Health inspection·August 22, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few *Resident had behavior problem: non-compliant/refusal of care at times. Goals included: Resident will have no evidence of behavior problems. Interventions included: Anticipate and meet the resident's needs. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situation. Document behavior and potential causes. *Resident had fluctuations in cognitive function/impaired thought process due to mental and behavioral disorder. Goals included: Resident will be able to communicate basic needs on a daily basis. Interventions included: Keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Ask yes/no questions to determine needs. Communicate with resident and his family/caregivers regarding his capabilities and needs. Cue, reorient, and supervise as needed. *Resident's skin was fragile, and he was at risk for skin/pressure injury due to new or worsening skin condition, immobility, and incontinence; Cancer lesion of the scalp (01/25/2023) - resident refused to see dermatology because the lesion was not bothering him. Goals included: Resident skin injury will resolve without associated complications. Interventions included: Apply treatment as ordered. Follow community's practice for assessing skin, reporting skin concerns to charge nurse, doctor, resident or representative and follow skin protocol in place as indicated. *Resident had an actual impairment to skin integrity of the scalp due to cancer lesion. Goals included: Resident will have no complications due to cancer lesion of the scalp. Interventions included: Cleanse top of the scalp with normal saline/wound cleanser, pat dry, apply A&D Ointment and cover with dry dressing PRN. Encourage good nutrition and hydration in order to promote healthier skin. Monitor for side effects of the antibiotics and over-the-counter pain medications. Monitor/document location, size, and treatment of sin injury. Report abnormalities, failure to heal, signs/symptoms of infection, and maceration to doctor. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and any other notable changes or observations. Observation and interview with Resident #1 on 07/21/2023 at 11:45 a.m. revealed he was alert, oriented, and very hard of hearing. Resident #1 was in bed and had a large, irregular shaped wound on the top of his head with a dark-colored scab. Further observation revealed there was no dressing covering the scalp wound. A follow-up observation and interview with Resident #1 on 07/21/2023 at 2:30 p.m. revealed his scalp wound was dressed and appropriately dated. Resident #1 stated the nurse came in a while ago to put a dressing on his head. He said he could not recall if the nurse attempted to cover his scalp wound earlier that morning (07/21/2023). Record review of Resident #1's physician's orders revealed the following orders: *Cleanse top of scalp with normal saline/wound cleanser, pat dry. Apply A&D Ointment and cover with dry dressing every MWF, every day shift every Monday, Wednesday, and Friday for wound treatment. Order date: 06/29/2023. Start Date: 06/30/2023. *Cleanse top of scalp with normal saline/wound cleanser, pat dry. Apply A&D Ointment and cover with dry dressing PRN, as needed for wound treatment. Order date: 06/29/2023. Start Date: 06/29/2023. Record review of Resident #1's TAR for July 2023, printed on 07/21/2023 at 1:44 p.m. revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676479 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 following: Level of Harm - Minimal harm or potential for actual harm Cleanse top of scalp with normal saline/wound cleanser, pat dry. Apply A&D Ointment and cover with dry dressing every MWF, every day shift every Monday, Wednesday, and Friday for wound treatment. The entry box for 07/21/2023 was checked and initialed by LVN A, indicating the treatment was completed. Residents Affected - Few In an interview with LVN A on 07/21/2023 at 12:15 p.m., she stated Resident #1 had orders to apply A&D ointment and cover his scalp wound with a dressing, but if she covered it, it would get mushy and would go in the wrong direction (get worse). LVN A stated Resident #1's current orders said to put a dressing on the scalp wound all the time. She said they were leaving it open before, as previously ordered by his doctor. She said Resident #1's scalp wound, and an ear wound were reoccurring due to cancer, so she was very familiar with treatments. She said she dealt with the wound daily, so she knew when it was not good to dress it. She said it was best to leave the wound open to the air so it would not accumulate moisture. She said that was what she did with his scalp wound. She said sometimes Resident #1 wanted a dressing on the scalp wound, and sometimes he did not. She said Resident #1 would tell her what to do and to not do. She said if a resident said to stop, that was what she did. She said when she did Resident #1's wound care earlier on 07/21/2023, she cleansed the scalp wound and was about to apply the dressing when he told her to stop. She said Resident #1 did not want her to put the dressing on. She said she would leave the wound open and return before the end of her shift to complete the treatment. LVN A stated Resident #1's family member complained about the resident's scalp wound not being covered when she visited, but she (LVN A) told the family member all she (LVN A) could do was chart that he did not want the dressing on there. She said Resident #1's scalp dressing was on the majority of the time when his family member visited. She said sometimes, Resident #1 did not want the dressing on his scalp when she initially attempted, and he told her to come back later. LVN A said she documented when Resident #1 did not allow her to apply a dressing on the scalp wound all day. She said if Resident #1 initially said no but allowed her to dress the wound later in the same day, she did not document in his notes. She said she completed Resident #1's other wound care earlier (on 07/21/2023), but she would return later to complete the scalp treatment. She stated Resident #1 never experienced a negative outcome from not having his scalp wound dressed. Record review of Resident #1's progress notes in the facility's computer system for June 2023 and July 2023 on 07/21/2023 at 12:30 p.m. revealed no documentation to indicate Resident #1 refused any wound care treatment or asked LVN A to return later to complete a wound care treatment. In a telephone interview with Resident #1's family member on 07/21/2023 at 2:00 p.m., she stated she visited Resident #1 regularly and there was often no dressing on his scalp wound. She stated she spoke to LVN A about the dressing several times, but she (LVN A) fought her about it and would not but the dressing on. In an interview with the DON on 07/21/2023 at 2:45 p.m., she stated Resident #1's scalp wound should have been dressed at all times and LVN A should have documented every time the resident refused the treatment even if he allowed her to complete the treatment later in the day. She stated Resident #1 never experienced a negative outcome from not having the wound covered. Record review of facility policy titled Treatment Administration dated June 2022 revealed, Policy: Treatment Administration, Responsibility: Licensed Nurse . Purpose: To provide treatment per physician's order. Procedure: 1. Review physician's orders for treatment . 30. Document the treatment on the treatment record as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676479 If continuation sheet Page 3 of 3