Health inspection·February 3, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's RP when there was a significant change in the resident's physical status for 1 of 3 (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified when he was sent out to the hospital for low blood pressure on 01/27/2025 while at his dialysis treatment. This failure could place residents at risk of their responsible party not being involved in ensuring safety. Findings included: A record review of Resident #1's face sheet dated 02/01/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis was end stage renal disease(kidneys lose the ability to remove waste and balance fluids) and unspecified dementia(signs of memory loss but specific underlying cause cannot be identified. A record review of Resident #1's Quarterly MDS assessment, dated 11/13/2024, reflected the resident had a BIMS score of 1, which indicated severe cognitive impairment. A record review of Resident #1's progress note dated 01/27/2025 did not reflect documentation of call made to family. During an interview with Resident #1's RP on 02/01/2025 at 11:03am, she stated that she was not made aware that Resident # 1 was sent to the hospital on [DATE] when he was at dialysis. The RP stated no one at the facility contacted her to let her know and she was made aware by dialysis staff the evening of 01/27/2025 . The RP could not recall the time dialysis staff had notified her that Resident # 1 had been sent out to the hospital for low blood pressure when he was there. During an interview with The Regional Nurse on 02/01/2025 at 12:45pm, The Regional Nurse stated it was expected for LVN A to have contacted Resident # 1's RP to notify that he was sent out to the hospital from dialysis due to low blood pressure. The Regional Nurse stated when there is a change of condition and the resident's family not notified would result in the family not being able to participate in the resident's plan of care. During an interview with LVN A on 02/01/2025 at 2:46 pm, LVN A stated that dialysis had made a call to the facility on [DATE] time not recalled, to advise Resident # 1 did not complete his dialysis Page 1 of 2 675909 675909 02/03/2025 Harker Heights Nursing & Rehabilitation 415 Indian Oaks Dr Harker Heights, TX 76548

F 0580 Level of Harm - Minimal harm or potential for actual harm treatment and had been sent out to the hospital for not feeling well. LVN A stated she did not make a call to Resident #1's RP because she thought the dialysis center would call. LVNA stated she had dropped the ball and she was responsible for calling the RP to let her know that Resident #1 had a change in condition. LVN A stated it was expected for her to call the RP and without notifying the RP they would not be involved in the care process. Residents Affected - Few During an interview on 02/01/2025 at 3:20pm, the ADM stated it was expected for LVN A to contact Resident #1's RP to let them know Resident #1 had been sent out to the hospital from dialysis. The ADM stated if the RP did not get notified, they would not know the condition of the resident. Review of facility's policy titled Changes in resident condition dated January 2023 reflected The resident, attending physician and resident representative or designated family member should be notified when changes in condition or certain events occur. 675909 Page 2 of 2