Health inspection·December 1, 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 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 1 of 3 residents (CR #1) reviewed for pressure ulcer treatment.The facility failed to ensure CR#1 with a documented sacral pressure injury (sustained force applied to the sacrum, the triangular bone at the base of the spine) received necessary wound treatment and monitoring.This failure could place the residents at risk of worsening wounds, infection, and hospitalization.Record review of CR #1's face sheet, dated 11/30/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and discharged on 11/16/2025. Record review of CR #1's admission MDS assessment, dated 09/22/2025, reflected diagnoses included of Sepsis unspecified organism (occurs when your immune system has a dangerous reaction to an infection) and Type 2 Diabetes (a lifelong disease that keeps your body from using insulin the way it should). CR #1's BIMS score was not reflected. The MDS revealed CR #1 had cognitive impairment. The MDS further revealed that Section M - Skin Conditions indicated CR #1 had pressure ulcers (injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time), among other skin alterations; upon admission to the facility on [DATE]. Record review of CR #1's care plan, dated 09/23/2025, reflected: Focus Area: Unstageable (wound) to sacrum. Goal: The resident will have no complications related to documented skin impairment through the review date. Interventions /Tasks: Evaluate and treat per physician's orders; evaluate resident for signs and symptoms of possible infections; follow facility protocols for treatment of injury; low air loss mattress, ensure functioning properly; nurse to assess/record/monitor wound healing with dressing changes. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements or declines to the MD; Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations, by wound nurse or provider. Record review of CR#1's clinical record revealed nursing staff submitted a wound care consultation at admission on [DATE]. Record review of CR #1's progress noted dated 09/19/2025, completed by Wound Care NP, revealed initial visit with Wound Care NP on 09/19/2025, there was no record of CR #1's identified sacral pressure injury being treated or assessed by the Wound Care NP at initial encounter on 09/19/2025 through CR #1's discharge date of 11/18/2025. Record review of CR #1 nurse progress note date 11/18/2025, reveal resident was transferred to hospital due to facial swelling to right side of face in the cheek area and eye. Record review of CR #1's EMR clinical documentation (MAR, TAR, Progress Notes and Physician order summary for September, October, and November 2025) revealed from 09/16/2025 through 11/18/2025:No documentation of wound care treatment was provided to the sacral pressure injury.No documented evidence of dressing changes on the sacral pressure injury.No documented evidence of wound staging and updates on the sacral pressure injury.No documented Residents Affected - Few Page 1 of 4 676454 676454 12/01/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few evidence of wound assessments of the sacral pressure injury.No documented evidence of measurements of the wound on the sacral pressure injury.There was also no documented evidence that nursing staff:Followed up with the provider regarding missing orders.Notified the DON or Administrator that orders were not provided.Escalated concerns when the wound was not being treated. Initiated interim wound care consistent with standards when no orders were received. Record review of CR #1' s Hospital admission record dated 12/05/2025 revealed CR #1 was admitted to the hospital on [DATE] with chief compliant of recurrence of R parotitis (term for a swollen parotid gland. Your parotid glands are located on the side of your face, between your ear and your jaw). CR #1 was previously admitted for sepsis on 09/08/2025 09/16/2025, underwent 2 tooth extractions of right upper molars with parotid duct fluid samples growing MRSA; discharged to SNF on 10 days of Bactrim, minocycline, Flagyl. There was multiple chronic pressure identified on CR # 1's admission to the hospital on [DATE]. There was no specific sacral pressure injury documented on CR # 1's admission to the hospital on [DATE]. As of 12/05/2025, the hospital noted pending SNF reauthorization for CR #1's return to the facility. Interview on 11/30/2025 at 2:00 PM, the DON stated that according to CR#1 admission evaluation and assessment completed on 09/16/2025 identified that CR #1 was admitted with a sacral pressure injury and several other identified skin conditions and injuries. She stated the expectation was when skin breakdown was identified, a wound consultation was submitted, and resident was assessed and treated by the Wound Care NP. She stated the Wound Care NP was responsible for providing orders related to wound care treatment. She stated that the nurse staff were responsible for implementing orders provided. She