Health inspection·February 8, 2023

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel. There were no staff on the 11p-7a shift certified to provide CPR on 5 of 25 dates reviewed from [DATE] through [DATE]. ([DATE], [DATE], [DATE], [DATE], and [DATE]) On [DATE] at 8:30 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could result in failure to treat cardiac arrest, delayed care during cardiac arrest, or death for residents who wished to be resuscitated in the event of cardiac arrest. Findings included: Record review of a daily census report dated [DATE], provided by the Administrator, indicated there were 42 residents who wished to be resuscitated in the event of cardiac arrest. During an interview on [DATE] at 2:50 p.m., RN C said she had been the Staff Development Nurse for approximately one month. RN C said she taught CNA classes, worked on incident reports, and provided training for the nurses on the Automated External Defibrillator (AED). RN C said nurses were not required to be CPR certified when hired, and when the facility hired a nurse that did not have a CPR certification, the facility tried to get them certified within a month. RN C said she did not know who was responsible for checking CPR certifications. During an interview on [DATE] at 3:23 p.m., the DON said it was the responsibility of the Staff Development Nurse (RN C) to check CPR certifications, but RN C was new in that position and had not had time to get it done. The DON said nurses were not required to have a CPR certification when they were hired. The surveyor asked the DON if the facility had a responsibility to ensure that at least one staff was certified to perform CPR on each shift. The DON said CPR was covered under the nurse's scope of practice, and the facility did not have a policy that required staff to be certified to perform CPR on each shift. During an interview on [DATE] at 3:50 p.m., the Administrator said he had been an Administrator for 36 years and had never heard that the facility was required to have staff certified to perform CPR on each shift. The Administrator said the facility knew who CPR was certified but did not say how Page 1 of 6 455753 455753 02/08/2023 Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791

F 0678 the facility knew which staff had current certifications to perform CPR. Level of Harm - Immediate jeopardy to resident health or safety During an interview on [DATE] at 5:07 PM, the DON said the facility was contacting staff in an attempt to get documentation of staff CPR certifications. The DON said the facility did not have copies of staff CPR certifications, and that the night shift staff were not answering their phones. The DON said someone from the facility would have to go to each staff members home to request the certifications. Residents Affected - Some A review of staffing schedules indicated there were no staff on the 11p-7a shift certified to provide CPR on 5 of 25 dates reviewed for the month of [DATE]. ([DATE], [DATE], [DATE], [DATE], and [DATE]) Review of records provided by the Administrator on [DATE] included all CPR certifications the facility could provide, and staff sign in sheets from [DATE] thru [DATE]. The records indicated there were five dates the facility did not have staff certified to perform CPR on the 11p-7a shift ([DATE], [DATE], [DATE], [DATE], and [DATE]). Record review of a facility audit of licensed nursing staff CPR certifications, dated [DATE], indicated 13 of 27 licensed nurses did not have current training in performing CPR. Staffing records indicated there were five dates the facility did not have staff certified to perform CPR on the 11p-7a shift ([DATE], [DATE], [DATE], [DATE], and [DATE]). During an interview on [DATE] at 9:00 a.m., the Administrator said the facility audit of CPR certifications was completed on [DATE] and included all licensed staff. The Administrator indicated 13 licensed staff did not have current CPR certifications. Record review of an e-mail from RN F, dated [DATE] at 9:38 p.m., indicated the regional nurse consultant had conducted an in service with the Administrator and DON. The email indicated the in-service was