Health inspection·January 5, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 6 of 27 residents (Residents #46, #79, #100, #102, #103 and #104) reviewed for care plans. Resident #46 did not have a care plan for visual, urinary incontinence, pressure ulcer risk and psychotropic drug use. Resident #79 did not have a care plan for urinary incontinence and pressure ulcer risk. Resident #100 did not have a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risk and psychotropic drug use. Resident #102 did not have a care plan for urinary incontinence and pressure ulcer risk. Resident #103 did not have a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risk and psychotropic drug use. Resident #104 did not have a care plan for pressure ulcer risk. These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Resident #46 Record review of Resident #46's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure with hypoxia (low oxygen in the body), depression, hypertension (high blood pressure), obesity, difficulty in walking, muscle weakness and lack of coordination. Record review of Resident #46's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the Page 1 of 11 675346 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 resident's cognition was severely impaired. Level of Harm - Minimal harm or potential for actual harm Section V Care Area Assessment (CAA) Summary: CAA Results: Residents Affected - Some 03. Visual Function 06. Urinary Incontinence and Indwelling Catheter 16. Pressure Ulcer 17. Psychotropic Drug Use Section B B1000 - Vision Ability to see in adequate light: 2 - Moderately impaired - limited vision, not able to see newspaper headlines but can identify objects Section H H0300 Urinary Continence: 3 - Always incontinent (no episodes of continent voiding) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Section N Medications

N0410. Medication Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. A. Antipsychotic - given the last 7 days C. Antidepressant - given the last 7 days Record review of Resident #46's care plan, dated 01/02/23, revealed no care plans for vision, urinary, pressure ulcers or psychotropic drug use. 675346 Page 2 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 Resident #79 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #79's undated admission record revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include pneumonia (lung infection), congestive heart failure, edema (swelling), hypotension (low blood pressure), stage 4 (severe) kidney failure, stage 2 pressure ulcer of sacral region (area between lower back and tailbone), and muscle weakness. Residents Affected - Some Record review of Resident #79's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence and Indwelling Catheter 16. Pressure Ulcer Section H H0300 Urinary Continence: 1 - Occasionally incontinent (less than 7 episodes of incontinence) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? Coded 1 = Yes M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage B. Stage 2 1. Number of Stage 2 pressure ulcers - Coded 1 = number of ulcers 2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - Coded 1 = number of ulcers M1200. Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed 675346 Page 3 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 E. Pressure ulcer/injury care Level of Harm - Minimal harm or potential for actual harm Record review of Resident #79's care plan, dated 12/06/22, revealed no care plans for urinary and pressure ulcers risks. Residents Affected - Some Resident #100 Record review of Resident #100's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include stroke, depression, diabetes (high blood sugar), hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease) and muscle weakness. Record review of Resident #100's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence and Indwelling Catheter 07. Psychosocial Well-Being 16. Pressure Ulcer 17. Psychotropic Drug Use Section D - Mood D0200. Resident Mood Interview (PHQ-9) A. Little interest or pleasure in doing things 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) B. Felling down, depressed, or hopeless 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 1 = 2-6 days (several days) D. Felling tired or having little energy 1. Symptom Presence - 1 = yes 675346 Page 4 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 2. Symptom Frequency - 1 = 2-6 days (several days) Level of Harm - Minimal harm or potential for actual harm D0300 Total Severity Score Add score for all frequency responses in Column 2 - 04 = mild depression Residents Affected - Some Section N Section N Medications

N0410. Medication Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. C. Antidepressant - given the last 7 days Section H H0300 Urinary Continence: 3 - Always incontinent (no episodes of continent voiding) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #100's care plan, dated 12/19/22, revealed no care plan for urinary, psychosocial well-being, pressure ulcer risk or psychotropic drug use. Resident #102 Record review of Resident #102's undated admission record revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include stroke, muscle spasms and diabetes (high blood sugar). Record review of Resident #102's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: 675346 Page 5 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 CAA Results: Level of Harm - Minimal harm or potential for actual harm 06. Urinary Incontinence and Indwelling Catheter 16. Pressure Ulcer Residents Affected - Some Section H H0300 Urinary Continence: 1 - Occasionally incontinent (less than 7 episodes of incontinence) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #102's care plan, dated 12/14/22, revealed no care plan for urinary and pressure ulcer risk. Resident #103 Record review of Resident #103's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder (depression), anxiety, repeated falls, weakness, hypertension (high blood pressure), congestive heart failure (fluid around the heart) and pain. Record review of Resident #103's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence and Indwelling Catheter 07. Psychosocial Well-Being 16. Pressure Ulcer 17. Psychotropic Drug Use 675346 Page 6 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 Section D - Mood Level of Harm - Minimal harm or potential for actual harm D0200. Resident Mood Interview (PHQ-9) A. Little interest or pleasure in doing things Residents Affected - Some 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) B. Felling down, depressed, or hopeless 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) C. Trouble falling or staying asleep, or sleeping too much 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) D. Felling tired or having little energy 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 1 = 2-6 days (several days) F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) D0300 Total Severity Score Add score for all frequency responses in Column 2 - 10 = severe depression Section N Section N Medications

