Ignite Medical Resort Katy, Llc

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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