Health inspection·September 10, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a therapeutic diet was offered when there were nutritional problems and the therapeutic diet was recommended for 1 of 2 residents reviewed for nutrition.The facility failed to put interventions in place when Resident # 1 had poor intake related to swallowing food, inability to consume meals as result of physical decline. Resident #1 had a wound and did not receive a dietician consult as needed. Resident #1 did not have updated care plan interventions related to her change in condition . This failure could cause residents to lose weight and not have interventions in place that could lead to significant weight loss.Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of abnormal weight loss.Record review of Resident #1's annual MDS dated [DATE] indicated Resident was cognitively stable with a BIMS score of 13. Resident #1's functional abilities with eating was setup or clean up assistance. The MDS indicated the resident did not have any nutritional issues.Record review of Resident #1's care plan that was in the system on 9/9/25 indicated the last care plan interventions for weight loss was dated 2/6/25 with interventions to monitor and assist as needed. There were no current problems identified with weight loss, pressure wounds, or swallowing issues.During a record review and interview on 9/9/25 at 12:48 p.m. the ADON said there were no revisions regarding Resident #1's weight loss, swallowing or wounds since 2/6/25. There was a care plan intervention dated 8/14/25 that indicated Resident #1 was non-compliant with removing her boot from her leg. During an interview on 9/10/25 at 1:43 p.m. with the RNC and DON, they said some revisions to Resident #1's care plan and added some interventions. They said Resident #1's weight would not have triggered in their system because it did not go in until the 7th of the month. Record review of Resident #1's care plan on 9/10/25 with the RNC indicated additional interventions that were not present on 9/9/25 to include a problem with a initiation date of 7/5/25 of a fracture of Resident #1's left out ankle, with interventions of reporting abnormalities to the physician. A care plan problem dated 8/7/25 indicated impaired skin integrity. The resident had a wound to her left leg. Some of the interventions were a referral to wound care for weekly skin assessments, maintain adequate nutrition and hydration, and staff were to report any skin changes. A problem dated 9/5/25 indicated the staff reported the resident required medications to be crushed. This varied from nurse to nurse because she would swallow well for certain nurses. The interventions were she was referred to speech therapy, and the physician was to be notified of significant changes. Record review of Resident #1's computerized physician orders indicated an order dated 6/13/25 for a regular diet consistency, with thin liquids and no added salt. Record review of Resident #1's Nutritional Therapy assessment dated [DATE] indicated a regular diet with boost two times daily (order discontinued 4/6/25). She was to be monitored for significant weight changes, labs, skin issues, monitor oral intake of food and fluid.Record review of Resident #1's nursing note dated 4/6/25 indicated the house shake order was discontinued, the residents weighed monthly, and the Residents Affected - Few Page 1 of 4 675561 675561 09/10/2025 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0692 Level of Harm - Actual harm Residents Affected - Few dietician will reassess if needed according to policy. The Resident has a good appetite, eats in the dining room and often obtains multiple snacks between meals and has bedtime snacks form the snack cart. Record review of Resident #1's weight log indicated on 7/4/25 Resident #1 weighed 212.60 pounds. Record review of Resident #1's pre albumin (measures nutritional status, specifically protein and calorie intake) dated 7/10/25 indicated a prealbumin of 15 which was low with a normal range of (20-40.) Record review of Resident #1's physician orders indicated on 7/17/25 she was placed on weekly weights. Record review of Resident #1's weight log indicated on 7/20/25 she weighed 198.40 pounds.Record review of Resident #1 wound care note from the wound care doctor dated 8/7/25 indicated she had a no pressure wound on left leg identified when cast was removed. The wound was 4.1 x 3.6 x 0.3 cm. The note indicated a plan to discuss the patient's abnormal body mass index (32.95) with the current dietitian. If the patient does not currently have a dietitian following, recommend dietary consult. Record review of Resident #1's per albumin lab completed on 8/13/25 revealed the prealbumin was 9 -low with a normal range of (20-40.) Record review of Resident #1's wound care note dated 8/15/25 indicated the wound care doctor