Health inspection·May 25, 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 8 of 12 residents (Residents #74, #48, #26, #47, #61, #71, #59 and #25) reviewed for care plans. The facility failed to address Residents #74, #48, #26, #47, #61, #71, #59 and #25's Code Status on their comprehensive person-centered care plan. This failure could place residents at risk of receiving cardiopulmonary resuscitation (CPR) against their wishes. Findings include: Record review of Residents #74, #48, #26, #47, #61, #71, #59 and #25 revealed no care plan for their code status. Record review of Resident #74's face sheet revealed the Code Status was Full Code. Record review of Resident #48's face sheet revealed the Code Status was DNR. Record review of Resident #26's face sheet revealed the Code status was Full Code. Record review of Resident #47's face sheet revealed a Code Status of DNR. Record review of Resident #61's face sheet revealed a Code status of DNR. Record review of Resident #71's face sheet revealed a Code Status of DNR. Record review of Resident #59's face sheet revealed the Code Status was Full Code. Record review of Resident #25's face sheet revealed the Code Status was Full Code. Interview on [DATE] at 11:24 AM with the R.N., she stated the purpose of a care plan was to ensure all resident needs were being provided and Plan of Care was comprehensive. The R.N. stated physician orders for each resident should be reflected in the plan of care. The R.N. stated Code status Page 1 of 6 675748 675748 05/25/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should be on each plan of care. The R.N. stated Code status was the residents' final wishes. The R.N. stated if she wanted to know Resident Code Status she would check the plan of care. Interview on [DATE] at 11:44 AM, LVN C stated a Care Plan described the resident needs and everything about the resident was included in the plan of care. LVN C stated her expectation of Physician's orders would be reflected in the residents plan of care. LVN C stated it was very important to include Code Status in the plan of care so staff would know how to treat a resident in an emergency. LVN C stated failure to follow Code status could have legal implications. LVN C stated failure to perform CPR on a resident with Full Code status could cause resident death. Interview on [DATE] at 11:58 AM, ADON A stated all disciplines were involved in individual care plan development. ADON A stated a care plan incorporated all of a residents needs and the plan was used by all disciplines to ensure resident needs were met. ADON A stated Physician Orders should be reflected in a care plan and Code Status should be included in all care plans so all staff would know the resident's wishes. ADON A stated DON, ADON, nurses and the Social Worker were all responsible for checking care plans to ensure plans were a correct reflection of resident needs. ADON A stated all care plans were reviewed quarterly and staff would talk to the family, resident, and doctor to ensure all needs were included. ADON A stated it was very important for code status to be included because staff had to know whether to perform CPR or not; and whether to send a resident to the hospital (even if resident was a DNR). ADON A stated everyone was responsible to obtain a DNR form if that was the residents wishes. ADON A stated failure to follow code orders was failure to follow physician orders and residents last wishes. Interview on [DATE] at 8:00 AM with the Social Worker, she stated she discussed Code Status with family/administration and if she needed to initiate a DNR, she would go over required paperwork with the family/resident. The Social Worker stated after discussion with resident/family, a care plan meeting was held, and she discussed Code Status with the care-plan team and Code Status would become part of the Care Plan. The Social Worker stated Code Status was discussed with resident/family at admission. The Social Worker stated the Care Plan described how the resident was to be cared for and it was important for all staff to know Code Status in the event of an emergency. The Social Worker stated all staff referred to care plans. The Social Worker stated she was not sure why Code Status would not be in the Care Plan. The Social Worker stated she usually obtained Code Status and gave information to the ADON or the charge nurse and they entered the information into the computer and into the care plan. The Social Worker stated failure to follow resident wishes was a failure to follow physician orders, as well. The Social Worker stated a Care Plan should reflect Physician Orders. Interview on [DATE] at 8:24 AM with ADON B, she stated the Admissions Coordinator provided Code Status to ADON B and to the nurses on Side One and she was not sure about how Side Two acquired Code information. ADON B stated she notified the physician of code status, and he initiated an order. ADON B stated she then entered status into the computer. ADON B stated the Code Status was entered into the Care Plan as a Team effort. ADON B stated no one person was responsible for entering Code Status into the Care Plan. ADON B stated the DON was responsible for ensuring Care Plans were complete. ADON B stated a resident plan of care should reflect Physician Orders. ADON B stated all nurses, Social Worker, therapy and dietary staff used information in Care Plans. ADON B stated when care plans were incomplete the resident did not receive all required needs. ADON B stated the impact of not including Code Status in the Care plan would be staff would not know how to treat a resident in an emergency. Interview on [DATE] at 10:35 AM with the DON stated the admission Coordinator would provide Code 675748 Page 2 of 6 675748 05/25/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Status on some residents and some residents did not have a code status on admission and the SW would discuss with the resident/family and initiate DNR paperwork as needed. The DON stated once Code Status was ascertained, the information would be given to the ADON's to enter into the computer. The DON stated all nursing staff were responsible for ensuring Code Status was included in the Plan of Care. The DON stated each Plan of Care should reflect the physician orders. The DON stated failure to include Code Status in the Plan of Care was a failure to follow the physician orders. Interview on [DATE] at 10:45 AM, the Administrator stated each resident should have a comprehensive care plan. The Administrator stated a resident plan of care should encompass all physician orders and failure to include Code Status in the plan of care was a failure to follow physician orders and could cause harm to the resident. Record review of the facility policy Care Plans, Comprehensive Person-Centered, dated 2001 (Revised [DATE]), reflected 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. Policy Interpretation and Implementation: The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including . exercising his or her rights, including the right to refuse treatment. 