Health inspection·April 26, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 7 (Resident #42) residents reviewed for care plan revisions. The facility failed to ensure Resident #42's care plan was updated to reflect he was receiving end of life hospice care. This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of Resident #42's face sheet dated 04/26/2023, indicated an [AGE] year-old male who initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory) and cardiomyopathy (a disease of the heart muscle, making it hard for the heard to deliver blood to the body). Record review of Resident #42's quarterly MDS dated [DATE], indicated he was sometimes understood and usually understood others. Section O, (special treatments, procedures, and programs) reflected Resident #42 received hospice care. Record review of Resident #42's order summary report dated 04/26/2023, indicated he had a physician's order to admit to hospice on 08/31/2022. Record review of Resident #42's comprehensive care plan dated 09/13/2022 failed to indicate he was receiving hospice services. During an interview on 04/25/2023 at 1:43 p.m., the ADON of Resident #42's hospice provider indicated he was receiving hospice services at this time. During an interview on 04/26/2023 at 2:10 p.m., the MDS nurse said she was responsible for updating Resident #42's care plan when he elected to receive hospice services. The MDS nurse said Resident #42 was at risk of not receiving the care he desired. The MDS nurse said the morning meetings was where she received information regarding updating the comprehensive care plans. During an interview on 04/26/2023 at 2:46 p.m., the DON said she expected the care plan to reflect the needs of Resident #42. The DON said Resident #42 was receiving hospice services. The DON said Page 1 of 9 455569 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing staff were responsible for updating the care plan during the morning meetings, during care plan meetings, and as needed. The DON said the care plan ensured Resident #42 received his desired services. During an interview on 04/26/2023 at 2:56 p.m., the Administrator said she expected Resident #42's care plan to reflect his desired care for hospice services. The Administrator said the care plan should reflect a picture of the resident's care needs. The Administrator said the nursing managers and the MDS nurse, were responsible for updating and monitoring the care plan for needed revisions. Record review of an undated Comprehensive Care Planning policy indicated the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. 455569 Page 2 of 9 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #48) reviewed for respiratory care and services. Residents Affected - Few The facility failed to administer oxygen at 3.5 liters per minute via nasal cannula as prescribed by the physician for Resident #48. This failure could place residents at risk for developing respiratory complications. Findings included: Record review of Resident #48's face sheet, dated 04/26/23, indicated Resident #48 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure (occurs when the heart muscle does not pump blood as well as it should), and chronic respiratory failure (condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). Record review of Resident #48's annual MDS, dated [DATE], indicated he was usually able to make himself understood and was usually able to understand others. He had a BIMS score of 14 which indicated intact cognition. He did not exhibit behaviors of rejection of care or wandering. He was independent in all activities of daily living except for toileting and personal hygiene, which required supervision assistance. He had oxygen therapy both while not a resident of the facility and while a resident of the facility. Record review of Resident #48's physician's orders, dated 04/26/23, indicated he was ordered O2 at 3.5 LPM via N/C. The order start date was 07/21/22. Record review of Resident #48's undated care plan indicated a care plan initiated on 02/14/23, and revised on 04/07/23, with a focus of oxygen therapy. The care plan had a goal of the resident will have no signs or symptoms of poor oxygen absorption through the review date. Interventions included: encourage or assist with ambulation as indicated, for residents who should be ambulatory, provide extension tubing or portable oxygen, monitor for signs and symptoms of respiratory distress and report to doctor as needed, and notify the nurse if oxygen is off the resident. Record review of Resident #48's MAR for the month of April 2023 indicated he received oxygen from 04/01/23 through 04/26/23. During an observation on 04/24/23 at 12:30 PM, Resident #48 had oxygen in place. His oxygen concentrator was set at 4 LPM. During an observation on 04/24/23 at 02:20 PM, Resident #48 was in the dining room playing Bingo, sitting upright in his wheelchair. He had oxygen in place. His portable oxygen tank was set to 4LPM. During an observation and interview on 04/25/23 at 08:26 AM, Resident #48 was sitting upright in 455569 Page 3 of 9 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0695 Level of Harm - Minimal harm or potential for actual harm his room in his bed. He had oxygen in place. His oxygen concentrator was set at 4LPM. He said he normally wears 3.5LPM of oxygen all the time. During an observation on 04/25/23 at 09:08 AM, Resident #48 was sitting upright in his wheelchair in Hall 3 with oxygen in place. His portable oxygen tank was set at 3LPM. Residents Affected - Few During an observation on 04/25/23 at 03:23 PM, Resident #48 was lying in bed in his room. His oxygen