Health inspection·September 19, 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, to a resident requiring emergency care prior to the arrival of emergency medical personnel in accordance with professional standards for one (Resident #1) of four residents reviewed for CPR. The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems. This failure could result in injury, harm, impairment or death to a resident receiving care in this facility. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old male admitted [DATE] with diagnoses that included Dementia (progressive memory loss), Heart Disease, Heart Failure, Chronic Obstructive Pulmonary Disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), Diabetes Mellitus (blood sugar regulation disorder), Hyperlipidemia (high cholesterol levels) and Liver Failure. Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 6, suggesting severe cognitive impairment. Further review of the MDS reflected Resident #1 could make himself understood and was able to understand verbal content. Review of Resident #1's care plan dated [DATE] reflected the focus: (Resident #1) has an advance Directive as evidenced by: Do not Resuscitate. Review of Resident #1's care plan meeting notes dated [DATE] signed by SW reflected under the Summary of Social Services section: Change to Full Code Status SDPOA provided Review of Resident #1's progress notes dated [DATE] to [DATE] (date of Resident #1's death), Page 1 of 17 675748 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few reflected no entry from any NF staff correcting Resident #1's care plan meeting notes on [DATE] listing resident's desire to change to code status as a mistake or error and that Resident #1 wanted to remain a code of DNR. Review of Resident #1's progress notes dated [DATE] @ 12:55 pm reflected: PT WAS PROPELLING SELF IN W/C THIS MORNING. NURSE PRACTITIONER (redacted) SAW PT THIS AM DURING ROUNDS. PT HAD NO S/S OF DISTRESS THIS AM. FSBS WAS OBTAINED AT 11:00AM PT WAS ALERT AND ORIENTED X 1WNL. FSBS 107. @ 1230 RESIDENT ROOMMATE REPORTED THAT PT WAS ON FLOOR IN BATHROOM. DON PERFORMED ASSESSMENT AND PRONOUNCED PT DEATH AT 1245. Review of Resident #1's DNR form dated [DATE] reflected a form signed by FM #2 and two witnesses. Review of Resident #1's SDPOA form dated [DATE] reflected Resident #1 had signed a SDPOA appointing FM #2 as his DPOA. During an interview with FM #1 on [DATE] at 1:29 pm, they stated they were at the care plan meeting on [DATE] when Resident #1 verbally expressed a desire to change his code status from DNR to full code. She stated she remembered this distinctly because she did not agree with Resident #1 being a Full Code due to his health issues, but she supported Resident #1's decision. They stated at this meeting they provided the facility staff with a Statutory Durable Power of Attorney (SDPOA) paperwork as well as a marriage certificate. FM #1 stated the facility did not ask Resident #1 to fill out any forms or paperwork redacting his DNR status in this meeting, nor requested Resident #1 put the request in writing. FM #1 stated after Resident #1's death, they went to the NF on [DATE] and DON informed FM #1 that Resident #1 had been found on the floor of the bathroom and that the NF had not provided any lifesaving measures because Resident #1 had a DNR. FM #1 stated they reminded the DON at that time that Resident #1 had changed his mind in the care plan meeting on [DATE] and wanted to be a Full Code and the DON denied that Resident #1 had said that. During an interview with FM #2 on [DATE] at 2:26 pm, they stated they had attended the care plan meeting on [DATE] with Resident #1, FM #1 and facility staff. FM #2 stated in that meeting, Resident #1's code status was reviewed, and Resident #1 stated he wanted to be a Full Code. FM #2 stated they received a call from FM #3 on [DATE] telling her that Resident #1 had been found on the floor at the NF and had passed. FM #2 stated she called the facility on [DATE] and spoke to the SW who informed her that Resident #1 had passed away. FM #2 stated they went to the facility shortly after this call and FM #2 informed her of what the DON had said regarding Resident #1's code status and the NF not doing CPR. FM #2 stated they were very upset and felt the NF lied about Resident #1's code status because they had not done CPR. During an interview with the SW on [DATE] at 2:36 pm, she stated she was at the care plan meeting on [DATE] with Resident #1, his family members and other NF staff. She stated Resident #1's FM #2 was very adamant during that meeting that he change his code status from DNR to Full Code. The SW stated due to FM #2's insistence, Resident #1 initially stated he wanted to change his code status from DNR to Full Code. The SW stated they reminded [FM#2] that it was Resident #1's decision to make and then asked Resident #1 directly and he stated he wanted his code status to stay as DNR. The investigator recited the care plan meeting notes to the SW and the SW confirmed the care plan meeting notes in