675748 Page 3 of 6 675748 05/25/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for one (Resident #194) of 18 residents reviewed for dental services. Residents Affected - Few The facility failed to assist in providing routine dental services for Resident #194 after learning of lost dentures. This failure could place residents at risk for oral complications, dental pain, and a diminished quality of life. Findings included: Record review of Resident #194's face sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #194 had diagnoses which included Metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood), acute pulmonary edema (an abnormal buildup of fluid in the lungs), bipolar disorder, without psychotic features (Mood is elevated out of keeping with the patient's circumstances and may vary from carefree joviality to almost uncontrollable excitement), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #194's modified MDS, dated [DATE], revealed a BIMS score of 9, which indicated the resident had moderately impaired cognition. Her functional status revealed she required extensive assistance with bed mobility, transfer, and toilet use. She required limited assistance personal hygiene and set up with oral hygiene. Record review of Resident #194's Order Summary Report revealed Resident #194 had a regular diet with a start date of 05/01/2021. Review of Resident #194's care plan, dated 03/10/2023, revealed she had an activities of daily living (ADL) self-care performance deficit related to dementia, fatigue, weakness, and debility. Record review of Resident #194's Certification of no medical contradiction - dental and Attending physician request for services form revealed they were signed by the physician on 02/06/2023. A review of the facility's medical authorization form revealed it was signed by Resident #194 and dated 2/22/2023. An interview on 05/23/2023 at 9:48AM with Resident #194 revealed she was missing her bottom denture for a long time. She said she did not recall how long and was not sure what happened to them. She said she told the social worker but had not heard back. She said her family members also spoke to the administrator about it. She said she did not have trouble eating most food but would like to have them replaced. An interview on 05/24/2023 at 4:19PM with the Social Worker revealed she did not recall when she was informed Resident #194's bottom dentures were missing. She said Resident #194's family member did contact her about it but she did not recall when. She said she had not documented the issue but did recall going to Resident #194's room to have her sign the consents for dental services. She said she did send a referral to the dentist on 02/22/2023 but would have to check her records to see if 675748 Page 4 of 6 675748 05/25/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0791 Resident #194 was ever seen by the dentist. She said she should have followed up with the referral. Level of Harm - Minimal harm or potential for actual harm An interview on 05/25/2023 at 11:22AM with ADON A revealed she was not sure if Resident #194 had seen the dentist recently. She said Resident #194 was sent to the emergency room on [DATE] and when she returned tested positive for COVID-19 which placed her in quarantine. ADON A stated the physician signed the request on 02/06/2023 so the dental referral should have been sent then. She stated she was not sure why the social worker had not sent the referral until 02/22/2023 but it was the social worker's responsibility to follow up wiht referrals. She said not having dentures could impact Resident #194's self-esteem and her ability to eat certain foods. She stated Resident #194 also had the right to have dental services in a timely manner. Residents Affected - Few An interview on 05/25/2023 at 9:46AM with the Administrator revealed Resident #194's family had spoken to him about her missing dentures, and he informed the Social Worker who then started a referral. He said he did not know why there was no follow up on the dental referral but expected the Social Worker to do that within days of getting the consents signed. He said he hated that Resident #194's referral Fell through the cracks, and was not followed up with. An interview on 05/25/2023 at 10:22AM with the DON revealed she had worked in the facility for fourteen months and Resident #194 had not had her bottom dentures the entire time. She stated the missing dentures were brought up during Resident #194's care plan meeting but was not sure about the follow up. She said the Social Worker would follow up with the dental referral to ensure appointments were timely. An interview on 05/25/2023 at 11:45AM with the Social Worker revealed the dental service providers were in the facility on 4/14/2023 and 05/12/2023 to provide services to other residents but Resident ##194 was not seen on either of those dates. She said she followed up with the dentist's office on 05/12/2023 and was informed the physician's printed name was not on the forms sent on 02/22/2023. She stated that was why Resident #194 did not get seen. The SW stated she corrected the form and resent the referral on 05/12/2023. She stated she had not followed up after sending the initial referral on 02/22/2023 and should have. She stated Resident #194 had a right to ensure her dental appointment was timely. An interview on 05/25/2023 at 12:10PM with the Speech Therapist revealed he was not currently working with Resident #194 and no triggers of choking or loss of appetite had been brought to his attention. He said nursing staff had not brought any issue with eating to his attention. He stated regardless of if Resident #194 had any physical issues as a result of not having her lower dentures, she had a right to see a dentist timely. Record review of the facility's policy titled , Dental Services, dated 12/2016, stated .Routine and 24-hour emergency dental services are provided to our residents through: a contract agreement with a dentist that comes to the facility monthly; referral to the dentist . social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan . if dentures are damaged or lost, residents will be referred for dental services within 3 days Record review of the facility's policy titled, Availability of Services, Dental, stated .Social services will be responsible for making necessary dental appointments . all requests for routine and emergency dental services should be directed to Social Services to assure that appointments can be 675748 Page 5 of 6 675748 05/25/2023 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0791 made in a timely manner . residents with lost or damaged dentures will be promptly referred to a dentist Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675748 Page 6 of 6