concentrator was set at 4LPM. During an observation on 04/26/23 at 08:17 AM, Resident #48 was sitting upright in his bed in his room. His oxygen concentrator was set to 4LPM. During an interview on 04/26/23 at 12:58 PM, LVN A said the oxygen concentrator should have been set at 3.5LPM. He said the direct care nurse was responsible for ensuring the oxygen concentrator and portable oxygen was set correctly. He said he checks the oxygen concentrator 3-4 times a day. He said he did not think Resident #48 would suffer any negative effects from his oxygen concentrator being set too high. He said if Resident #48 was not getting enough oxygen he could suffer dyspnea (shortness of breath) or low oxygen saturation (the amount of oxygen circulating in the blood). He said the portable oxygen could have been bumped to the wrong rate while Resident #48 was moving around in the wheelchair. He said the concentrator set at the wrong rate could be Resident #48 messing with it. During an interview on 04/26/23 at 01:12 PM, the ADON said the direct care nurse was responsible for ensuring the oxygen concentrator and portable oxygen was set at the ordered LPM. She expected the oxygen set to the rate the doctor had ordered. She said Resident #48 could have decreased respiratory drive when his oxygen was set too high. She said the DON was responsible for monitoring the oxygen concentrators. She said when Resident #48's oxygen was set too low he could suffer dizziness and shortness of breath. She said she expected the nurses to check the oxygen concentrators at least three times a shift. She said it was possible Resident #48 could have bumped the oxygen concentrator and caused the rate to be set incorrectly. During an interview on 04/26/23 at 02:31 PM, the DON said she expected the oxygen concentrator to be set at the ordered rate. She said the nurses were responsible for ensuring the rate was set correctly. She said the ADON and DON were responsible for ensuring the nurses were checking the oxygen concentrators. She said she expected the nurses to check the oxygen concentrators at least once a shift, and when they did any treatments. She said Resident #48 could become confused when the oxygen concentrator was set too high. She said Resident #48 could have shortness of breath when the oxygen was set too low. During an interview on 04/26/23 at 02:35 PM, the Administrator said she expected the nurses to follow physician orders. She said the direct care nurses were responsible for ensuring the oxygen concentrators were set at the correct rate. She said the DON and ADON were responsible for ensuring the nurses were checking the oxygen concentrators. She said she was not sure if Resident #48 could suffer harm by receiving the wrong rate of oxygen. Record review of the facility's Oxygen Administration policy, last revised 02/13/07, stated: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (I/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of 455569 Page 4 of 9 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0695 Level of Harm - Minimal harm or potential for actual harm concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator Residents Affected - Few .Procedure 1. Become familiar with the type of oxygen administration, medical diagnosis, and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered .5. Assemble the concentrator: . .b. Turn on the flow and set the desired rate. Note that the water in the humidifier is bubbling and hold hand near the device to feel the flow. 6. Assemble the cylinder .d. Open the regulator and adjust to the desired rate . 455569 Page 5 of 9 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 20 residents (Resident # 18) reviewed for dialysis. Residents Affected - Few The facility failed to ensure Resident #18 had a physician order for dialysis. This failure could place residents at risk for not receiving appropriate care and treatment services. Findings included: Record review of a Resident #18's face sheet, dated 04/26/2023, indicated a [AGE] year-old-female who admitted on [DATE] with diagnoses including chronic kidney disease stage 5 (kidney cease functioning on a permanent basis) with dependence on renal (kidney) dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Record review of Resident #18's admission MDS, dated [DATE], indicated he was understood and understood others. Resident #18 had a BIMSs (Brief Interview for Mental Status) score was 14 indicated she had intact cognition. The MDS indicated in Section O (special treatments, procedures, and programs) Resident #18 received dialysis. Record review of Resident #18's comprehensive care plan, created on 04/18/2023, indicated Resident #18 needed hemodialysis related to renal failure. The care plan indicated Resident #18 was encouraged to attend the scheduled dialysis appointments. Record review of Resident #18's order summary report, dated 04/26/2023, indicated there was no order for hemodialysis. During an observation and interview on 04/25/2023 at 8:30 a.m., Resident #18 said she received hemodialysis in a dialysis center outside the facility three times a week on Monday, Wednesday, and Friday. Resident #18 said she had to restart hemodialysis due to her kidney transplant failing. During an interview on 04/26/2023 at 2:31 p.m., LVN A said he was unaware Resident #18 did not have a physician's order for hemodialysis. LVN A said all procedures including hemodialysis required a physician's order. LVN A said Resident #18 not having an order for hemodialysis placed her, at risk for missing her dialysis treatment. During an interview on 04/26/2023 at 2:46 p.m., the DON said Resident #18 should have had an order for dialysis, but she did not. The DON said not having the physician's order for dialysis placed Resident #18 at risk for not receiving her scheduled dialysis treatments. The DON said she was responsible for reviewing the admission orders. During an interview on 04/26/2023 at 3:01 p.m., the Administrator said she expected Resident #18 to have an order for hemodialysis. The Administrator said a physician's order was needed for all care. The Administrator said by not having a physician's order for dialysis Resident #18 was at risk for 455569 Page 6 of 9 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not receiving her services. The Administrator said admission orders were reviewed by the nursing managers. Record review of the facility's policy and procedure titled Physician's Orders dated 2015 indicated the purpose was to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.4. The receiving nurse will contact any other department, or external facilities as required, i.e., dietary department, pharmacy, lab provider, x-ray provider, etc. 455569 Page 7 of 9 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

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, interview, and record review, the facility failed to 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 1 of 2 residents (Resident #17) reviewed for infection control practices. Residents Affected - Few CNA B during incontinent care failed to perform hand hygiene prior to exiting Resident #17's room to obtain more gloves and exiting Resident #17's room after incontinent care for a pillowcase. These failures could place residents and staff at risk for cross contamination and the spread of infection. Findings included: Record review of Resident #17's face sheet dated 04/26/2023, indicated a [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE] with the diagnoses of Alzheimer's dementia (a progressive disease that destroys memory) and difficulty swallowing. Record review of Resident #17's quarterly MDS dated [DATE], indicated she was rarely understood and rarely understood others. The MDS indicated Resident #17 required total assistance with bed mobility, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #17 was always incontinent of bowel and bladder. Record review of Resident #17's comprehensive care plan, dated 12/06/2022, indicated she was dependent on staff for ADLs. During an observation and interview on 04/26/2023 at 9:05 a.m., CNA B donned (applied) clean gloves, removed the trash bag from the trashcan next to Resident #17's bed and placed it on the bed linen. CNA B removed numerous incontinent wipes and placed them inside the trashcan liner on Resident #17's bed. Resident #17's was soiled with urine. CNA B cleansed Resident #17's front perineal area, then touched the incontinent wipe package to remove more wipes with the same pair of gloves. CNA B moved Resident #17's bed and repositioned Resident #17 with the same unclean gloves she used to provide incontinent care. CNA B removed the unclean gloves, and without performing hand hygiene, exited Resident #17's room to retrieve more gloves from the linen cart. CNA B reentered Resident #17's room, washed her hands, and donned clean gloves. CNA B provided Resident #17's incontinent care to her buttock area. CNA B then applied Resident #17's clean brief. CNA B removed her gloves, and adjusted Resident #17's bed linen. CNA B then picked up Resident #17's pillow off the floor, she removed the pillowcase and then exited the room without performing hand hygiene. CNA B returned to Resident #17's room and applied the pillowcase. CNA B then washed her hands. CNA B said she should have been more prepared when she performed incontinent care. CNA B said she should have had her gloves and the cleansing wipes in a clean bag. CNA B said she should have washed her hands prior to exiting the room to retrieve the gloves and pillowcase. CNA B said not performing hand hygiene could spread infection. Record review of CNA B's Proficiency Audit dated 11/16/2022, indicated she was proficient in handwashing and perineal care. During an interview on 04/26/2023 at 2:46 p.m., the DON said she expected CNA B to perform hand 455569 Page 8 of 9 455569 04/26/2023 Heritage at Longview Healthcare Center 112 Ruthlynn Dr Longview, TX 75605

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hygiene before the initiation of care, during care as needed, and after care. The DON said not performing hand hygiene could cause a break in infection control. The DON said she completed skill check offs with the nursing staff to ensure compliance with infection control and technique. During an interview on 04/26/2023 at 2:56 p.m., the Administrator said exiting a resident's room without performing proper hand hygiene could cause cross contamination. The Administrator said the DON or designee monitored hand hygiene monthly with a random audit. The Administrator said the DON was responsible for ensuring compliance with the infection control program. Record review of a Personal Care policy with an effective date of 05/11/2022 revealed an incontinent resident of urine and or bowel should be identified, assess, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing, infections and skin irritation, and observing the resident's skin condition. Start .10. Perform hand hygiene 11. DON gloves 24. Doff gloves .25. Perform hand hygiene Important Points Always perform hand hygiene before and after glove use. Record review of an Infection Control Policy dated 03/2023 revealed the facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. 455569 Page 9 of 9