Health inspection·September 5, 2023

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 received treatment and care in accordance with professional standards of practice based on the comprehensive assessment of a resident for 1 (Resident #1) of 5 residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure that Resident #1 received timely orders for wound care for wounds present on admission to the facility. The failure could place residents at risk of infection and wound deterioration. Findings include: Record review of Resident #1's face sheet dated, 8/31/2023, Resident #1 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included fracture right hip and femur (large thigh bone) Record review of Residents #1's admission MDS dated [DATE], revealed a BIMS score of 11 indicative of moderate cognitive impairment. Section M/skin conditions revealed the presence of a surgical wound and diabetic foot ulcer. Resident #1 required the assistance of 1 staff member for all ADL care and was dependent on staff for bathing. Record review of Resident #1's initial admission Record completed by LVN A dated 8/16/2023 section 12: Skin integrity revealed skin problems on admission was marked as yes. Site was marked as other toes; type of issue was marked as vascular. Documentation reads scabs to bil toes, redness to BIL heels and coccyx (lower back). Record review of Resident #1's Progress note entry dated 8/23/2023 indicated Resident #1 was seen by the WCP for initial wound care consultation. The Wounds were documented as follows: *Site #1 diabetic wound to left heel measurements 2.5x2.5cm with no visible drainage, blood filled blister present to wound bed. *Site #2 diabetic wound to left fourth toe with full thickness (all levels of the skin), measurements 0.7x0.7cm without visible drainage, wound bed is covered with a thick black clump of dead tissue. *Site #3 diabetic wound to left third toe with partial thickness (involves 2 levels of skin) measurements 0.6x0.5cm with no visible drainage. Page 1 of 5 676395 676395 09/05/2023 The Healthcare Resort of Plano 3325 West Plano Parkway Plano, TX 75075

F 0684 *Site #4 diabetic wound to left first toe with partial thickness, measurements 0.3x0.4cm no visible drainage. Level of Harm - Minimal harm or potential for actual harm *Site #5 arterial (caused by damaged blood vessel) wound to right first toe with full thickness, measurements 2.9x2.4 cm with no visible drainage. Wound bed was covered by a thick black clump of dead tissue. Residents Affected - Few *Site #6 diabetic wound to right heel, full thickness measurements 3.6x4.0x0.2cm with visible light serous (thin, watery fluid) drainage. Wound bed was covered by a thick black clump of dead tissue. There was no documentation reflecting acknowledgement of the presence of a surgical wound to the right hip. Review of Skin Ulcer Non-Pressure Weekly report dated 8/24/2023 completed by the WCN, revealed wounds named as sites 1 - 5 were identified on admission to the facility on 8/16/2023. Review of Resident #1's physician orders dated 8/31/2023 revealed the absence of orders for wound care prior to 8/23/2023 for the following wounds: Left heel, left first, third and fourth toe, right heel and right first toe. Review of Resident #1's physician orders dated 8/31/2023 revealed as of 8/26/2023 wound care: incision right lateral hip. Cleanse with NS, Pat dry, cover with non-adherent dressing daily and PRN soiling or dislodged, every day shift. Prior to 8/26/2023 no order for wound care to the right hip was found. Review of Resident #1's TAR, dated August 2023 revealed there was no documentation of the completion of wound care specific to the right lateral hip until 8/30/2023. In an interview on 08/31/2023 at 3:40 PM, the WCN stated Resident #1 was admitted after hours. She does not recall receiving information from the admitting nurse regarding the initial skin assessment. The WCN admitted that no treatment was received for the surgical site until 8/30/2023. She stated we missed it on admission, and she was made aware of it when questioned by the provider after a follow up appointment on 8/26/2023. Orders were obtained for the surgical wound on the right hip but not entered into the TAR until 08/30/2023. The WCN stated this delay in treatment could put the resident at risk for complications. In an interview on 8/31/2023 at 4:20 PM the ADM was not aware of the delay in obtaining wound care orders for Resident #1. In an interview on 9/5/2023 at 10:24 AM the WCN stated on 8/17/2023 and 8/18/2023 she was not in the facility for her regularly scheduled hours. The WCN stated the facility did not have a person identified as the back-up to the wound care nurse. The WCN stated on 8/22/2023 she notified the WCP that treatment orders were needed for a new admission who admitted [DATE] with no orders for wound care. The WCP provided treatment orders for the following wounds: left heel, left first, third and fourth toe, right heel and right first toe. In an interview of 9/5/2023 at 11:32 AM the DON stated skin issues found during the initial skin assessment were to be communicated to the WCN verbally or via text message. It was the DON's expectation that the WCN reviews all admission skin assessments and completes a skin assessment focused on 676395 Page 2 of 5 676395 09/05/2023 The Healthcare Resort of Plano 3325 West Plano Parkway Plano, TX 75075

