Health inspection·November 20, 2025

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 interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (CR #1) reviewed for quality of care.-The facility failed to ensure a thorough head to toe skin assessment was completed on CR #1 on 8/29/25. CR #1 was discharged to an acute care hospital on 8/30/25 and was diagnosed with a left groin abscess.This failure could place residents at risk of delayed treatment, pain and infection.Findings Include:Record review of CR #1's admission record dated 11/10/25 revealed a [AGE] year-old male who admitted on [DATE] and discharged on 8/30/25 to an acute care hospital. His diagnosis included in part, Alzheimer's disease, pain, basal cell carcinoma of skin of left upper limb, and basal cell carcinoma of skin of right upper limb. (Basal cell carcinoma is a type of skin cancer).Record review of CR #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 00 out of 15 which indicated severe cognitive impairment. He required supervision or touching assistance and setup or clean-up assistance with ADL care. He did not exhibit behaviors of rejection of care during the assessment period.Record review of CR #1's care plan revealed he had impaired urinary elimination related to obstruction of urinary flow secondary to enlarged prostate gland. Interventions were to assess and monitor urinary incontinence and skin condition, assess and monitor urinary status and signs/symptoms of infection, perineal care, date initiated 5/28/25. CR #1 was at risk for pressure ulcer related to decreased mobility, incontinent of bowel and bladder, use of right ankle brace, use of CPAP at bedtime, CR #1 reluctant to allow staff to assist with peri care and/or ADL care, date initiated 12/1/24 and revised on 9/5/25. Interventions were to check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown, date initiated 1/3/25. Record review of CR #1's Order Summary Report dated 11/20/25 indicated an order for Weekly Head to Toe Skin Assessment every day shift every Friday, N=new, E=existing skin alteration, C= clear, order date 1/7/25.Record review of CR #1's nursing note dated 8/27/25 written by LVN F read in part, Resident's sitter reported to this writer about 1030 hrs (10:30 a.m.) that resident's pullup had what appears to be a little bit of blood-tinged urine in it. This writer monitored resident for other bleeding the rest of the shift and none was seen. Provider notified of isolated incident and order was given for UA with C&S. [family members] notified.Record review of CR #1's SBAR dated 8/27/25 completed by LVN F revealed the resident had blood in urine and a skin evaluation was not clinically applicable to the change in condition being reported.Record review of CR #1's MAR for August 2025 indicated on 8/29/25 a weekly head to toe skin assessment was documented as completed by LVN J. There was an e documented which indicated existing skin alteration. Record review of CR #1's nursing note dated 8/29/25 written by LVN J read in part, .late entry. skin assessment completed, noted with existing upper back skin abnormalities. No s/s of redness/infection noted to right shoulder biopsy site. Skin intact. Resident schedule for DERM appointment today.Record review of CR Residents Affected - Few Page 1 of 3 676357 676357 11/20/2025 The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1's nursing note dated 8/30/25 written by LVN F read in part, Resident noted with what appears to be an abscess to the left groin area, between the crease of the left leg and the pubic area. Abscess was draining and had a real foul odor. Resident groaned in pain when palpated (examined by touch). [Family member] at bedside. Vitals stable. NPs of MD J was notified, and they ordered for him to be sent to the ED for further evaluation.Record review of CR #1's hospital records dated 9/4/25 indicated CR #1 was admitted from the ED on 8/30/25 and on 8/31/25 had an incision and drainage of left groin. The infectious disease progress note revealed a 3.6 x 2.3 cm medial (middle) left groin abscess adjacent to hip adductors (a group of muscles located in the medial compartment of the thigh). Assessment/plan: polymicrobial (several types of microorganisms) left inguinal (groin) abscess with enteric flora (bacteria that exist in the intestines of animals and humans) status post-surgical I&D with clinical improvement. CT of the abdomen and pelvis with IV contrast completed on admission without evidence of any perineal or GI tract pathology to explain abscess formation. Exam on admission did show evidence of skin breakdown in the area with 2 wounds which could have led to contamination with enteric flora due to its location and eventual abscess formation.In an interview on 11/18/25 at 2:26 p.m. LVN F said CR #1 had a private sitter and a few days before he was sent out to the hospital the sitter said there was a little bit of blood in his pull up. She said she and another staff did a skin check on CR #1 (on 8/27/25) and did not see any open areas. She said there was no pain or odor. She said she tried to look in the creases but did not pry because CR #1 would not allow it, refused to be touched and was not easy to redirect. CR #1 said no stop, and zipped up his pants. She said she reported to the NP that she did not see any bleeding, no odor, and there was no sign of anything being there. She said she got an order for a UA and thought the blood was coming from his urine. She said the urinalysis was collected 2 days later because CR #1's dementia was bad, and he did not know what to do when staff tried to collect the urine. She said when she returned to work on Saturday 8/30/25 CR #1's family member found an open area on him that looked like an abscess. She said she lifted up his penis and the abscess was in the fold and crease. She said the abscess was oozing and the odor was really bad and foul and he