Health inspection·November 3, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to notify, consistent with his or her authority, the resident Residents Affected - Some representative(s) for 2 of 6 sampled residents (Resident #1 and Resident #4) when there was a significant change. LVN A failed to document notification of Family Member A or Family Member B when Resident #1 developed new open areas on his skin. LVN B and LVN A failed to document notification of Resident #4's Family Member C when he had a change of condition, and new orders were received. This deficient practice had the potential to place residents at risk for not having their family or legal representative notified when having a change of condition. The findings include: Resident #1 Record review of Resident #1's undated facesheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] with the following diagnosis of hemiparesis (muscular weakness) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side, nontraumatic intracerebral hemorrhage (spontaneous bleeding in the brain), shortness of breath, dysphagia (difficulty swallowing, cognitive communication deficit (difficulty with thinking and how someone uses language), hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (buildup of plaque inside the artery walls, that slows down the flow of blood), paroxysmal atrial fibrillation (rapid erratic heart rate begins suddenly and then stops on its own within seven days), chronic systolic congestive heart failure (the hearts left ventricle or bottom chamber is weak and cannot contract to produce enough pressure to push blood into circulation), and type 2 diabetes mellitus (the body does not produce enough insulin, or it resists insulin). Record review of MDS assessment summary, dated [DATE], documented Resident #1' BIMS as 12 (moderately impaired), required extensive assistance of two staff members for bed mobility, transfers, and toileting, extensive assistance of one staff member for eating, feeding tube, one pressure ulcer that was unstageable, pressure reducing device for bed, pressure injury/ulcer care, applications of non-surgical dressings, and application of ointments or medication. Page 1 of 5 675346 675346 11/03/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0580 Record review of Resident #1's care plan dated [DATE] revealed: Level of Harm - Minimal harm or potential for actual harm Problem start date: [DATE]: Pressure Ulcer/Injury-resident at risk for pressure ulcer development. Goal date of [DATE]: Prevent/heal pressure sores and skin breakdown. Approaches documented: follow facility skin care protocol, pressure reducing mattress, report to charge nurse any redness or skin breakdown immediately, and turn every two hours and as needed (prn). Residents Affected - Some Record review of Resident Progress Note dated [DATE] at 4:56 PM, LVN A was made aware Resident #1 had an open area to his right buttock. The Nurse Practitioner (NP) was notified with new orders received. LVN A documented the NP would also assess Resident #1's wound on her visit/wound rounds on Thursday, [DATE]. There was no supporting documentation that Resident #1's family was notified about the open area. Record review of Facility Wound Summary Report for [DATE],revealed the following: * [DATE] at 4:01 PM Resident #1 had a pressure ulcer to coccyx measuring 9 cm x 11 cm. *[DATE] at 5:01 PM documentation revealed Resident #1 had an unspecified ulcer to right buttock, not measured. Record review of physician order dated [DATE] revealed to treat open area to right buttock and coccyx by cleaning with normal saline or wound cleanser, apply med honey and calcium alginate, and cover with adhesive foam. During a phone interview on [DATE] at 12:25 PM with Resident #1's Family Member B, revealed that she was not notified about her the residents pressure ulcer. Family Member B reported she did not know about the pressure ulcer until the day Resident #1 was sent to the hospital on [DATE], when she saw a dressing on Resident #1's right buttock. Family Member B stated she did not know about the pressure area on the coccyx. During a phone interview on [DATE] at 5:52 AM LVN A stated she would notify the family and the physician if a resident developed a new pressure ulcer. LVN A stated she documented the notifications in the resident progress notes if she called the family she would document it, but if she told them in person, probably not. During an interview on [DATE] at 1:15 PM with LVN A she reported she had talked to Resident #1's Family Member A, on several occasions when she was at the facility, and reported that Family Member A would ask how the wounds were doing, but LVN A stated she did not document it. Interview on [DATE] at 9:55 AM with the DON revealed that her expectations for a change of condition, was to notify her so she can do her own assessment of the resident, and for them to notify the physician and the family member or responsible party of the residents change in condition. The DON stated a change in condition included a change in ADL's, a new medication or reaction, altered mental status, a new pressure ulcer, or anything that is out of the ordinary care of that resident. The DON stated she expected staff to document the change and notifications in the progress notes. During an interview on [DATE] at 12:44 PM with the ADM, revealed his expectations for a change of condition, is to notify the DON, the physician, and the family member or responsible party and to document the change and notifications in the progress notes. 