recommended a dietician consult for protein optimization.Record review of Resident #1's weight log indicated on 8/29/25 she weighed 193.40.Record review of Resident #1's nursing note dated 9/1/25 at 6:44 p.m. Resident having increased difficulty swallow suggested the resident took 1 pill at a time. The resident was having difficulty eating, the writer brought resident food today. She consumed only the soft portions, during dinner the resident tried mechanical soft with purred vegetables with no change with the amount consumed. The family was informed of the appetite decline. Resident #1 continue to want to go and smoke. Signed by LVN ARecord review of Resident #1's nursing note dated 9/2/25 at 3:29 p.m. indicated Resident #1 did not want to try and take medications at this time. The medications were crushed. Her appetite remained poor with only soft foods consumed. The resident continued to go outside, and smoke and she was medicated for pain prior to wound care. The Np was here and assessed the wound and regarding current health. Signed by LVN A Record review of Resident #1's physician wound care report dated 9/4/25 indicated Resident #1's wound had exacerbated due to the resident noncompliance with wound care. Record review of Resident #1's weight log indicated on 9/5/25 she weighed 183 pounds.On 8/15/25 the resident weighed 198.6 pounds and on 8/29/25 the resident weighed 193.4 with a loss of 5.2 pounds and 2.5 percent. On 9/25/25 Resident #1 weighed 183 pounds for a total of 10.4-pound weight loss at 7.76 percent. (Which according to staff and policy the last weight would not have been noted until 9/7/25.)Record review of Resident #1's nutrition follow-up note dated 9/9/25 indicated the resident was currently hospitalized . The resident was reported with a decreased oral intake prior to hospitalization. The resident was noted with a non-pressure wound to the right leg. Recommended diet as prescribed, add MVI, house shakes three times a day, and continue with vitamins C.During an interview on 9/9/25 at 1:50 p.m. the DON said the dietician had last seen evaluated Resident # #1 on 12/12/25. The DON said the dietician had not reviewed Resident #1's nutritional status. The DON said she was not aware of Resident #1's pre albumin being low, of her not eating, and that she had lost weight. She said today she had written a note because she had just triggered for weight loss. Record review Resident #1's hospital records dated 9/7/25 indicated she was admitted due to left foot pain and ankle pain. Resident #1's Albumin was 3.0 Low with a normal range between 3.5 and 5.7. Resident had a left ankle fracture in July after a fall and was treated with a boot cast, Following the removal of the cast she developed an ulcer over the left foot which has progressively worsened. During an interview on 9/9/25 at 2:03 p.m. the NP said she was told Resident #1 was refusing to eat. She said LVN A requested she go in and talk to Resident #1 on 9/2/25 because she had concerns Resident #1 was not eating and her wound appeared to be 675561 Page 2 of 4 675561 09/10/2025 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0692 Level of Harm - Actual harm Residents Affected - Few getting worse. She said she had talked to Resident #1 about eating and Resident #1 told her she was eating just fine. She said she had encouraged the resident to get her protein for wound healing. The NP said she was under the impression the Nurse said she changed Resident #1's diet order to a soft diet and had talked with therapy about ordering a swallow test. She said Resident #1 told her she did not have any problems. The NP said she did not know Resident #1 had lost that much weight. She also said the wound care physician had ordered the pre albumin and she was not aware it was low, no one had reported it to her. She said she had observed the wound on 9/2/25 and the wound was not healing. The NP said Resident #1 was non-compliant with recommendations of wearing the boot and elevating her foot to keep the swelling down. During an interview on 9/9/25 at 2:27 p.m. LVN A said Resident #1 would eat but wanted soft food, said she was having trouble swallowing. The LVN said Resident#1 ate about 25 percent. She said about a week ago she had bought her lunch that she said she wanted, however, Resident #1 would only eat soft stuff from the meal. LVN A said she had talked to speech therapist about Resident #1 not eating and they watched her a shot while. LVN A said she did not know Resident #1 was losing weight. She said the resident had really declined with her food intake the last two weeks. She said Resident #1 was non-compliant with recommendations of wearing the boot and elevating her foot to keep the swelling down. She said the resident wanted to stay up in her wheelchair and go out to smoke. LVN A said even when they tried to lay the resident