related to requirements for long term care in regard to CPR certification. The in-service indicated the facility must have current CPR certification on nursing staff and ensure availability of certified staff every shift. Systems were discussed for future oversight and maintenance to ensure deficient practice does not reoccur. The in-service was signed by the Administrator and DON. During an interview on [DATE] at 8:50 a.m., RN F said the facility had reviewed the regulations and that she had provided an in-service to the Administrator and the DON regarding the requirement to have someone in the facility who was CPR certified on each shift, and that an online refresher alone was not adequate. RN F said, I can't apologize enough that this has happened. RN F said there would be a CPR class in the facility at 10:00 a.m. During an interview on [DATE] at 9:00 a.m., the Administrator said LVN L worked on the 11p to 7a shift. The Administrator said LVN L told the facility her CPR certification was valid, but the facility did not receive a copy of it when she was hired. The administrator said, we should have. He said when the facility requested a copy of her certification on [DATE] LVN L told them it had expired. The administrator said the HR staff should have obtained a copy of LVN L's CPR certification when she was hired, and that the person who does that now knows to make sure that is done when nurses are hired. The administrator said the facility had been trying to arrange for someone to teach a CPR class, but it hasn't happened yet. The administrator said, It should have already been done. During an interview [DATE] at 9:58 a.m., RN F said at one time there was a system in place to 455753 Page 2 of 6 455753 02/08/2023 Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some ensure CPR certifications were tracked. She said the facility had experienced turnover in management and that tracking CPR certifications had falling through the cracks, and that has led to this system failure. RN F said usually the HR staff would check CPR certifications when nurses were hired, but in this facility, they intended to assign that task to the RN C, but they didn't, and the system failed. During an interview on [DATE] at 11:02 a.m., LVN H said she worked 8a-5p shift and had worked at the facility for about 3 weeks. She said her CPR certification was current, but the facility never asked to see it when she was hired. During an interview on [DATE] at 11:15 a.m., LVN I said she worked the 3p-11p shift. LVN I said her CPR certification had expired, but she was not sure when. She said the last class she had taken was in 2020. LVN I said when her CPR certification expired the facility did not prompt her to renew it. During an interview on [DATE] at 11:20 a.m., LVN J said she had worked on the 11p-7a shift for about 5 years. She said her CPR certification had expired in [DATE]. LVN J said she did not recall the facility prompting her to renew her CPR certification. During an interview on [DATE] at 11:30 a.m., LVN K said she worked 8a-5p. LVN K said her CPR certification had expired in [DATE]. She said the facility told her once in June or [DATE] to renew her certification, but that was the only time. During an interview on [DATE] at 12:15 p.m., LVN L said she had worked at the facility for about a month on the 11p-7a shift. She said the facility had asked whether she was certified to perform CPR when she was hired and she told them yes. LVN L said the facility did not ask to see documentation of her CPR certification nor ask for a copy of it when she was hired. LVN L said she discovered her CPR certification had expired a couple of days ago when she cleaned out her purse. LVN L said she did not recall the date her certification had expired and that she had thrown the card away. During an interview on [DATE] at 2:49 the administrator said the failure of the facility to ensure there was someone certified to perform CPR on each shift was a system failure related to not understanding who was responsible for keeping records. He said there had been changes in staff and a lack of knowledge on the part of quite a few people who were