stated once the order was provided it would appear in the clinical MAR or TAR as an order or task to be implemented. She stated once orders were entered there was EMR monitoring and notification system to alert staff when wound treatments were overdue or missing. She stated that if orders were not provided and treatment was not implemented, it could delay wound healing and increase the risk of infection. She stated that she was familiar with CR #1 and had assisted in providing wound care to CR #1. She stated she recalled several wounds being treated but did not recall if a sacral pressure injury was treated. She stated a wound audit was completed monthly which included wounds being treated. Skin assessment and NP wound rounds were completed weekly. She could not explain how the CR #1's sacral pressure injury was missing. She also stated it was possibly due to the change in wound care documenting system that took place in September/2025. She stated the facility transitioned from one system to the current system (Wound Rounds) September/2025. She stated a skin sweep was completed on 12/01/2025, and no current residents residing at the facility were noted with missing identified skin breakdown. She stated as of 11/30/2025, she implemented a tracking system to ensure wound consults resulted in provider orders and treatment and or were congruent with nursing evaluation and skin assessment. She stated that when applicable, a follow-up with the provider regarding any identified missing wound assessments, treatment and orders was now required weekly. She stated staff would be trained starting 12/01/2025. Interview attempt via telephone, with Nurse K (nurse of record who completed the admission assessment on 09/16/2025) on 11/30/2025 at 3:20PM and 12/09/2025 at 6:45PM was unsuccessful as Nurse K was no longer employed by the facility and the telephone number on file was disconnected. Interview on 12/01/2025 at 1:39 PM, the Wound Care NP revealed it was her responsibility to assess, provide treatment, and provide wound care orders when she received a wound care consultation. The Wound Care NP stated she was familiar with CR #1. She stated CR #1 was admitted to the facility with several chronic pressure injuries. She stated that she had several wound treatment encounters with CR #1. She stated CR #1 was usually seen weekly, on Friday during wound care rounds and treatment provided was documented and reflected in the EMR record. She stated she could not recall if she 676454 Page 2 of 4 676454 12/01/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had provided treatment to CR #1's sacrum area. She confirmed that if CR #1 received treatment to a sacrum area wound, it was documented in the EMR progress note where orders and treatment plan are reflected. She stated a written record of treatment was also provided to the facility's Wound Care Nurse to reflect treatment implemented and updates related to all wounds treated and assessed. She stated both the EMR record, and written record were identical and should include wound care treatment implemented during wound care rounds, treatment orders such as dressing changes, wound staging, wound measurements, updates reflecting if wound was resolved, and any wound progression or deterioration. She stated if there was not a record documented then treatment was not provided. She stated CR #1 had several chronic pressure and skin injuries upon admission with delayed wound healing possibly related to the resident's was chronic infection history of an unknown source. She stated if the sacral pressure injury was not reflected in her treatment round notes and CR #1 had a sacral pressure injury documented in the initial skin assessment by the admitting nurse and wound care nurse the sacral pressure injury had been missed and left untreated and assessed in human error. She stated that when a wound consultation was received, she would review the residents' history and nursing evaluation provided by the facility's Wound Care Nurse to guide her in her initial assessment. She stated that she was uncertain how she missed the wound, if the sacral pressure injury was documented in the initial nursing evaluation. She stated that it was necessary to ensure all residents with skin breakdown received necessary treatment and services, consistent with professional standards of practice. She stated that if wound treatment was not received it placed the resident at risk for delayed wound healing and infection. She denied having any knowledge CR #1 presented with a worsening infection or decline in overall wellbeing.Interview on 12/01/2025 at 3:00 PM, the Wound Care Nurse confirmed the sacral wound was identified on admission and that a wound care consult was submitted. She stated per her assessment documentation; the sacral wound was identified. She stated she never received wound treatment orders per her review of CR #1's order summary. The Wound Care Nurse stated she could not recall if CR #1's sacral pressure injury was treated. She acknowledged