down, she would hold her foot over the side of the bed and not elevate the foot to keep the swelling down. During your interview on 9/9/25 at 2:50 p.m. CNA F said one day last week Resident #1 was not eating very well especially during the last week or so.During an interview on 9/10/25 at 8:30 a.m. the dietary aide said she monitored the dining room daily. She said Resident #1 would take small bites and sometimes she said she could not swallow. The dietary aide said after Resident #1 had the cast on her foot, she did not eat well. She said the last couple of weeks Resident #1 did not eat very much at all. She said Resident #1 was on a regular diet. The dietary aide said it appeared Resident #1 was not able to eat solid foods so she would get her chopped meat to see if she would eat that and she still ate very little. She said the speech therapist was in the dining room one day about a week, and she asked her to look at Resident #1.During an interview on 9/9/25 at 5:40 p.m. with Resident #1 at the hospital. Resident #1 said she had not been feeling like eating. She said she just did not have an appetite. She said the facility staff knew she was not eating. She could not remember anything special they had done. Resident #1 said different staff encouraged her to eat but she had just not wanted the food. During an interview on 9/10/25 at 9:04 a.m. the Speech Therapist said on last week LVN A and an aide told her Resident #1 had swallowing issues. She said she did not know how long it had been going on but that morning when she watched her at breakfast, she was not eating at all. She had told her manager and on 9/2/25 they had submitted a request to see if Resident #1 qualified for therapy. During an interview on 9/10/25 at 9:17 a.m. the dietary manager said she had not gotten an order to change Resident #1's diet. She said Resident #1 was still on a regular diet. She said that the dietary aide would be the one that knew about Resident #1's eating. The dietary manger said the aide worked in the dining room with the residents. She said the dietary aide knew what the residents liked, what they did not like, what they would eat, and what they would not eat. She said the aide may have gone to the kitchen and request a mechanical soft meat for Resident #1, but no one had put in an order to change the consistency of her food.During an interview on 9/10/25 at 9:20 a.m. the dishwasher said she worked in the dining room from time to time. She said Resident #1 would nibble on her food and would not eat very well. She said that once she had broken her foot that her appetite appeared to decrease after that but more so the last couple of weeks. The dishwasher said it was hard to find something 675561 Page 3 of 4 675561 09/10/2025 Heritage Plaza Nursing Center 600 W 52nd St Texarkana, TX 75501

F 0692 Level of Harm - Actual harm Residents Affected - Few Resident #1 would eat. They would ask her if she wanted something else, but she would not eat very much. During an interview on 9/10/25 at 9:40 a.m. CNA E said that she worked from 6 a.m. to 2 p.m. She said Resident #1 said had not been eating for about two weeks. She said that she had kind of slowed down with eating over the last few months. CNA E said Resident #1 would rather smoke than eat most of the time. She said had reported to the LVN A. She said about two weeks ago Resident #1 was not eating. She said Resident #1 said she could not swallow. She said LVN A requested she go out and get some chicken (Resident #1's favorite meal), but Resident #1 only ate the soft stuff. She said the resident would not keep her boot on or her feet elevated. During an interview on 9/10/25 at 9:45 a.m. LVN G said that she worked PRN and the last time she worked with a Resident #1 was on Thursday, 9/4/25. She said the resident was confused and she had two falls on that day. She said that she was not eating and what she did eat it took her a longer time to eat her food. She said that day she crushed her medications because she said she could not swallow. Record review of the facility Treatment of Wound and Nutrition Related Wound Care policy dated July 2028 indicated the purpose was to insure residents with pressure ulcers received nutrition therapy that promoted optimal wound progress and prevention. The facility will request a referral for a qualified dietitian related to care plan development factors such as nutrition screening, nutrition assessment, care planning, energy intake, protein intake, hydration, vitamins and minerals. Record review of the facility Weight Monitoring policy dated May 19,2023 indicated the resident's weight will be monitored at a minimum monthly. If there is an actual weekly weight gain or loss of 2 percent the physician and registered dietitian would be notified. The monthly weights would be logged by the 7th calendar day of the month. 675561 Page 4 of 4