unnamed. During a telephone interview on [DATE] at 11:00 a.m., the Human Resources manager said she became responsible for ensuring CPR certifications were valid upon hire after the survey ended on [DATE]. The HR manager said that task was previously assigned to the staffing coordinator, who's last day to work at the facility was [DATE]. The HR manager said she did not know who was responsible for the task between [DATE] and [DATE]. During a telephone interview on [DATE] at 1:57 p.m., the DON said the facility did not provide training on how to perform CPR, other than a CPR class. Record review of a facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised [DATE], included a policy statement indicating personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of cardiac arrest. The policy also indicated: The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately 455753 Page 3 of 6 455753 02/08/2023 Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791

F 0678 upon collapse. Level of Harm - Immediate jeopardy to resident health or safety Select and identify a CPR Team for each shift in the case of an actual cardiac arrest. To the extent possible designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. Residents Affected - Some The CPR team in this facility shall include at least one nurse, one LVN and two CNA's all of whom have received training and certification in CPR Continue with CPR until emergency medical personnel arrive This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 8:30 p.m. The Administrator was notified on [DATE] at 8:30 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The Administrator was provided with the IJ template on [DATE] at 8:30 p.m. The following Plan of Removal was submitted by the facility. The plan of removal was accepted on [DATE] at 3:15 p.m., and included the following: I. RESIDENTS WHO HAVE SUFFERED, OR ARE LIKELY TO SUFFER, A SERIOUS ADVERSE OUTCOME AS A RESULT OF THE NON-COMPLIANCE THE FAILURE TO ENSURE THAT EMPLOYEES HAD THE APPROPRIATE TRAINING AND COMPENTENCAY IN CPR CREATED A FINDING OF IMMEDIATE JEOPARDY. THIS HAD THE POTENTIAL TO IMPACT ALL 42 FULL CODE RESIDENTS WHO DID NOT HAVE AN OOH DNR AND HAD ELECTED TO BE RESUCCIATED IN THE EVENT OF AN CARDIAC ARREST. II. ACTIONS THE FACILITY WILL TAKE ADMINISTRATOR AND DON WERE INSERVICED ON [DATE] AT 9:15 PM BY REGIONAL NURSE ON THE POLICY AND PROCEDURE FACILITIES CPR POLICY AND TRAINING REQUIREMENTS ON THE REGULATION OF F678 WHICH INCLUDES FACILITIES MUST ENSURE THAT PROPERLY TRAINED PERSONNEL (AND CERTIFIED IN CPR FOR HEALTHCARE PROVIDERS) ARE AVAILABLE IMMEDIATELY (24 HOURS PER DAY) TO PROVIDE BASIC LIFE SUPPORT, INCLUDING CARDIOPULMONARY RESUSCITATION (CPR), TO RESIDENTS REQUIRING EMERGENCY CARE PRIOR TO THE ARRIVAL OF EMERGENCY MEDICAL PERSONNEL, AND SUBJECT TO ACCEPTED PROFESSIONAL GUIDELINES, THE RESIDENT'S ADVANCE DIRECTIVES, AND PHYSICIAN ORDERS. INTIATED: [DATE] COMPLETED: [DATE] 10:00 A.M. IN-SERVICES ON THE ON CPR POLICY WERE STARTED ON [DATE] AT 9:20PM BY DON FOR ALL FACILITY STAFF, INCLUDING: DIRECT NURSING STAFF, CHARGE NURSES, DIETARY STAFF, SOCIAL WORKER, MDS NURSES, MAINTENANCE, AND THE RECEPTIONIST.NO EMPLOYEE WILL BE ALLOWED TO WORK UNTIL THEY HAVE BEEN IN-SERVICED ON THE POLICY AND REQUIREMENTS OF ADEQUATELY CPR TRAINED STAFF COVERAGE IN BUILDING AND THE REQUIREMENTS OF CPR TRAINING TO INCLUDE A SKILLS CHECKOFF. ALL IN-SERVICE TRAINING TO BE COMPLETED BY EMPLOYEES NEXT WORKING SHIFT. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. ADMINISTRATOR VERIFIED THAT A CERTIFIED CPR TRAINED LVN, PER REGULATORY REQUIREMENTS INCLUDING RETURN DEMONSTRTATION, WILL BE ON SHIFT AT 11:00P.M. ON [DATE] AND WILL STAY ON SHIFT UNTIL 7:00 A.M ON [DATE]. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. 455753 Page 4 of 6 455753 02/08/2023 Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some AN AUDIT OF ALL EMPLOYEES FOR CPR CERTIFICATION AND TRAINING WAS COMPLETED BY ADMINISTRATOR ON [DATE] FOR CPR COMPLIANCE. INITIATED: [DATE] COMPLETED: [DATE] 11:00 P.M. ADMINISTRATOR HAS ARRANGED A BLS CERTIFIED INSTRUCTOR TO APPLY TRAINING AND CERTIFICATION FOR 10 EMPLOYEES ON [DATE] AT 10:00A.M. THIS TRAINING WILL INCLUDE A SKILLS CHECK-OFF. EMPLOYEES INCLUDED IN TRAINING CONSIST OF 1 CHARGE NURSE LVN 11 P.M.