Health inspection·February 9, 2024

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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 interviews and record reviews, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 of 2 residents (CR #1) reviewed for basic life support, including CPR. The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. The facility failed to immediately initiate CPR at about 3:28 AM on 2/4/24 when CR#1 was found unresponsive, by waiting an additional 7 minutes. The facility failed to ensure CPR was performed appropriately and accurately for approximately 10 minutes once initiated by staff. An Immediate Jeopardy (IJ) was identified on 02/07/24 at 3:20pm. While the IJ was removed on 02/09/24 at 4:00 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern. as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings Included: Record Review of CR#1's face sheet revealed, a [AGE] year-old female, admitted to the facility on [DATE] with primary diagnoses of Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Dysphagia (Difficulty swallowing), Oropharynegeal phase (voluntary and depends on motor and sensory pathways that move food posteriorly through the oral cavity to the oropharynx, triggering as series of reflexive mov), Cognitive communication deficit (may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage, which result in difficulty with thinking and how someone uses language), cardiac arrest (sudden unexplained loss of heart function, breathing and consciousness), epilepsy (Brain disorder that causes reoccurring, unprovoked seizures), not intractable, without status epilepticus (can't be controlled through anti-seizure medications), type 1 Diabetes Mellitus without complications (Insulin dependent), Hypothyroidism (deficiency of thyroid hormones), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), Hypertension Page 1 of 7 675714 675714 02/09/2024 Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few (condition in which the force of the blood against artery walls is too high), Acidosis, (Too much acid in body fluids), Elevated white blood cell count (the immune system is working to destroy an infection, a sign of physical or emotional stress, or particular types of cancer), , anoxic brain damage (the brain is starved of oxygen), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), Morbid (severe) Obesity (More than a 100 pounds over you ideal body weight) Record Review of the MDS dated [DATE], revealed CR#1 was unable to respond and had no BIMS (Brief Interview for Mental Status) score, which suggest severe impairment. Record Review of Care Plan dated 12/28/23 revealed CR #1 was full code. Staff to anticipate needs. Record Review of Orders revealed: Assess for pain every shift and document using: Numerical Scale of 0-10 if verbal or PAINAD if non-verbal 12/28/23 2200 D/C Date 2/4/24 0856; Enteral feed order-every shift check G/T placement prior to administration of meds and hanging enteral feedings 12/28/23 2200 D/C Date 2/4/24 0856; Enteral feed order-every shift check gastric residual volume. Hold feeding for 1 hr and notify physician for residual greater than 70cc; Eternal Feed Order-every shift Flush enteral tube with 30ml water pre/post medication administration and 5-10 ml water between each medication 12/28/23 2200 D/C Date 2/4/24 0856; Enteral Feed Order every shift keep HOB elevated 30-45 degrees at all times-aspiration precautions 12/28/23 2200 D/C Date 2/4/24 0856; HOB elevated at 30 degrees due to SOB while lying flat. 12/28/23 2200 D/C Date 2/4/24 0856; Monitor 02 sat, respirations, and lung sounds q shift. Every shift for Tracheostomy Lung Sounds: C=Clear, W=Wheezes, D=Diminished, R=Rales/Rhonchl; Respiratory Quality: U=Even and Unlabored, S=Shallow, L=Labored, D=Distress 12/28/23 2200 D/C Date 2/4/24 0856; Oral care Q shift-every shift Suction with a yankuer daily 12/28/23 2200 D/C Date 2/4/24 0856; Provide oral care Qshift & PRN every shift 12/28/23 0600 D/C Date 2/4/24 0856; Suction Qshift & PRN. Report abnormal secretions to MD 12/28/23 2200 D/C Date 2/4/24 0856; Trach care Qshift and PRN. Notify MD with changes every shift 12/28/23 2200 D/C Date 2/4/24 0856; Verify the following emergency supplies are at the bedside (above the HOB): Ambu bag, Obturator, Water-soluble lubricant, Trach in the size ordered, Trach in a size below and size above (preferably), E-cyclinder at the bedside for emergency 02 use. 12/28/23 2200 D/C Date 2/4/24 0856; Enteral Feed Order four times a day (Bolus) Enteral Feeding: Glucerna 1.5 Amount:240 ml 4x/day, volume to be delivered 948 ml.