the EMR were completed by her and that she had signed the notes stating Resident #1 wanted to change his code status from DNR to Full Code. She stated in that meeting on [DATE], there was a period of time that he (Resident #1) was in agreement with (FM #2) and that's probably when I typed in 675748 Page 2 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Change to Full Code, and I did not go back in and review that before I finalized the note. The SW stated she made a mistake in her documentation. When informed there were no other progress notes on this care plan meeting in the EMR, the SW stated she does not recall whether she made any additional notes in the EMR, and she was no longer working at the facility so she could not check and does not recall if she went back and correct it. The SW stated that whatever notes were in the EMR was what was documented. During an interview with the DON on [DATE] at 3:48 pm she stated she was in the care plan meeting on [DATE] with Resident #1, [FM#1, FM#2] and SW. The DON stated that the SW reviewed Resident #1's DNR status and [[FM#2] wanted him to be a Full Code. She stated Resident #1 had his head down and was mumbling so the DON asked him if he wanted to be a DNR. The DON stated she explained the Resident #1 what that meant, and Resident # 1 stated he wanted to keep it like it is as a DNR. She stated she did not put in any progress notes related to what was said or happened in the meeting but remembered the [FM#2] pushing him to change it and Resident #1 ultimately saying he wanted to remain a DNR. She stated there were no forms filled out or anything put in writing because Resident #1 was already a DNR, and he stated he did not want to change. During an interview with the AD on [DATE] at 3:29 pm the AD stated he was not aware that Resident #1 had expressed a desire to change his code status from DNR to Full code in the care plan meeting on [DATE] . The AD stated his expectation was that if a resident changes their mind about a code status they can let any staff know and they will direct resident to the SW and make sure the change takes place. The AD stated his expectations were that any request to change code status by a resident would be turned around in less than 72 hours and that if it would be changed - a resident has a right to have advanced directives. The AD was shown the care plan meeting notes from [DATE] showing the SW documented that Resident #1 wanted a change in code status from DNR to Full Code and AD stated he was not aware of those notes and that if the SW had made a mistake in documentation, it should have been corrected. Attempts to reach the MD on [DATE] by phone at 12:36 pm and by text on [DATE] at 12:39 pm, [DATE] at 8:54 am and 9:45 am were unsuccessful, however the MD did leave a return voicemail that they were out of the country traveling and MD responded to texts, but we were unable to connect. Review of facility policy dated [DATE] entitled Charting and Documentation revealed the following policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care and additionally: 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; 675748 Page 3 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0678 e. Events, incidents or accidents involving the resident; and Level of Harm - Immediate jeopardy to resident health or safety f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Residents Affected - Few The AD was notified on [DATE] at 4:24 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on [DATE] at 2:00 pm. On [DATE], an investigation was initiated at [name of facility]. At approximately 4:25 p.m. on [DATE], a at [name of facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: F-0842 - The facility failed to update Resident #1's records to reflect that Resident #1 requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR were not provided to Resident #1 on [DATE] when Resident #1 was found unresponsive. Corrective Actions and Identification of Others: Immediate Resident Review and Audit: Action: Conduct a comprehensive audit of all current residents' advance directives and code status forms to identify any discrepancies, incomplete documentation, or missing physician signatures. No discrepancies were found. Moving forward, if any discrepancies are found they will be corrected. Responsible party and MD will be notified. Plan of care will be updated to reflect current status if needed. Responsible Party: Director of Nursing (DON), Social Worker. Timeline: Completed on [DATE] Measurement of Success: 100% of residents will have an accurate, up-to-date code status documented in their medical records and reflected in plan of care. Systemic Change: Staff Education and Training: Action: Implement mandatory in-service training for all staff members involved in resident care (nurses, CNAs) to review the policy on DNR vs. Full Code status, including the correct processes for verifying and documenting code status. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. Focus on key areas: advance directives, communication with families, and identifying/flagging code 675748 Page 4 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0678 status on medical records. Level of Harm - Immediate jeopardy to resident health or safety Responsible Party: DON, ADONs, and Chief of Clinical Services. Timeline: Completed on [DATE], Residents Affected - Few Measurement of Success: Chief of Clinical services provided training to Admin team. From there, the Director of Nursing/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Staff Education and Training: Action: Corporate Clinical consultant completed education with IDT team on proper steps to follow upon family or resident requesting to revoke or change current code status. This should include, verifying resident responsible party or POA, notification to all responsible parties, notification to MD, and complete documentation in resident record to reflect what current code status will be. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. Responsible Party: Corporate Clinical Consultant Timeline: Completed on [DATE], Measurement of Success: 100% of clinical IDT team, including DON, SSW, Nurse managers, Administrator, will complete education on code status Enhanced Documentation Protocol: Action: Implement an improved documentation protocol that includes: A standardized advance directive form that must be completed upon admission. Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. Responsible Party: Nursing Department, Social Worker. Timeline: Documentation protocols will be revised and implemented by [DATE] Measurement of Success: 100% of residents will have complete and correct advance directives documented using the new protocol. Communication with Residents and Families: Action: Establish a clear communication plan with residents and their families regarding the code status decision-making process: At admission, all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. 675748 Page 5 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0678 Families will be notified immediately of any changes in the residents' condition that may prompt a review of the advance directive. Level of Harm - Immediate jeopardy to resident health or safety Responsible Party: Social Services Director, Admissions Coordinator. Residents Affected - Few Timeline: Communication plan to be implemented and completed by [DATE] with current and new residents/families. Measurement of Success: 100% of families will be contacted to confirm their understanding of the resident's advance directive and code status within 5 days of admission or change in condition. Monitoring and Quality Improvement: Action: Integrate advance directive and code status accuracy into the facility's ongoing Quality Assurance and Performance Improvement (QAPI) process: Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. Include code status tracking as part of the quarterly QAPI meetings to review any issues or incidents related to discrepancies. Responsible Party: QAPI Committee, Administrator, Director of Nursing, Social Worker. Timeline: Audits will begin immediately, on [DATE], and results will be reviewed in the next QAPI meeting. Measurement of Success: A 100% compliance rate for correct advance directive documentation in audits, with any errors identified and corrected within 48 hours. QAPI REVIEW Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on CPR, Advanced directives, and Plan of removal/response to Immediate Jeopardy Citation on [DATE] Start Date: [DATE] Responsible: Administrator Monitoring for Effectiveness: Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review The surveyor monitored the POR on as followed: A comprehensive audit of all current residents an advanced directives and code status forms was 675748 Page 6 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few completed on [DATE]. In an interview on [DATE] at 1:00pm with the DON, she stated they went down the resident roster on all residents and called families to verify code status on all residents. The staff then ensured all advanced directives and DNRs were signed on the chart, in the red code book at the nurses' station and the order in the computer correlated with the residents wishes. That was completed on [DATE]. The DNR status was correct on all residents the day of audit and day of entry from state. During an interview on [DATE] at 1:00pm with The DON staff education and training was completed on [DATE] including policy review on DNR vs Full Code. This education included verifying documents, location of documents process for verifying and documenting code status. All staff were given a policy for advanced directives. Staff confirmed they had received training and were able to verbalize the process of code status, where it would be located and procedures on what to do if a resident or RP would like to change their code status. The DON stated that the AD and DON were trained first By the Cooperate clinical consultant along with the IDT team. The DON stated the IDT team then instructed all staff, she stated night shift was educated first, we had the policy reviewed it with each employee including where to look for DNR status. The DON reviewed the DNR book at each nurse's station with the staff and informed them that if a resident changes their mind related to code status, they need to inform the DON and ADON so the proper process can be verified and updated. In an interview on [DATE] at 1:00pm with The DON and AD they confirmed an enhanced documentation protocol plan was completed [DATE]. The plan included A standardized advance directive form that must be completed upon admission. Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. The DON explained that the plan would ensure that if a resident wants to make a change to their code status and completing the advanced directive upon admission. She stated the nursing department heads would be responsible for ensuring documentation was correct. The DON stated the IDT would monitor daily with new admission. She stated the Team are reviewing and monitoring this process daily in morning meeting. During an interview on [DATE] at 1:00pm with The DON and AD, The AD stated communication with Residents and Families should start upon admission. Upon admission all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. The DON stated that she and the admissions coordinator would be responsible for explaining the differences between full code and DNR educating residents and family on life savings protocols. The DON stated this would include suppling and assisting with the proper paperwork to ensure resident wishes were made clear. The DON stated they do break the explanation down in layman's terms and ensure families understand and give examples of what it means to be Full Code vs DNR. The AD stated the process would be reviewed every day in morning meeting with the internal document system. The DON stated at times the family doesn't always agree and in those cases, we have a meeting with the family and the resident together and again make it as simple as possible in layman's terms. We address it heavily on care plan day always. During an interview on [DATE] at 1:00pm The AD and DON stated Monitoring and Quality Improvement plan was to Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. The ADON and DON will be responsible for the monitoring and review daily as well as during the QAPI meeting. The AD stated the QAPI will be held monthly. During interviews on [DATE] at 2:30pm Staff interviews were completed on [DATE] with 3 LVNs, 1RN, 2 CNA, 1 MA- reflected that staff were aware of code status policy. The staff were able to verbally 675748 Page 7 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0678 Level of Harm - Immediate jeopardy to resident health or safety demonstrate how to check for code status. They were able to locate the red code book on each hall and verify code status within the EMR. Staff were able to verbalize steps of notification to DON/ADON for resident request in changing code status. Staff stated they were confident they would be able to effectively complete a code blue (full code) if needed. Staff verbalized they had received a copy of full code, DNR policy and education provided by the IDT including the correct processes for verifying and documenting code status. Staff were also able to locate each AED at the nurses station on crash carts readily available. Residents Affected - Few Review of an in-service, dated [DATE] and conducted by the CNO, reflected the AD and the DON were in-serviced on the following: Review policy on DNR vs. Full Code status Review process for verifying and documenting code status Review process on how to change or revoke a resident's current code status Review policy on advanced directives. Review of in-service dated [DATE], conducted by the AD, reflected all staff from all shifts were being inserviced on the following: DNR / Advanced Directives Policy Charting and Documentation Record review of Advanced Directives audit reflected all residents were reviewed for code status on [DATE]. Review of an Ad Hoc QAPI Agenda, dated [DATE], reflected the AD, MD, DON, ADONS, Dietary and Director of Rehabilitation were in attendance. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems. 675748 Page 8 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 Level of Harm - Immediate jeopardy to resident health or safety Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interviews and record reviews, the facility failed to ensure that medical records were accurately documented for one (Resident #1) of four residents reviewed for accurate clinical records, in that: Residents Affected - Few The facility failed to update Resident #1's records to reflect he requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR (Cardiopulmonary Resuscitation) were not provided to Resident #1 when Resident #1 was found unresponsive and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ Template was provided to the facility on [DATE] at 4:25 pm. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems. This failure could result in injury, harm, impairment or death to a resident receiving care in this facility. Findings included: Review of Resident #1's face sheet dated [DATE] reflected a [AGE] year-old male admitted [DATE] with diagnoses that included Dementia (progressive memory loss), Heart Disease, Heart Failure, Chronic Obstructive Pulmonary Disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe), Diabetes Mellitus (blood sugar regulation disorder), Hyperlipidemia (high cholesterol levels) and Liver Failure. Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 6, suggesting severe cognitive impairment. Further review of the MDS reflected Resident #1 could make himself understood and was able to understand verbal content. Review of Resident #1's care plan dated [DATE] reflected the focus: (Resident #1) has an advance Directive as evidenced by: Do not Resuscitate. Review of Resident #1's care plan meeting notes dated [DATE] signed by SW reflected under the Summary of Social Services section: Change to Full Code Status SDPOA provided Review of Resident #1's progress notes dated [DATE] to [DATE] (date of Resident #1's death), reflected no entry from any NF staff correcting Resident #1's care plan meeting notes on [DATE] listing resident's desire to change to code status as a mistake or error and that Resident #1 wanted to remain a code of DNR. Review of Resident #1's progress notes dated [DATE] @ 12:55 pm reflected: PT WAS PROPELLING SELF IN W/C THIS MORNING. NURSE PRACTITIONER (redacted) SAW PT THIS AM DURING ROUNDS. PT HAD NO S/S OF DISTRESS THIS AM. FSBS WAS OBTAINED AT 11:00AM PT WAS ALERT AND ORIENTED X 1WNL. FSBS 107. @ 1230 RESIDENT ROOMMATE REPORTED THAT PT WAS ON FLOOR IN BATHROOM. DON PERFORMED ASSESSMENT AND PRONOUNCED PT DEATH AT 1245. 675748 Page 9 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 Review of Resident #1's DNR form dated [DATE] reflected a form signed by FM #2 and two witnesses. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's SDPOA form dated [DATE] reflected Resident #1 had signed a SDPOA appointing FM #2 as his DPOA. Residents Affected - Few During an interview with FM #1 on [DATE] at 1:29 pm, they stated they were at the care plan meeting on [DATE] when Resident #1 verbally expressed a desire to change his code status from DNR to full code. She stated she remembered this distinctly because she did not agree with Resident #1 being a Full Code due to his health issues, but she supported Resident #1's decision. They stated at this meeting they provided the facility staff with a Statutory Durable Power of Attorney (SDPOA) paperwork as well as a marriage certificate. FM #1 stated the facility did not ask Resident #1 to fill out any forms or paperwork redacting his DNR status in this meeting, nor requested Resident #1 put the request in writing. FM #1 stated after Resident #1's death, they went to the NF on [DATE] and DON informed FM #1 that Resident #1 had been found on the floor of the bathroom and that the NF had not provided any lifesaving measures because Resident #1 had a DNR. FM #1 stated they reminded the DON at that time that Resident #1 had changed his mind in the care plan meeting on [DATE] and wanted to be a Full Code and the DON denied that Resident #1 had said that. During an interview with FM #2 on [DATE] at 2:26 pm, they stated they had attended the care plan meeting on [DATE] with Resident #1, FM #1 and facility staff. FM #2 stated in that meeting, Resident #1's code status was reviewed, and Resident #1 stated he wanted to be a Full Code. FM #2 stated they received a call from FM #3 on [DATE] telling her that Resident #1 had been found on the floor at the NF and had passed. FM #2 stated she called the facility on [DATE] and spoke to the SW who informed her that Resident #1 had passed away. FM #2 stated they went to the facility shortly after this call and FM #2 informed her of what the DON had said regarding Resident #1's code status and the NF not doing CPR. FM #2 stated they were very upset and felt the NF lied about Resident #1's code status because they had not done CPR. During an interview with the SW on [DATE] at 2:36 pm, she stated she was at the care plan meeting on [DATE] with Resident #1, his family members and other NF staff. She stated Resident #1's FM #2 was very adamant during that meeting that he change his code status from DNR to Full Code. The SW stated due to FM #2's insistence, Resident #1 initially stated he wanted to change his code status from DNR to Full Code. The SW stated they reminded [FM#2] that it was Resident #1's decision to make and then asked Resident #1 directly and he stated he wanted his code status to stay as DNR. The investigator recited the care plan meeting notes to the SW and the SW confirmed the care plan meeting notes in the EMR were completed by her and that she had signed the notes stating Resident #1 wanted to change his code status from DNR to Full Code. She stated in that meeting on [DATE], there was a period of time that he (Resident #1) was in agreement with (FM #2) and that's probably when I typed in Change to Full Code, and I did not go back in and review that before I finalized the note. The SW stated she made a mistake in her documentation. When informed there were no other progress notes on this care plan meeting in the EMR, the SW stated she does not recall whether she made any additional notes in the EMR, and she was no longer working at the facility so she could not check and does not recall if she went back and correct it. The SW stated that whatever notes were in the EMR was what was documented. During an interview with the DON on [DATE] at 3:48 pm she stated she was in the care plan meeting on [DATE] with Resident #1, [FM#1, FM#2] and SW. The DON stated that the SW reviewed Resident #1's DNR status and [[FM#2] wanted him to be a Full Code. She stated Resident #1 had his head down and was mumbling so the DON asked him if he wanted to be a DNR. The DON stated she explained the Resident #1 675748 Page 10 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few what that meant, and Resident # 1 stated he wanted to keep it like it is as a DNR. She stated she did not put in any progress notes related to what was said or happened in the meeting but remembered the [FM#2] pushing him to change it and Resident #1 ultimately saying he wanted to remain a DNR. She stated there were no forms filled out or anything put in writing because Resident #1 was already a DNR, and he stated he did not want to change. During an interview with the AD on [DATE] at 3:29 pm the AD stated he was not aware that Resident #1 had expressed a desire to change his code status from DNR to Full code in the care plan meeting on [DATE] . The AD stated his expectation was that if a resident changes their mind about a code status they can let any staff know and they will direct resident to the SW and make sure the change takes place. The AD stated his expectations were that any request to change code status by a resident would be turned around in less than 72 hours and that if it would be changed - a resident has a right to have advanced directives. The AD was shown the care plan meeting notes from [DATE] showing the SW documented that Resident #1 wanted a change in code status from DNR to Full Code and AD stated he was not aware of those notes and that if the SW had made a mistake in documentation, it should have been corrected. Attempts to reach the MD on [DATE] by phone at 12:36 pm and by text on [DATE] at 12:39 pm, [DATE] at 8:54 am and 9:45 am were unsuccessful, however the MD did leave a return voicemail that they were out of the country traveling and MD responded to texts, but we were unable to connect. Review of facility policy dated [DATE] entitled Charting and Documentation revealed the following policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care and additionally: 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The AD was notified on [DATE] at 4:24 pm, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. 675748 Page 11 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 The following POR was accepted on [DATE] at 2:00 pm. Level of Harm - Immediate jeopardy to resident health or safety On [DATE], an investigation was initiated at [name of facility]. At approximately 4:25 p.m. on [DATE], a at [name of facility] constitute immediate jeopardy to resident health and safety. The Immediate Jeopardy findings were identified in the following areas: Residents Affected - Few F-0842 - The facility failed to update Resident #1's records to reflect that Resident #1 requested a change in his code status on [DATE] from DNR (do not resuscitate) to Full Code. As a result, basic life support measures, including CPR were not provided to Resident #1 on [DATE] when Resident #1 was found unresponsive. Corrective Actions and Identification of Others: Immediate Resident Review and Audit: • Action: Conduct a comprehensive audit of all current residents' advance directives and code status forms to identify any discrepancies, incomplete documentation, or missing physician signatures. No discrepancies were found. Moving forward, if any discrepancies are found they will be corrected. Responsible party and MD will be notified. Plan of care will be updated to reflect current status if needed. • Responsible Party: Director of Nursing (DON), Social Worker. • Timeline: Completed on [DATE] • Measurement of Success: 100% of residents will have an accurate, up-to-date code status documented in their medical records and reflected in plan of care. Systemic Change: Staff Education and Training: • Action: Implement mandatory in-service training for all staff members involved in resident care (nurses, CNAs) to review the policy on DNR vs. Full Code status, including the correct processes for verifying and documenting code status. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. • 675748 Page 12 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 Level of Harm - Immediate jeopardy to resident health or safety Focus on key areas: advance directives, communication with families, and identifying/flagging code status on medical records. • Responsible Party: DON, ADONs, and Chief of Clinical Services. Timeline: Completed on [DATE], Residents Affected - Few • Measurement of Success: Chief of Clinical services provided training to Admin team. From there, the Director of Nursing/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Staff Education and Training: • Action: Corporate Clinical consultant completed education with IDT team on proper steps to follow upon family or resident requesting to revoke or change current code status. This should include, verifying resident responsible party or POA, notification to all responsible parties, notification to MD, and complete documentation in resident record to reflect what current code status will be. Our policy for Advance Directives was provided to all staff. Comprehension will be verified by the staff verbalizing and signing the in-service. • Responsible Party: Corporate Clinical Consultant • Timeline: Completed on [DATE], • Measurement of Success: 100% of clinical IDT team, including DON, SSW, Nurse managers, Administrator, will complete education on code status Enhanced Documentation Protocol: • Action: Implement an improved documentation protocol that includes: • A standardized advance directive form that must be completed upon admission. 675748 Page 13 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 • Level of Harm - Immediate jeopardy to resident health or safety Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. • Residents Affected - Few Responsible Party: Nursing Department, Social Worker. • Timeline: Documentation protocols will be revised and implemented by [DATE] • Measurement of Success: 100% of residents will have complete and correct advance directives documented using the new protocol. Communication with Residents and Families: • Action: Establish a clear communication plan with residents and their families regarding the code status decision-making process: • At admission, all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. • Families will be notified immediately of any changes in the residents' condition that may prompt a review of the advance directive. • Responsible Party: Social Services Director, Admissions Coordinator. • Timeline: Communication plan to be implemented and completed by [DATE] with current and new residents/families. • Measurement of Success: 100% of families will be contacted to confirm their understanding of the resident's advance directive and code status within 5 days of admission or change in condition. 675748 Page 14 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 Monitoring and Quality Improvement: Level of Harm - Immediate jeopardy to resident health or safety • Action: Integrate advance directive and code status accuracy into the facility's ongoing Quality Assurance and Performance Improvement (QAPI) process: Residents Affected - Few • Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. • Include code status tracking as part of the quarterly QAPI meetings to review any issues or incidents related to discrepancies. • Responsible Party: QAPI Committee, Administrator, Director of Nursing, Social Worker. • Timeline: Audits will begin immediately, on [DATE], and results will be reviewed in the next QAPI meeting. • Measurement of Success: A 100% compliance rate for correct advance directive documentation in audits, with any errors identified and corrected within 48 hours. QAPI REVIEW Action: Ad hoc QAPI meeting held with IDT team and MD to review policy on CPR, Advanced directives, and Plan of removal/response to Immediate Jeopardy Citation on [DATE] Start Date: [DATE] Responsible: Administrator Monitoring for Effectiveness: Any trends or concerns were/will be addressed with Quality Assurance Performance Committee and continue until a lessor frequency deemed appropriate through QAPI review The surveyor monitored the POR on as followed: 675748 Page 15 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 Level of Harm - Immediate jeopardy to resident health or safety A comprehensive audit of all current residents an advanced directives and code status forms was completed on [DATE]. In an interview on [DATE] at 1:00pm with the DON, she stated they went down the resident roster on all residents and called families to verify code status on all residents. The staff then ensured all advanced directives and DNRs were signed on the chart, in the red code book at the nurses' station and the order in the computer correlated with the residents wishes. That was completed on [DATE]. The DNR status was correct on all residents the day of audit and day of entry from state. Residents Affected - Few During an interview on [DATE] at 1:00pm with The DON staff education and training was completed on [DATE] including policy review on DNR vs Full Code. This education included verifying documents, location of documents process for verifying and documenting code status. All staff were given a policy for advanced directives. Staff confirmed they