F 0684 Level of Harm - Minimal harm or potential for actual harm the identified skin issues. In this instance, the WCN was not in the facility on 8/17/2023 or 8/18/2023 during her regular hours. The facility does not have a person designated as back up to the WCN. This caused a resident to not have his wounds treated timely, which could lead to them getting worse. Residents Affected - Few 676395 Page 3 of 5 676395 09/05/2023 The Healthcare Resort of Plano 3325 West Plano Parkway Plano, TX 75075

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #3) of four residents reviewed for infection control. Residents Affected - Few WCN failed to utilize appropriate infection control practices during wound care to Resident #3. This deficient practice could place residents at risk of infection, slow wound healing, and or a decline in health. Findings include: Record review of Residents #3's face sheet revealed an [AGE] year-old male admitted to the facility 08/24/2023. His diagnosis included cellulitis (infection of the skin caused by bacteria) of the right lower leg. Resident #3's admission MDS dated [DATE], revealed Resident #3 rarely understood and was rarely able to understand. The MDS was in progress at the time of the investigation. Review of Resident #3's wound care orders reflected: as of 08/30/2023 cleanse wound to right heal : cleanse with NS, pat dry. Apply hydrogel (water based antibacterial gel), calcium alginate (medicated gauze patch) w silver, cover with ABD(super absorbent dressing) pad and wrap with gauze roll once daily for 30 days. Observation of wound care on 08/31/2023 at 10:04 AM, WCN nurse was observed to place supplies needed for wound care on a sanitized bedside table. Supplies included NS, gauze squares, a plastic medicine cup which contained antibacterial gel, a medicated patch, 1 abd pad, and 1 roll of rolled gauze. The wound was located on Resident #3's right heel. The wound was observed as circular in appearance, estimated size 2x2 cm with an area dark/black tissue in the center of the wound bed. The WCN applied new gloves and cleaned the wound with NS and patted the wound dry. She removed her gloves, performed hand hygiene and applied clean gloves. The WCN picked up the plastic cup of the antibacterial wound gel and used her gloved right index finger scooped the antibacterial gel onto her finger and applied it directly on the wound. The WCN picked up the medicated patch and placed it on top of the gel and covered it with the ABD pad and secured everything in place with the rolled gauze. In an interview on 8/31/2023 at 3:40 PM the WCN stated when applying ointments or gels to wounds one should use something sterile i.e. qtip or tongue depressor. The WCN said she used her clean gloved finger when doing Residents #3's wound care because she did not have any applicators. The WCN was not aware of a reason why she did not have any tools for applying gels or ointments to a wound. The WCN said using something sterile would prevent contamination of a wound which could cause a wound to get worse and cause the resident to be sick. In an interview on 08/31/2023 at 3:58 PM, the DON stated when applying gels or ointments directly on a wound, an applicator such as a tongue blade should be used. The DON has not been told that the facility does not have items that could be used during wound care to apply ointments or gels. The use 676395 Page 4 of 5 676395 09/05/2023 The Healthcare Resort of Plano 3325 West Plano Parkway Plano, TX 75075

F 0880 of applicators during wound care prevents contamination of the wound. Level of Harm - Minimal harm or potential for actual harm In an interview on 08/31/2023 4:20 PM, the Adm was not aware of any issues regarding supplies needed for wound care. Residents Affected - Few Review of facility policy, revised May 2007, and titled Infection Control Policy/Procedure: Wound Care Treatment Guidelines did not address the application of gels or ointments directly to a wound bed. 676395 Page 5 of 5