all wound care treatment and orders were reflected in PCC (EMR system used by facility). She stated that if care was not documented in PCC no wound treatments were performed, and no provider orders were received and entered. She knowledge that she was present during wound care rounds completed by the Wound Care NP on 09/19/2025. She was unable to explain why the lack of treatment orders was not escalated to the DON or Medical Director. She stated she had not previously experienced missing a wound and a wound going untreated. She stated it was possible that the sacral wound was treated but not documented due to CR #1 condition of multiple. She stated that if wound treatment was not received it placed the resident at risk for delayed wound healing, infection and quality of care. She denied having any knowledge CR #1 presenting with worsening infection or decline in overall wellbeing. She confirmed that facility training related to wound care management and prevention had been provided but did not verbalize when. Interview on 12/01/2025 at 3:00 PM with Nurse A and CNA M, who were assigned to CR #1 during 09/16/2025 through 11/18/2025 revealed they were familiar and had provided care for CR #1. Both stated they recalled several wounds being treated for CR #1 but did not recall if a sacral pressure injury was treated. Nurse A stated that skin observations were not completed each shift, but were completed on the residents' shower days, and weekly by the wound care nurse. She stated it was everyone's responsible to the resident to ensure that wound treatment was provided. She stated it was possible for a wound and treatment to be missed if skin assessments were not completed and wound care orders were not provided. She stated if she identified a wound that may have been missed by the Wound Care Nurse or NP, she would notify both to obtain an order and implement care as soon as possible. She stated that 676454 Page 3 of 4 676454 12/01/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if wound treatment was not received it placed the resident at risk for delayed wound healing and infection. She denied having any knowledge CR #1 presenting with worsening infection or decline in overall wellbeing. Nurse A and CNA M stated that wound care prevention and infection control, and repositioning training had been recently provided but could not recall date of recent training. Interview on 12/02/2025 at 9:18 AM, the Wound Care Doctor stated that he was not familiar with CR #1. He confirmed that he was the medical provider the wound care nurse reported to. He stated that a wound consultation was submitted, the resident was assessed, and treatment was guided by the Wound Care NP. He stated that the initial skin evaluation and consultation was completed by the facility's nursing staff. He stated the Wound Care NP was then responsible for assessment and treatment planning for the identified wound. He stated the Wound Care NP assessment should identify the wound location, wound staging, wound measurements, and wound identification/type. He stated the assessment detail then would indicate the treatment plan, orders provided, and treatment implemented. He stated the Wound Care NP was responsible for treatment of all identified pressure injuries identified by the facility. He stated that if wound treatment was not received it placed the resident at risk for delayed wound healing and infection. He denied having any knowledge CR #1 presenting with worsening infection or decline in overall wellbeing related to lack of wound care provided. Interviews with staff (CNA D, Staff J, Nurse A, Nurse R) at varies times between 12N - 5PM on 11/30/2025 and 12/01/2025 revealed that staff had been trained on wound prevention, repositioning, infection control, and abuse and neglect. Record review and observations and conducted in the facility on 11/30/2025 and 12/01/2025, between 11AM - 3PM revealed pressure-relieving devices available for Residents (#1 and #2) with wounds. November MAR/TAR reveal treatment provided to Resident #1 and Resident #2. Progress notes and skin assessment for November 2025 reveal that documentation was congruent with Residents (1 and #2) wound present during surveyor's observation Staff observed repositioning residents. In-service and training documentation related to wound care order, prevention and management was requested on 11/30/2025, 12/01/2025, and 12/08/2025 and not provided by the facility. Review of the facility's current policy dated March 2020 titled, Treatment of Wounds: Dressing Changes-Performing reflected: The facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Typically, the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus.Any Wounds assessed will be captured in the PCC nursing evaluation, in progress notes, or by completing in Wound Rounds via Quick Shot (within 2-6 hours of admission) .Orders are verified or obtained as needed.Assessments and interventions implemented are documented in the resident clinical record. 676454 Page 4 of 4