #2's March 2025 Physician Order Sheet, dated, 03/20/25, reflected Wound Treatment-Skin Prep, Notes: Cleanse DTI area to Left heel with Normal Saline or Skin Cleanser. Pat Dry. Apply Skin Prep to affected area. Cover with Dry Dressing . with order date 01/24/25. Record review of Resident #2's March 2025 Treatments Administration record, dated 03/19/25, reflected Wound Treatment-Skin Prep One Time Daily Starting 01/24/25 . Cleanse DTI area to Left heel with Normal Saline or Skin Cleanser, Pat Dry. Apply Skin Prep to affected area. Cover with Dry Dressing . with Day Treatments signed off by nurses from March 1st to March 19th to include LVN B signing off for completing these treatments on March 19, 2025. Resident #2 declined to participate in an interview on 03/19/25 at 2:53 PM. Interview on 03/20/25 at 12:30 PM, CNA D provided care to Resident #2 and revealed Resident #2 did not have a wound to his left heel so there was no wound treatment done for this resident. Interview on 03/20/25 at 12:50 PM, LVN B revealed Resident #2 did not have any wounds on his foot because it healed. She revealed sign off that wound care per doctor's orders were done, but they did not need to put a dressing on Resident #2's foot anymore because it was healed. She further revealed the wound treatment nurse oversaw discontinuing these orders when the wounds had improved, but he had left, and the staff were adjusting to his absence and taking over his duties slowly. She further revealed she did not know when Resident #2's wound healed. Interview on 03/20/25 at 2:08 PM, the wound treatment nurse revealed the doctor orders of Resident #1 and Resident #2's wound treatment should have been changed to monitor the wounds and not provide wound treatment to them, because they have healed. He revealed he may not have relayed that information or updated before he left. He revealed the wounds have all improved when he was doing wound treatment before he left. Interview on 03/20/25 at 3:39 PM, ADON C revealed the LVN A and LVN B were new nurses and needed extra training to include signing off on doctor's orders. She revealed if the nurses signed the MAR this meant they completed that doctor's orders. She further revealed the wound treatment nurse left recently and the facility was taking over the wound treatment nurse's duties like updated the doctor's 676353 Page 2 of 3 676353 03/21/2025 Coronado at Stone Oak 19638 Stone Oak Parkway San Antonio, TX 78258

F 0842 orders for wound treatments. Level of Harm - Minimal harm or potential for actual harm Interview on 03/20/25 at 5:20 PM, the DON revealed the wound treatment for Resident #1 and Resident #2 were marked completed. She revealed the wound treatment nurse oversaw the doctor's orders and would have discontinued the wound care treatment orders after the wounds were healed. The DON further revealed she expected the nurses to not sign off that these treatments were done per doctor's orders. She further revealed these nurses should have let the ADON and DON know so they could update these doctor's orders. Residents Affected - Few Requested policy for following doctor's orders, specifically for treatments, and the DON revealed they did not have this policy on 03/21/25 at 11:45 AM. Requested policy for discontinuing orders and the DON revealed they did not have a policy for this on 03/21/25 at 1:46 PM. 676353 Page 3 of 3