- 7:00 A.M SHIFT, 4 CHARGE NURSE LVNS 7:00 A.M. - 3:00 P.M. SHIFT, 1 CHARGE NURSE LVN 3:00 P.M. - 11:00 P.M. SHIFT, 1 R.N - DIRECTOR OF NURSES, 1 RN - ASSISTANT DIRECTOR OF NURSES, 1 RN - WOUND CARE NURSE, AND 1 CHARGE NURSE RN 3:00 P.M. - 11:00 P.M. SHIFT. ALL 11:00 P.M. - 7:00 A.M. ARE NOW CPR CERTIFIED - INITIATED: [DATE] COMPLETED: [DATE] 2:00 P.M. III. SYSTEMS, POLICIES, AND PROCEDURES FACILITIES POLICY AND PROCEDURE TITLED EMERGENCY PROCEDURE- CARDIOPULMONARY RESUCITTATION WAS REVIEWED AND UPDATED BY ADMINISTRATOR AND REGIONAL NURSE ON [DATE] TO ENSURE THAT CURRENT POLICY MEETS THE STANDARDS OF PRACTICE AND REGULATORY REQUIREMENTS ON PROPERLY TRAINED STAFF ARE IN THE BUILDING 24/7. INITATED: [DATE] COMPLETED: [DATE] 12:00 P.M. IV. MONITORING, AUDITS, AND QAPI ONGOING SYSTEMATIC CHANGE TO ENSURE CPR TRAINED STAFF ARE ON ALL SHIFTS IS THAT ALL LICENSED PERSONELL WILL NOW BE REQUIRED TO OBTAIN CPR CERTIFICATION. A BINDER WITH ALL CERTIFICATIONS AND CARDS WILL BE KEPT IN THE HUMAN RESOURCE DEPARTMENT AND AUDITED MONTHLY BY HUMARN RESOURCE DIRECTOR TO ENSURE THAT CARDS ARE CURRENT AND NOT EXPIRED. HUMAN RESOURCE DIRECTOR HAS BEEN TRAINED ON HER DUTIES, CPR REQUIREMENTS, AND WHICH CPR CLASSES ARE ACCEPTABLE PER REGULATORY REQUIREMENTS. SHE WILL POST AND NOTIFY SUPERVISORS 60 DAYS BEFORE CPR CERTIFICATION EXPIRES. BINDER WILL BE SEPERATED BY DIVIDERS FOR EACH SHIFT TO ENSURE THAT EACH SHIFT HAS PROPERLY TRAINED PERSONELL. THE ADMINISTRATOR AND OR REGIONAL NURSE WILL MONITOR FOR COMPLIANCE MONTHLY. INITIATED: [DATE] COMPLETED [DATE] 2:30 P.M. THE QAPI TEAM, LED BY THE ADMINISTRATOR, WILL MEET WEEKLY FOR 3 WEEKS TO DISCUSS COORDINATION OF COMPLETION OF ALL IN-SERVICES, ASSESSMENTS, AND INTERVENTIONS ARE UTILIZED AND COMPLETED TO ENSURE THAT APPROPRIATE CPR TRAINED STAFF ARE ON DUTY FOR EACH SHIFT. THE MEDICAL DIRECTOR WAS NOTIFIED ON [DATE] OF THE IMMEDIATE JEOPARDY CALLED ON FACILITY. INITIATED: [DATE] COMPLETED: [DATE] 12:00 P.M. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Record review of the staffing schedule for [DATE] indicated LVN G had been scheduled to work the 11p-7a shift to ensure staff certified to perform CPR were available. Documentation for LVN G's CPR certification was reviewed. Record review of an email from RN F, dated [DATE] at 9:38 p.m., indicated the administrator and DON had received an in-service on [DATE] regarding the requirement that the facility must provide staff who are certified to perform CPR on each shift, and that an online only certification was not sufficient to meet the requirement. 455753 Page 5 of 6 455753 02/08/2023 Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Observation on [DATE] at 10:00 a.m. indicated the facility had provided an instructor lead CPR class which included return demonstration of skills Record review of an invoice, dated [DATE] and given to the facility by a CPR instructor, indicated 10 staff members had attended a CPR class on that date. Review of the CPR class roster indicated the following nurses by position and shift had completed the CPR certification: of 1 LVN charge nurse on the 11p-7a shift, 4 LVN charge nurses on the 7a-3p shift, 1 LVN charge nurse on the 3p to 11p shift, the DON, 1 RN ADON, 1 RN Wound Care Nurse, and 1 RN charge nurse on the 3p-11p shift. An additional LVN charge nurse on the 11p-7a shift completed a CPR certification outside the facility and provided documentation to the facility. During interviews on [DATE] between 10:00 am and 12:15 p.m., 1 RN and 8 LVNs, representing all shifts, indicated they were CPR certified and could correctly identify the rate of compressions, depth of compressions, and ratio of compressions to rescue breaths (ADON, LVN M, LVN G, LVN H, LVN I, LVN J, LVN N, LVN O, LVN L) All nurses interviewed indicated they were aware the facility was required to ensure staff certified to provide CPR were available on each shift. The administrator was informed the Immediate Jeopardy was removed on [DATE] at 4:00 p.m. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 455753 Page 6 of 6