***(May use Diabetlsource A/A or Glucerma 1.2 if 1.5 is not available)*** 12/29/23 0600 D/C Date 2/4/24 0856; Enteral Feed Order four times a day (Bolus) Enteral Feeding: Glucema 1.5 Amount 240 ml 4x/day, volume to be delivered 948 ml.**(May use Dlalbetlsource A/A or Glucema 1.2 if 1.5 is not available) 1/27/23 2200 D/C Date 2/4/24 1050; Enteral Feed Order four times a day (Bolus) Enteral Feeding: Glucema 1.5 Amount 240 ml 4x/day, volume to be delivered 948 ml.**(May use Dlalbetlsource A/A or Glucema 1.2 if 1.5 is not available.)***2/3/24 1200-Hold Date- from 2/3/24 1724 to 2/4/24 0856 D/C Date 2/4/24 0856; Enteral Feed Order four times a day Flush peg tube with 90 ml water before and after each bolus feeding. Start date 01/27/24 1200 -D/C Date-2/4/24 0856; Enteral Feed Order four times a day for 5 days Jevity 1.5 four times a day 8 fluid ounces-start date-2/3/24 2000-D/C date2/4/24 0856; Insulin Lispro [NAME] KwikPen Subcutanious Solution Pen-Injector 100 UNIT/ML (Insulin Lispro)-Inject as per sliding sale: if 151-200=2 units, 201-250=4units, 251-300=6units, 301-350=8units, 351-400=10 units 401 and above give 12 units and notify the NP/MD, subcutaneously before meals and at bedtime for DM-start date 12/29/23 0630-D/C 2/4/24 0856. Record review of last documented Vitals revealed the following for Blood Sugar: 675714 Page 2 of 7 675714 02/09/2024 Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375

F 0678 2/3/2024 at 9:10pm:10 121.0 mg/dL-Blood Sugar Level of Harm - Immediate jeopardy to resident health or safety 2/3/2024 at 5:16pm 81.0 mg/dL-Blood Sugar Residents Affected - Few 2/3/2024 at 8:24am 98.0 mg/dL-Blood Sugar 2/3/2024 at 11:38am 101.0 mg/dL-Blood Sugar Record review of last documented Vitals revealed the following for breaths/min 2/3/2024 at 5:51pm 18-breaths/min 2/3/2024 at 9:58am 18-breaths/min 2/3/2024 at 12:01am 18-breaths/min Record review of last documented Vitals revealed the following for Trach 2/3/2024 at 5:51pm 96.0% Trach 2/3/2024 at 9:58am 96.0% Trach 2/3/2024 at 12:01am 96.0% Trach Record review of last documented Vitals revealed the following for Pain Level 2/3/2024 at 10:38pm 0 bpm Pain ad-Pain Level 2/3/2024 at 2:53pm 0 bpm Numerical-Pain Level 2/3/2024 at 9:58am 0 mg/dL-Painad-Pain Level 2/3/2024 at 12:00am 0 mg/dL-Numerical-Pain Level Record review of progress note revealed the only note documented on 2/4/24 at 05:11AM by LVN A reflected, [CR#1] was found nonresponsive around 3:30AM CPR was started and 911 was called. EMS arrived at 3:40AM to take over. EMS attempted to revive CR#1 until 4:04AM when they informed staff that they could not get any vitals and asked if we had anyone to pronounce time of death on duty. Staff RN pronounced CR#1 dead. Body was put back in bed via lift by staff and was cleaned up. [LVN A] informed FM that CR#1 had passed. FM called Mortuary to come pick up CR#1, they said they would call back with ETA. Family removed all belonging from room. MD and DON informed. In a telephone interview on 2/6/24 at 2:30pm with LVN A said CNA B came to her and told her that something was wrong with CR#1. LVN A stated she came back to the nursing station and immediately telephoned 911. LVN A stated she checked on CR#1 by sticking her head around the curtain about 11:30pm to ensure she was breathing. At that time, she stated she did not provide any services to CR#1 even though her initials indicated she did. LVN A stated when she cam on to shift, she put her initial on the computer, then made note of who she needed to see during the night. She was asked if she thought that indicating in the treatment notes was professionally appropriate when she had not provided any 675714 Page 3 of 7 675714 02/09/2024 Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few treatment services to residents. She stated she didn't see anything wrong with it since she was going to see her patients anyway. Observation of surveillance camera revealed on 2/4/2024 at 3:28AM CR#1 was found unresponsive by CNA's A & B then they exited the room. LVN B began compressions 7 minutes after CR#1 was initially found unresponsive. LVN B was told by RN to stop the compressions while she placed the board under CR#1's back. Four minutes later, RN attached the ambu bag to the oxygen tank. Three minutes later EMS arrived to CR#1's room