Health inspection·September 18, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, based on the comprehensive assessment of a resident, the facility must ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of two residents) Resident #4 reviewed for pressure sores.The facility failed to ensure Resident #4 received treatment for a pressure sore to the sacrum according to orders. This failure could place residents at risk for worsening of the pressure sore and for infection. Findings included: Record review of the admission Record for Resident #4 revealed an [AGE] year old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included, but were not limited to, protein-calorie malnutrition, weakness, and gastrostomy status (feeding tube). Record review of Resident #4's Physician's Order, dated 08/26/25, revealed Resident #4 had a Stage 2 pressure sore. The order reflected the wound was to be cleansed with Dakins solution, pat dry, have medihoney applied, followed by Calcium Alginate. The wound was to be covered with a bordered foam gauze. The treatment was to be provided every three days. Record review of Resident #4's Care Plan, dated 03/10/25, read, in part .Administer treatments as ordered and monitor for effectiveness. Observation on 09/16/25 at 12:55 p.m. revealed GVN B assisted Resident #4 onto his left side. GVN B loosened the resident's brief. The resident had a 4 x 4 inch bordered gauze dressing on his sacral area. The date on the dressing was 09/12 (2025). It appeared to reflect an initial of LVN E There was a second 4 x 4 inch bordered gauze dressing on the resident's left buttock. The date was reflected as 09/12 (2025) and an initial of LVN E. The date and the initials were verified by GVN B.In an interview on 09/16/25 at 1:01 p.m., ADON A said Resident #4 received Hospice Services, and the Hospice nurse provided the treatments. She said if the date on the sacral dressing was 09/12/25, it should have been changed on 09/15/25, the previous day. Observation on 09/16/25 at 1:14 p.m. revealed GVN B provided wound care for Resident #4, accompanied by CNA C,. ADON A was also present. When Resident #4 was turned onto his left side, the dates on the sacral and left buttock were visible. Both dressings were removed and discarded by GVN B. Observation revealed an open wound at the sacral area of approximately 1.5 cm diameter. There was yellow slough visible, making depth measurement unobtainable. Observation revealed an open area on the left buttock approximately 1.5 cm diameter, with superficial depth. Observation of wound care technique revealed no concern.In an interview on 09/16/25 at 3:50 p.m., ADON A said the initial documented on Resident #4's dressing would be for LVN E. ADON A said Hospice usually provided wound care for Resident #4, but the Hospice service was transitioning nurses, so the facility nurses were providing wound care. In an interview via telephone on 09/17/25 at 5:00 a.m., LVN D said she had not provided wound care for Resident #4 recently. She said when she worked on Sunday (09/14/25) she did not provide the scheduled wound care because it had been done PRN on 09/12/25. In an interview on 09/18/25 at 12:48 p.m., the DON said Hospice had been providing wound care Residents Affected - Few Page 1 of 3 676396 676396 09/18/2025 S.P.J.S.T. Rest Home 3 248 Wisteria Lane El Campo, TX 77437

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for Resident #4. She said they did not use the communication book, but they would provide verbal report to the facility nurses. She said the dressing should have been changed on the routine day regardless of PRN treatments. She said going forward the facility nurses would be providing the treatments.Record review on 09/16/25 at 2:20 p.m. of Resident #4's September 2025 TAR revealed LVN D signed she provided the wound care on 09/14/25. LVN D's initial was not the initial documented on Resident #4's dressing. Record review of the facility's policy Wound Care (October 2010) read, in part .Documentation.2. The date and time the wound care was given.4. The name and title of the individual performing the wound care. 676396 Page 2 of 3 676396 09/18/2025 S.P.J.S.T. Rest Home 3 248 Wisteria Lane El Campo, TX 77437

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication cart (Medication Carts #1, #2 and #3) and 1 of 2 treatment carts (Treatment Cart #1) reviewed for medication storage. 1. The facility failed to ensure OTC medication stored in medication carts was labeled with the open date. 2. The facility failed to ensure wound care creams stored in the treatment cart were labeled with an open date. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. The findings include: Observation on 09/17/2025 at 11:10 a.m., of Medications Cart #1, #2 and #3 and Treatment Cart #1 with the DON, revealed the following: Medication Cart #1.Geri - Tussin, Robitussin oral solution, loosens and relieves chest congestion, did not have an open date. Medication Cart #2.Tylenol Extra strength 500mg, did not have an open date. Medication Cart #3.Vitamin D3 1000 [NAME] (25Mcg), did not have an open date.Refresh tear lubricant eye drop did not have an open date.Thera tears, therapy for your eyes, dry eye therapy, lubricant eye drops, did not have an open date. Treatment Cart #1Desenex, Antifungal foot powder with 2% Miconazole Nitrate, did not have an open date.Solosite wound gel, did not have an open date.Dermasil dry skin treatment, did not have an open date.SilvaKollagen Gel. Silver collagen wound Gel, did not have an open date.Hydrocortisone cream USP, 2.5%, did not have an open date.Coloplast, Triad Hydrophilic wound dressing, did not have an open date. Interview with MA A on 09/17/2025 at 11:30AM, MA A stated the OTC medication should have an open date written on them. She said they were still within the expiration date. She said that the medication aide and the nursing staff are responsible for ensuring all medications were labeled with an open date. She said it was important to write the open date to know for how long the bottle had been opened and may affect the health of the residents. This can put the residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. Interview with the DON on 9/17/25 at 1:35 PM, the DON stated the OTCs should have an open date written on them. She said they were still within the expiration date. She said it was important to write the open date to know how long the bottle had been opened and avoid putting residents at risk for not receiving the therapeutic effects of the medication or treatment. The DON said nurses and medication aides were responsible for checking the medication bottles and writing an open date on them. Interview with LVN A, on 9/17/25 at 2:20 PM, LVN A stated the OTCs should have an open date written on them. She said they were still within the expiration date. She said when medications were not dated when opened, the effectiveness of the medication could be altered, and residents would not get the full benefit of the medication when administered. Record review of the facility's policy and procedure titled Medication Labeling and Storage revised in February 2023 revealed: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 676396 Page 3 of 3