Health inspection·January 28, 2026

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility did not ensure that the resident's requests, refusals, discontinuations, and advance directives were honored for 1 of 1 (CR#1) resident's DNR. LVN A provided CPR to CR #1 prior to determining if the resident had advanced directives in place resulting in CR #1 receiving life-saving intervention from LVN A and then emergency responders. Emergency responders did restore CR #1's pulse and CR#1 was transported to the hospital where CR#1 expired. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This deficient practice could place residents at risk of harm and injury due to inadequate care.Findings include:Review of CR #1's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Cerebral infraction, Muscle weakness, Hyperlipidemia, Type 2 diabetes without complications, Quadriplegia, acute posthemorrhagic Anemia, and Hypotension. Record Review of CR #1's Care Plan dated [DATE] revealed he was care planned for DNR. Intervention dated [DATE] required staff to check resident file for DNR before calling a code. Review of CR #1's progress note dated [DATE] shows that the following entry was made by RN B. During routine rounding, the nurse observed the resident gasping for air, sweating profusely, and then becoming unresponsive. A code was called, life-saving measures were initiated, and 911 was contacted. Upon EMS arrival, life-saving efforts were transferred to them, and the Do Not Resuscitate (DNR) documentation was subsequently located and confirmed as active. At that point, EMS successfully restored the resident's pulse and blood pressure, and the resident was transported to the hospital. The Nurse Practitioner (NP) was notified and informed about the events. The responsible party (RP) was also contacted and made aware of the situation, including the life-saving measures performed before the DNR was retrieved. The RP expressed understanding and requested the address of the hospital's emergency room where the resident was taken. Record review on [DATE] at 12:00p.m. of facilities in-service documents reflected that on [DATE], the facility conducted an audit of its long-term care and skilled nursing units. The purpose of the audit was to review the list of residents with Do Not Resuscitate (DNR) orders. This list was compiled by the facility's social worker, and the Assistant Director of Nursing (ADON) is responsible for checking it daily for accuracy.In an interview with the ADON On [DATE] at 12:22p.m. she stated that on [DATE], the facility created two binders to expedite the identification of residents with a DNR. The binders were placed on the crash carts and at the nurses' station.Record review on [DATE] at 12:24 p.m. reflected that on [DATE], the facility conducted an in-service training for nursing staff. The training focused on the importance of checking all patients' code status before initiating any life-saving measures. If a Do Not Resuscitate (DNR) order is in place, cardiopulmonary resuscitation (CPR) should not be initiated, as this would contradict the selected end-of-life measures and orders.In an interview on [DATE] at 11:50 a.m., the Administrator Page 1 of 2 676208 676208 01/28/2026 Eagle Crest Rapid Recovery 9602 Huffmeister Rd Houston, TX 77095

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated that, before CPR was performed on CR #1, it was essential to verify the patient's code status. He noted that LVN A's failure to check CR #1's code status violated policy and required the initiation of life-saving measures for CR #1.In an interview on [DATE] at 12:25 p.m., the ADON stated that, before LVN A called a code and initiated Life-Saving Measures on CR #1, the DNR status should have been verified. She indicated that LVN A's failure to check CR #1's DNR status constituted a violation of policy.An unsuccessful attempt was made to contact LVN A on [DATE], at 12:26 p.m., at 10:30 a.m. on [DATE] and 1:00pm on [DATE]. In an interview on [DATE] at 12:55 p.m., LVN B stated that she believed LVN A had already confirmed the code status for CR #1. LVN B mentioned that, per their policy, anyone who calls a code is responsible for verifying the DNR status before initiating the code. LVN B stated that she had been in-serviced to check a resident's code status before initiating life-saving measures. In an interview on [DATE] at 1:17 p.m., with LVN C, she stated that she had received training on /[DATE] to check a resident's code status before initiating life-saving measures. She mentioned that the training emphasized checking the DNR binder on the crash carts, as it was faster than looking it up in the PCC system.In an interview on [DATE] at 2:30 p.m., with CNA A, she stated that she had been trained to check a resident's DNR status. She explained that a book located on the crash carts indicated whether a resident had a DNR. Additionally, she mentioned that the facility offers CPR classes for all CNAs.In an interview on [DATE] at 2:35 p.m., with CNA B, she stated that she had been trained to check a resident's DNR status.In an interview on [DATE] at 2:40 p.m., with CNA C, she stated that she had been trained to check a resident's DNR status.In an interview on [DATE], at 2:45 p.m., with CNA C, she stated that she had been trained to check a resident's DNR status.In a phone interview on [DATE], at 3:30 p.m., with the Regional Director of Nursing for facilities, she stated that on [DATE], she instructed the facility to create a binder to help staff easily identify which residents have a DNR order.Record review of the facility's DNR policy (undated) on [DATE] at 4:00 p.m., revealed that, before any life-saving measures are taken, staff must first determine whether the resident has a DNR in place.Record review of the facility provider report dated o[DATE] reflected that CR#1 received life-saving measures during a medical episode despite having a DNR in place. The nurse on duty failed to comply with CR#1's DNR by calling a code and initiating life-saving measures.measures. If a Do Not Resuscitate (DNR) order is in place, cardiopulmonary resuscitation (CPR) should not be initiated, as this would contradict the selected end-of-life measures and orders.In an interview with the administrator on [DATE], the facility management team suspended LVN A and LVN B because of providing Life Saving Measures to CR #1. CR #1 had a DNR in place, and the nurses failed to confirm the DNR before performing CPR. In an interview on [DATE] at 3:25 p.m., the Medical Director stated that he did participate in a QAPI regarding DNR. He also stated that the negative outcome of not checking for a code status could be unnecessary trauma to the resident's body. In an interview with the facility administrator on [DATE], at 3:25 p.m., the facility held a Quality Assurance and Performance Improvement (QAPI) meeting. The Medical Director confirmed his participation in discussions regarding Do Not Resuscitate (DNR) orders during this meeting.Record review of facility in-service dated [DATE], reflected that the facility held a CPR course that was open to all staff. The course also covered the facility policy on when to initiate and when not to initiate Life-Saving Measures. Record review of LVN_A disciplinary form dated 01 /23/26, the facility management terminated LVN A for failing to verify whether CR #1 had a DNR before calling code and EMS.The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. 676208 Page 2 of 2