and took control. In an interview on 2/6/24 at 5:38pm with CNA B revealed the facility was short staff. Both CNA's Had 30 residents a piece. CNA A asked for assistant round 12:30am to assist with changing resident. Around 3:30 family called went back into the room to assist. She went in the resident room, tongue yellowish color. Noticed she wasn't breathing. She went and got nurse. Completed full code. Stated she believes the nurse on break. Stated she went to the car and got the nurse. Stated she went out and got nurse LVN who was on break. Stated she was in the room when Fire and Rescue police, then EMS arrived. EMS took over. Stated LVN B was performing CPR alone. He started compressions. Nurse supervisor was supposed to be assisting LVN B. Did not go into the room. In an interview on 2/6/24 at 5:50pm with CNA A, revealed she initially observed CR#1 around 12:00am when she went in the room to change resident. The resident was still alive. Around after 2:00am or 3:00am FM called and stated the nurse has not been in CR#1's room. Five (5) minutes after speaking with FM, we (CNA A and CNA B) went to check on CR#1 and change her. CNA A stated that the two of them began removing the pillows supporting CR#1's hand because she needed to be changed. When we looked at her face, she did not look the same as she did when we went in her room at 12:00am. We immediately left and called the nurse and told her what we observed. Someone called emergency. In an interview on 2/6/24 at 9:29pm with LVN B who stated CNA A and CNA B came to him around 3:30am and said CR#1 was not breathing. He stated he immediately checked the face sheet and scrolled through the miscellaneous paperwork to ensure there was no DNR. LVN B went to CR#1's room, was assisted by other staff in getting CR#1 on the floor where he began compressions. He continued compressions until EMS arrived and took over. LVN B said RN got the (ambu) bag (known as a manual resuscitator). He stated the primary nurse, LVN A called EMS. EMS took over and started the compressions and placed tube in the resident throat and continued 15-20 minutes. EMS stated they did everything then they called code and asked the facility to sign documents and RN stated CR#1 was dead. LVN B also stated he could not remember when dates of his CPR certification, but stated the facility could pull it up on their computer. In an interview on 2/7/24 at 1:30pm with DON revealed, when a code is called protocol is urgency and immediate! The compressions and oxygen bag are simultaneously. RN should not have asked LVN B to stop doing compressions to allow her to place a board under CR#1's back. This was determined to be an Immediate Jeopardy (IJ) on 2/7/24 at 3:20PM. The Administrator, the DON and the Regional Nurse were notified. The Administrator was provided with the IJ template and a POR was requested at this time. The following Plan of Removal submitted by the facility and was accepted on 2/9/2024 at 4:00PM Tag Cited: F-678 675714 Page 4 of 7 675714 02/09/2024 Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375

F 0678 Issue Cited: Level of Harm - Immediate jeopardy to resident health or safety Failure to ensure that a resident received CPR in accordance with professional standards of practice. Residents Affected - Few A. Immediate Action Taken Resident # 1 expired in the facility on 2/4/2024. B. On 2/7/2024 the DON/Designee began In Service education to all licensed nurses on Cardiopulmonary Resuscitation Policy that is a guideline for processing the patient's right and choice regarding Cardiopulmonary Resuscitation, to provide basic life support, including CPR to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advanced directive or a Do Not Resuscitate order. This In-Service education was completed on 2/7/2024 at 7:30 pm, and no licensed nurse was allowed to work until they had completed this In-Service. C. On 2/7/2024 Social Worker/Designee began 100% audit of all resident's code status to correctly identify if they are a full code or DNR. This will be completed on 2/7/2024 at 7:30 pm and corrective action will be addressed if identified. D. On 2/7/2024 DON/Designee reviewed the crash cart check list and validated that all items were present on crash cart. E. On 2/7/2024, an audit was completed by Human Resources to validate that 14 of 17 licensed nurses were CPR certified. The 3 licensed nurses what were not CPR certified, will not be allowed to work until