N0410. Medication Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. C. Antidepressant - given the last 7 days 675346 Page 7 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 Section H Level of Harm - Minimal harm or potential for actual harm H0300 Urinary Continence: Residents Affected - Some 2 - Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #103's care plan, dated 12/20/22, revealed no care plans for urinary, psychosocial well-being, pressure ulcer risk or psychotropic drug use. Resident #104 Record review of Resident #104's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include mild intellectual disabilities, pneumonia, and history of COVID-19 (Coronavirus). Record review of Resident #104's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 16. Pressure Ulcer Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #104's care plan, dated 01/03/23, revealed no care plan for pressure ulcer risk. 675346 Page 8 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interviewed LVN A and LVN B on 01/05/23 at 10:30 AM, LVN B stated they are both responsible for care planning triggered care areas on the MDS . LVN A reviewed Resident #102's care plan and stated she did not see a care plan for urinary incontinence, or pressure ulcer risks . LVN B reviewed the care plan for Resident #46's and stated she did not see a care plan for visual, urinary incontinence, pressure ulcer risks or psychotropic drug use. LVN A reviewed the care plan for Resident #79's and stated she did not see a care plan for urinary incontinence or pressure ulcers. LVN A reviewed the care plan for Resident #100's and stated she did not see a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risks or psychotropic drug use. LVN B reviewed the care plan for Resident #103's and stated she did not see a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risks or psychotropic drug use. LVN A reviewed the care plan for Resident #104's and stated she did not see a care plan for pressure ulcer risks. LVN B stated missed care areas were triggered for Residents #46, #79, #100, #102, #103 and #104 in section V of the MDS and should have been care planned. The LVN B stated care plans are developed using triggered care areas in section C of the MDS and anything brought up in the daily meeting. LVN B stated the ADON's and the DON care plan acute care issues and the wound care nurse and activities care plan wounds and activities. LVN B stated They are behind on care plans and are trying to get them all updated. LVN B stated the care plan is used to notify staff what is going on with the residents. LVN B stated everyone uses the care plan. LVN B stated if triggered care areas were not care planned staff would not know how to handle a specific care area for the resident. LVN A stated it could cause harm or an incident to happen to the resident. LVN B stated there was no system in place to monitor care plans. LVN B stated she has been trained on care plans in the past. LVN A stated she was trained by LVN B on how to complete and develop a care plan. Interviewed the DON on 01/05/23 at 10:45 AM, he stated the MDS nurses are responsible for care planning triggered care areas on the MDS. The DON reviewed the care plans for Residents #46, #79, #100, #102, #103 and #104 and stated the triggered care areas were not care planned. He stated care plans are developed by using admission for baseline, diagnoses and medication and triggered care areas on the MDS . He stated there is no reason the triggered care areas would not be care planned. He stated the care plan is a guide on how to treat and care for the residents. He stated all staff use the care plans. He stated, Missing care areas that triggered on the MDS that are not care planned could cause residents to miss out on care and their needs not being met. He stated he did not know why the triggered care areas were not care planned but would find out. He stated he is not aware of any system in place to monitor care plans. He stated his expectation of what should be in the care plan is care areas that triggered, special needs and anything to meet residents' needs. He stated he is not sure if the MDS nurses have been to special training, but they do have a corporate MDS nurse support. Interviewed the Admin on 01/05/23 at 11:08 AM, he stated the MDS nurses are responsible for care plans. When asked if there was a reason triggered care areas would not be care planned, he stated Not that I know of. He stated the care plan is used to ensure proper care for each resident. He stated if the care plan is not complete, staff would not be aware of the care needed for that resident. Record review the facility policy titled Care Area Assessments with revision date 11/2019, revealed: Policy statement Care Area Assessment (CAAs) are used to help analyze data obtained from the MDS and to develop individualized care plans. 675346 Page 9 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 Policy interpretation and implementation Level of Harm - Minimal harm or potential for actual harm 1. Triggered care areas are evaluated by the end disciplinary team to determine the underlying causes, potential consequences and relationships to other triggered care areas. Residents Affected - Some 2. The Care Area Assessments (CAAs) process consists of the following steps: a. Identify areas of concern triggered on the MDS: (1) This can be done using software or by manually using the CAT logic tables in the RAI User's Manual. b. Review the triggered CAA's by doing an in-depth, resident-specific assessment of the triggered condition. (1) History taking; (2) Physical assessment; (3) Gathering of relevant information (labs, test, etc); and (4) Sequencing of clinically significant events. c. Define the problem(s): (1) Identify the functional, physical, and or behavioral implications of the problem(s); (2) Identify the relationships between risk factors, triggers and problems; (3) Distinguish between causes and consequences; and (4) Look for common causes and consequences; and d. Make decisions about the care plan: (1) Determine whether the problem(s) need intervention; (2) Evaluate the resident's goals, wishes, strengths and needs; (3) Design intervention's goals, wishes, strengths and needs; (4) Establish which items need further assessment or additional review. e. Document interventions on the care plan: (1) Include specific interventions, including those that address common cause of multiple issues; and (2) Include recommendations for monitoring and follow-up timeframes. 675346 Page 10 of 11 675346 01/05/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0656 4. CAA Documentation explains the basis for the care plan. The documentation should include: Level of Harm - Minimal harm or potential for actual harm a. Causes and contributing factors for the triggered care areas; i. Completion of section V of the MDS. Residents Affected - Some Record review the facility policy titled Care Plans, Comprehensive Person-Centered with revision date 12/2020, revealed: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally competent and trauma informed. Policy Interpretation and Implementation 1. the Interdisciplinary Team (IDT), in conjunction with resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will; g. Incorporate identified problem areas; 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 675346 Page 11 of 11