had received training and were able to verbalize the process of code status, where it would be located and procedures on what to do if a resident or RP would like to change their code status. The DON stated that the AD and DON were trained first By the Cooperate clinical consultant along with the IDT team. The DON stated the IDT team then instructed all staff, she stated night shift was educated first, we had the policy reviewed it with each employee including where to look for DNR status. The DON reviewed the DNR book at each nurse's station with the staff and informed them that if a resident changes their mind related to code status, they need to inform the DON and ADON so the proper process can be verified and updated. In an interview on [DATE] at 1:00pm with The DON and AD they confirmed an enhanced documentation protocol plan was completed [DATE]. The plan included A standardized advance directive form that must be completed upon admission. Clear placement of code status (DNR or Full Code) in the resident's chart, electronic health record, and daily care plan. The DON explained that the plan would ensure that if a resident wants to make a change to their code status and completing the advanced directive upon admission. She stated the nursing department heads would be responsible for ensuring documentation was correct. The DON stated the IDT would monitor daily with new admission. She stated the Team are reviewing and monitoring this process daily in morning meeting. During an interview on [DATE] at 1:00pm with The DON and AD, The AD stated communication with Residents and Families should start upon admission. Upon admission all residents/families will receive education on the differences between DNR and Full Code, and the options for advance directives. The DON stated that she and the admissions coordinator would be responsible for explaining the differences between full code and DNR educating residents and family on life savings protocols. The DON stated this would include suppling and assisting with the proper paperwork to ensure resident wishes were made clear. The DON stated they do break the explanation down in layman's terms and ensure families understand and give examples of what it means to be Full Code vs DNR. The AD stated the process would be reviewed every day in morning meeting with the internal document system. The DON stated at times the family doesn't always agree and in those cases, we have a meeting with the family and the resident together and again make it as simple as possible in layman's terms. We address it heavily on care plan day always. During an interview on [DATE] at 1:00pm The AD and DON stated Monitoring and Quality Improvement plan was to Conduct review of all new admissions and 10% of current resident files, weekly, to ensure that code status is documented correctly and that the DNR/Full Code status is being followed. The ADON and DON will be responsible for the monitoring and review daily as well as during the QAPI meeting. The AD stated the QAPI will be held monthly. During interviews on [DATE] at 2:30pm Staff interviews were completed on [DATE] with 3 LVNs, 1RN, 2 675748 Page 16 of 17 675748 09/19/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0842 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few CNA, 1 MA- reflected that staff were aware of code status policy. The staff were able to verbally demonstrate how to check for code status. They were able to locate the red code book on each hall and verify code status within the EMR. Staff were able to verbalize steps of notification to DON/ADON for resident request in changing code status. Staff stated they were confident they would be able to effectively complete a code blue (full code) if needed. Staff verbalized they had received a copy of full code, DNR policy and education provided by the IDT including the correct processes for verifying and documenting code status. Staff were also able to locate each AED at the nurses station on crash carts readily available. Review of an in-service, dated [DATE] and conducted by the CNO, reflected the AD and the DON were in-serviced on the following: Review policy on DNR vs. Full Code status Review process for verifying and documenting code status Review process on how to change or revoke a resident's current code status Review policy on advanced directives. Review of in-service dated [DATE], conducted by the AD, reflected all staff from all shifts were being inserviced on the following: DNR / Advanced Directives Policy Charting and Documentation Record review of Advanced Directives audit reflected all residents were reviewed for code status on [DATE]. Review of an Ad Hoc QAPI Agenda, dated [DATE], reflected the AD, MD, DON, ADONS, Dietary and Director of Rehabilitation were in attendance. While the IJ was removed on [DATE] at 5:03 pm, the facility remained out of compliance at a level of no actual harm at a scope of isolated because the facility's need to evaluate the effectiveness of the corrective systems. 675748 Page 17 of 17