they attend the CPR training course on 2/8/2024. F. On 2/6/2023 the primary night nurse for resident # 1was suspended and will be terminated. Two other nurses involved in the incident will not be allowed to work until they receive 1:1 education from the DON or Regional Nurse Consultant regarding Cardiopulmonary Resuscitation, to provide basic life support, including CPR to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advanced directive or a Do Not Resuscitate order. G. On 2/7/2024 the DON/Designee conducted a mock CPR drill with the 2 pm to 10 pm shift, after the IJ was called. H. The DON/Designee will conduct a mock CPR drill on each shift daily x 3 days, beginning on 2/7/2024. 1. 675714 Page 5 of 7 675714 02/09/2024 Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375

F 0678 Identification of Residents Affected or Likely to be Affected: Level of Harm - Immediate jeopardy to resident health or safety 2. Residents Affected - Few 3. Actions to Prevent Occurrence/Recurrence: The DON/Designee validated that there are no other like residents in the facility at this time. A. On 2/8/2024 all license nurses will receive in-person CPR training by a Certified CPR Instructor. No license nurse will be allowed to work until they have received CPR certification. B. On 2/8/2024 all certified Nurse Aides on the evening and night shifts will receive in-person CPR training by a Certified CPR Instructor. No certified Nurse Aide on the evening or night shift will be allowed to work until they have received CPR certification. C. DON/Designee will do mock drills weekly x 4 weeks, 2 x month x 2 months, then monthly ongoing. D. Starting 2/7/2024 any newly hired licensed nurse, or certified nurse aide will be required to have CPR certification within 2 weeks of hire. E. For all new or readmissions, the social worker or designee will review resident's code status daily in the morning meeting to validate that resident's code status is correct. F. DON will review crash cart check list 5 x weekly to validate that all needed items to conduct a code is available, this will be on going. E. On 2/7/2024 an ad hoc meeting regarding the immediate Jeopardy was conducted to review the plan of removal and interventions. On 2/7/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to start CPR in accordance with professional standards of practice, and reviewed plan to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ______2/8/2024___________ Monitoring completed from 2/7/2024 through 2/9/2024. Interview were conducted with the following employees from varying shifts: Administrator, DON, RN A, RN B, LVN A, LVN B LVN C, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F and CMA A, all of whom indicated they received training on 2/7/24 in the areas of CPR and protocol. During an interview, each employee listed, indicated they are aware of performing CPR and the protocols (which entailed the resident is Full-Code and Not DNR prior to performing CPR). Each employee was able to give an example of a Code Blue and the procedures they were to follow (ex.calling Help Room # and Bring Crashcart the individual responsible for calling 911 and ensuring that all actions taken are urgent). Record Review for the In-service training in the following areas: AHS Emergency Codes (specifically code blue) on 2/7/2024; Cardiopulmonary Resuscitation -Advanced Directives Policy 2/7/2024; Clinical Document Guideline 2/7/2024; Mock CPR-Drill conducted on 2/7/2024 at 1:07am and ending 1:38am; Code Blue documentation timeline & steps during a code blue 2/7/2024; and auditing of the residents who 675714 Page 6 of 7 675714 02/09/2024 Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375

F 0678 Level of Harm - Immediate jeopardy to resident health or safety are DNR, Full-Code and those needing a Code Status in PCC; BLS (RN from the American Heart Association) which includes applying the Ambu bag to a trach for CPR. The Facility's Policy Review on Cardiopulmonary Resuscitation-Advance Directives revised date 3/14/2014 reads, Licensed nurses must maintain current CPR certification for Healthcare Providers through a CPR provider who training includes hands-on-practice and in-person skills assessment. Residents Affected - Few The IJ was lowered on 02/09/24 at 4:00 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern. as the facility continued to monitor the implementation and effectiveness of their plan of removal. 675714 Page 7 of 7