was in pain. In an interview on 11/19/25 at 11:13 a.m. CR #1's family member said she knew there was something going on with CR #1 because he had blood in his pull up. She said she arrived at the facility on Saturday morning, 8/30/25, and there was blood all over his chair and bed. She said she had CR #1 lay down so she could examine him, and the smell was unholy. She made the facility call 911 and get CR #1 into an ambulance. She said she believed the abscess had been there for weeks and had gone internally. In an interview on 11/19/25 at 12:33 p.m. CR #1's private sitter said one day she took CR #1's pants down and there was blood in his pull up and on the side which was unusual. She said she took a picture and notified the nurse who said they would do a urinary tract test. She said she assisted him with a bath on that day, and he pushed her hand away when she tried to assist him. She said every day was different with showers because of his dementia, and CR #1 would usually say he would wash himself. She said CR #1 had a doctor's visit on 8/29/25 and the facility bathed him. She said she did not recall seeing any blood spots or anything unusual on that day. She described the abscess as a huge hole in the groin with pus and said you could not see it unless you put your face under his groin. In an interview on 11/19/25 at 1:40 p.m. LVN J said on 8/29/25 she completed a head-to-toe assessment on CR #1 but did not look at his groin area and did not lift his balls because he did not complain of discomfort, there was no blood anywhere including the pull up, and she did not suspect anything. She said the only areas she did not lift during the assessment were his scrotum/balls area. She said when she returned to work it was reported that the abscess was found in that area. She said during a head-to-toe skin assessment you have to 676357 Page 2 of 3 676357 11/20/2025 The Broadmoor at Creekside Park 5665 Creekside Forest Drive The Woodlands, TX 77389

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few check and look at everything. She said she was trained on head-to-toe skin assessments and should look at the person and review for any abnormalities or anything suspected. She said the purpose of the head-to-to-toe skin assessment was to prevent any open areas, which would be reported to the supervisor and wound care nurse. She was unsure of what could happen if every part of the resident's body was not examined during a head-to-toe skin assessment. In an interview on 11/19/25 at 1:52 p.m. the DON said they believed CR #1's tinge of blood was a UTI but found out he had an abscess that had not ruptured yet. She said the facility staff had not seen an abscess on CR #1. She said nurses should look at the creases, moist areas, folds, and every inch of the body during a head-to-toe skin assessment. She said those areas of the body were more susceptible to bacteria. She said as a result of the incident with CR #1, the facility conducted in-services, conducted a QAPI, PIP and a very thorough skin sweep. She said the ADON, wound care nurse, and unit managers were overseeing the skin assessments.In an interview on 11/19/25 at 2:15 p.m. the Administrator said the facility was treating CR #1's small blood as a possible UTI and a UA was ordered. She said the area was a boil and the resident would not allow the staff to wash him. She said during his shower there was nothing on the washcloth. She said the facility always investigated concerns and 99% of the time she would take the time and re-educate staff. She said head to toe assessments were conducted on all residents and the facility QAPI'd the incident. She said the conclusion of their investigation was that something may have been festering but the abscess just popped out. She said head to toe skin assessments should be completed regularly and were based on the patients' behavior and compliance. In an interview on 11/19/25 at 3:33 p.m. CR #1's MD J said an abscess just popped up on CR #1 and CR #1's family member noticed it. He said the abscess was in the groin area and if it was small, it could be hard to feel. He said an abscess could absolutely pop up overnight and the resident would show signs that something was there. He said signs and symptoms of an abscess could be fever, pain, and being uncomfortable.In an interview on 11/20/25 at 10:35 a.m. CNA S said she assisted CR #1 with a shower on 8/29/25. She said CR #1 washed in between his private area and underneath his balls (testicles) and there was no blood on the white bath towel or in his pull up. He dried the front and back of his body with no concerns and no pain expressed. She said she did not see his private area. She said CR #1's sitter rechanged his pull up, dressed him, and took him to a doctor's appointment. CR #1 did not complain of any pain to her on Friday 8/29/25. She said she would have reported any areas of concern to the nurse. Record review of the facility's Skin Assessment policy dated 10/1/25 read in part, . policy: it is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. 2. Procedure. e. begin head to toe, thoroughly examining the resident's skin for condition. Pay close attention to pressure points, bony prominences, and underneath medical devices.Record review of the facility's Ad Hoc QAPI Plan dated 9/4/25 read in part, Problem: External reportable to HHSC for allegation of neglect. Abscess to resident groin. Resident refuses care and toilets himself. Facility action: patient safe surveys on interviewable patients, safe survey follow up if appropriate, head to toe assessments, in-service on ANE, in-service on skin, Inservice on continence, in-service on ADLs and dealing with difficult residents, medical director notification, psychosocial well being assessment if resident returns to the facility, accident/incident report, pain monitoring audit, head to toe evaluations audit. 676357 Page 3 of 3