675346 Page 2 of 5 675346 11/03/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0580 Resident #4 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #4's undated facesheet reveals a [AGE] year old male admitted to the facility on [DATE], with a readmission date of [DATE]. Resident #4 had the following diagnosis of atherosclerotic heart disease of native coronary artery (buildup of plaque inside the artery walls, that slows down the flow of blood), constipation (fewer than three stools a week, or has difficult bowel movements), bacterial pneumonia (infection of lungs by certain bacteria), acquired absence of limb, post COVID-19 condition (includes fatigue, fever, or difficulty breathing or shortness of breath, and cough), chronic obstructive pulmonary disease (condition that blocks airflow and makes it difficult to breath), cognitive communication deficit (difficulty with thinking and how someone uses language), traumatic subdural hemorrhage with loss of consciousness of unspecified duration (caused by a traumatic head injury, such as a blow to the head, or fall), alcohol dependence, type 2 diabetes mellitus (the body does not produce enough insulin, or it resists insulin), diabetic polyneuropathy (affects multiple peripheral sensory and motor nerves that branch out from the spinal cord into the arms, hands, legs, and feet), heart failure (the heart does not pump blood as well as it should), peripheral vascular disease (any condition that affects your circulatory system, or system of blood vessels), diabetic chronic kidney disease (disease of the kidneys leading to renal failure), hyperlipidemia (blood has to many fats such as cholesterol and triglycerides), restless legs syndrome (irresistible urge to move the legs, typically in the evenings), insomnia (trouble falling or staying asleep), phantom limb syndrome with pain (condition where there is sensations in a limb that does not exist), secondary vitreoretinal degeneration of right eye (gradual changes in the structure and function of the clear gel-like substance that is in the eye and retina that can be caused by trauma, infection, or inflammation), hypertension (high blood pressure), benign prostatic hyperplasia with lower urinary tract symptoms (a condition in men in which the prostate gland is enlarged causing blockage of urine flow out of the bladder). Residents Affected - Some Record review of Resident #4's MDS assessments revealed on [DATE], there was a Discharge with Return Anticipated. Resident was readmitted to the facility with entry date on [DATE]. Death in facility MDS assessment dated [DATE]. Record review of Resident #4's Care plan dated [DATE] revealed: Problem Start Date: [DATE] ADL Functional/Rehab Potential - I need assist with ADL's. Approach Start Date: [DATE] Ambulation/Transferring - Extensive assist of 1-2. Bathing/Hygiene - Total assist of one. Dressing/Grooming - Extensive assist of 1-2. Eating - Supervision/Set up. Wheelchair for mobility. Record review of Resident #4's Resident Progress Notes dated [DATE] at 1:30 PM revealed that LVN B requested the DON to assess the resident. Upon assessment, the DON obtained vital signs that were within normal limits. Resident #4 was oriented only to self; resident reported the year as 1933 and that he was in Mexico City. Resident #4 reported he was not in pain at this time. Resident #4 had a busted blood vessel in his right eye and a tremor to his right hand. DON reported her findings to LVN B and requested for her to call to send the resident out. Record review of Resident #4's Resident Progress Notes dated [DATE] at 1:55 PM revealed that LVN B documented that Resident #4 is very confused, right inner eye is blood shot red, and resident has a new tremor to right hand. Vital signs are within normal limits, oxygen saturation reading 76%. LVN B started order prn (as needed) oxygen at 4 liters per minute via nasal cannula and oxygen saturations increased to 96%. Resident #4 is scheduled for dialysis in the morning at 10:00 AM. LVN B notified 675346 Page 3 of 5 675346 11/03/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some NP on [DATE] and received new orders to collect CBC, CMP, BNP, chest x-ray, and to swab resident for the flu and COVID. Report the results to NP as soon as possible. There is no documentation of LVN B notifying Resident #4's family of the new orders, or of Resident #4's change of condition. Record review of Resident #4's Resident Progress Notes dated [DATE] at 9:49 PM revealed that LVN A documented that she had received the chest x-ray, and she sent the results to the NP. The NP gave new orders for Rocephin 1 gram IM (intramuscular) injection for 5 days after hemodialysis (HD) and to give Resident #4 a now dose of Lasix 40 mg, and then change Resident #4's Lasix orders to 120 mg on non HD days and to change the morning dose to non- HD days only, and handheld nebulizer (HHN) of DuoNeb's four times a day (QID) for 5 days. LVN A documented that she had administered Resident #4's initial dose of Rocephin. There is no documentation of LVN A notifying Resident #4's family member of new orders or of Resident #4's change of condition. Record review of physician orders dated [DATE] revealed to collect portable 2V chest x-ray stat, due to SOB to r/o illness, due to resident confined to a nursing home. Lasix 80 mg, administer 2 tabs to equal 180 mg oral. Ceftriaxone 1 gram (reconstituted solution) 1 gram injection. Ipratrupuim-albuterol solution for nebulation 0.5-3 mg (2,5 mg) base 3 ml, adminsiter one vial; inhalation for post-COVID conditon. During an interview on [DATE] at 3:50 PM with the Physical Therapist (PT) revealed that she went to evaluate Resident #4 on the afternoon of Monday, [DATE] and that Resident #4 was very confused and was struggling to breath. The PT stated that Resident #4's oxygen saturation was low, so she let LVN B know that they needed an oxygen concentrator. Oxygen was started at 3 to 5 liters of oxygen per minute, and reported Resident #4's oxygen saturation level went up to the 90's via nasal cannula. The PT reported that Resident #4 was up in the wheelchair, but his oxygen saturations would still dip down, even with the oxygen. The PT reported that she did notice that one of his eyes were red. The PT stated when she came to work with Resident #4 on Tuesday, [DATE] she was told that Resident #4 had expired that morning. During an interview on [DATE] at 1:15 PM with LVN A revealed that she did not notify family regarding Resident #4 because there was no change in his condition during her 12-hour shift. LVN A stated that she checked on Resident #4 frequently throughout the night and there was no change. LVN A stated she faxed the chest x-ray orders to the NP when she received it. Then LVN A received orders from the NP to give Rocephin and Lasix, then to monitor Resident #4 throughout the night, and she was told that the Physician Assistant (PA) would be at the facility in the morning. LVN A stated she followed the orders. During an interview on [DATE] at 3:00 PM with the CMA regarding Resident #4, revealed that the last time she saw him was on [DATE] and Resident #4 was breathing shallow and did not look good. The CMA stated that LVN B notified the provider and received new orders, and she thought LVN B had tried to call Resident #4's family member. The CMA revealed that a change of condition needed to be reported immediately to the charge nurse, so the resident could be evaluated. During an interview on [DATE] at 3:07 PM with CNA C revealed that on Monday, [DATE] that Resident #4 was not himself. CNA C reported that Resident #4 was not eating, and that therapy had tried to work with him, but they had to put him back in bed because he was too weak. CNA C stated that she knew the physician was notified, and she thought LVN B had tried calling the daughter. CNA C stated that she would report any change of condition to her charge nurse immediately, because any little change could be something big. 675346 Page 4 of 5 675346 11/03/2023 Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE] at 3:17 PM with CNA D revealed on [DATE] Resident #4 was having trouble breathing, so she notified LVN B who went to assess him. CNA D then reported that the DON went into assess him as well. CNA D reported that LVN B notified the physician, and thought she tried calling the daughter. CNA D stated that she did notify the charge nurse when she noticed a change in condition. CNA D stated it was important to report a change of condition immediately, because the resident could have a UTI, dehydration, or something else that needed to be checked on. During an interview on [DATE] at 3:37 PM with LVN B revealed when Resident #4 was noted to have a change of condition, that she notified the physician and received orders for labs and a chest x-ray. LVN B reported that Resident #4 did not want to go back to the hospital. LVN B stated she called Family Member C on two different occasions but did not get an answer. LVN B stated she did not feel comfortable with leaving a message, and stated that she thought that when Family Member C saw the facility number she would call back. LVN B stated she did not document her attempts of contacting Family member C. LVN B stated that when Resident #4 returned back to the facility from dialysis on Saturday, [DATE], she noticed that his right eye was red. LVN B reported when Resident #4 returned it was close to change of shift, so she reported to LVN A and asked her to look at his eye. During an interview on [DATE] at 4:25 PM with the ADON, she reported that that she did call and talk to Family Member C on [DATE] when Resident #4 was readmitted from the hospital. ADON stated that it was important to quickly assess a resident that is noted to have a change of condition, to keep them from getting worse. During an interview on [DATE] at 4:30 PM, the DON stated going forward, the next time she assessed a resident for a change of condition, that she would not only report to the charge nurse, but she would also document her findings and notify the family or responsible party as well. Record review of a facility policy titled, Change in a Resident's Condition or Status, revised [DATE] documented the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status(e.g., changes in the level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 3. The nurse/designee will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status. 675346 Page 5 of 5