Health inspection·February 20, 2024

F 0578 Level of Harm - Immediate jeopardy to resident health or safety 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 Interview and record review, the facility failed to protect the resident right to request, refuse and/or discontinue treatment for 1 (Resident #1) of 34 residents reviewed for advance directives. Residents Affected - Few The facility failed to ensure Resident's # 1 OOHDNR was processed and updated in EMR and care plan when signed by physician on [DATE]. The resident had a seizure on [DATE] that resulted in life saving measures being given, as the EMR showed resident was a full code, AED was applied and shock given, CPR was started, and resident was transferred to the hospital . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. This failure placed residents at risk of not having their wishes known, respected, and a potential of prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against their wishes. Findings Include: Review of Resident # 1's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Progressive supranuclear ophthalmoplegia (an inability to look down and focus) Brain Stem Stroke syndrome (when blood supply to the base of the brain is interrupted or stopped.), other symptoms and signs involving cognitive functions and awareness ( Mild mental impairment that can include memory loss, mood swings and behavioral changes ) and palliative care. Review of Resident # 1's admission MDS was in progress with a start date of [DATE]. Review of Resident # 1's discharge BIMs completed on [DATE] reflect a score of 10 out of 15 reflecting Moderate cognitive impairment. Review of Resident #1 's Base line care plan dated [DATE] revealed full code status. No updated on [DATE] with change of code status to OOH-DNR Review of Resident # 1's Comprehensive care plan updated [DATE] revealed DNR status. Review of Resident # 1's Physicians orders revealed admission order on [DATE] of full code status. Physicians order written on [DATE] and signed by the physician on [DATE] change status to OOH-DNR. Page 1 of 18 676364 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident # 1's Out of hospital do-not-resuscitate on chart signed by resident on [DATE] and physician on [DATE]. Reflecting that as of [DATE] the resident wishes were to not have advanced life saving measures during a medical emergency. Review of Resident #1's progress notes dated [DATE] at 5:20 PM written by DON, revealed resident was in dining room when he had a seizure, staff call the DON, CMA pulled up EMR, to obtain code status. EMR information screen showed full code status, resident was given respiratory support, transferred to room and 911 was called. Staff followed emergency operator's instructions, applied AED which advised shock. Shock given as instructed and CPR initiated per instruction. Interview [DATE] at 09:30 am with SW, she stated that the resident's RR came to her on [DATE] in the morning requesting resident be made a DNR, the social worker gave her an OOHDNR. Several hours later (no sure of the time but it was the same day) the RR brought the document back completed, requesting a notary, the SW found one who discovered that Resident #1 had signed in the incorrect spot. The RR, SW and Notary then went to the room and witnessed Resident #1 sign the document in the correct place. The charge nurse was notified, and the document was placed in the folder for the physician to sign when she came in. Interview [DATE] at 10:00 am with DON, she was at the facility the day of the incident and responded to yells from the dining room. Upon arriving she saw Resident # 1 having a seizure, an CMA pulled up the code status in the EMR as a Full code. Resident # 1 was per DON agonal breathing (insufficient breathing that often sounds like snoring, snorting, gasping or labored breathing), he was given respiratory support, transferred to his room. 911 was contact, assessment by RN given over the phone, instructed to place AED and follow instructions until paramedics arrived. AED applied, shock advised and given, after shock CPR was started per AED instructions. Paramedics arrived and took over CPR. Upon review of chart while making transfer packet it was discovered that an OOHDNR was on the chart, signed by the resident and the Physician. A signed physician's order dated [DATE] and signed [DATE] was also located in the paper chart. Updated information given to paramedics; resident was transported to hospital. Per conversation with Resident #1's RR on [DATE] resident had survived, no updates since then. Per DON nurse the worked that day and was on duty the day the order was signed, resigned the day after the incident with no notice. Interview [DATE] 11:45 am ADM stated she was not in the building when the incident occurred, but she was made aware of it and the IDT met the next morning to evaluate the event and identify the root causes, Review [DATE] 1:00 PM Review of Policy Medication and treatment orders dated [DATE] revealed All orders must be charted and made part of the resident medical record and plan of care. Review [DATE] 1:10 PM review of Policy Advanced Directive Revised [DATE] 20. The Director of Nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 02:50 PM and the administrator was notified at 02:50 PM. The Administrator was provided with the IJ Template on [DATE]. The following Plan of Removal was accepted on [DATE] at 02:44 PM. POR 676364 Page 2 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. On [DATE] an abbreviated survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of immediate threat states as follows: The facility failed to ensure Resident #1 has the right to formulate an advance directive and determine the choice to receive or not CPR (cardiopulmonary resuscitation). The deficient practice did result in harm to resident #1. The medical Director has been notified of the deficient practice on 02.15.2024. The resident #1 Code Status has been updated on Electronic Medical Records System (EMR) and on the paper chart to reflect that the resident is OOHDNR. The resident's care plan has been reviewed and updated. Implementation date is 02.16.2024 by DON. Completed on 02.16.2024. The Divisional Director of Nursing, Director of Nursing, Social Worker, and MD have done a full facility wide audit to make sure that all the residents at the facility have accurate Code Status on both the EMR and the Paper chart. Residents' care plans were reviewed during the audit. Every resident's code status is accurately documented and accurately reflected on the care plans. Implementation date is 02.16.2024 by DDRC, DON, SW. Completed on 02.16.2024 and will be ongoing. The DON has created a Code Status Binder with updated code status for every resident and made available at the nurses' stations for easy access by the staff. Changes will be reported to the DON, Administrator and ADON, and will be updated immediately by the DON or designee. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Each resident's code status and Advance Directives will be reviewed daily for 30 days by the DON, the Administrator after which there will be weekly audits for 90 days. The facility will review each resident's code status and Advance Directives during monthly QAPI meetings. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. New Admits charts will be reviewed daily during morning meetings by the IDT team led by DON, Social Worker, and the Administrator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. The DON will include code status reviews at the weekly Risk Meeting to ensure that every resident's code status will remain up to date. The Risk Meeting will be attended by the IDT team, the DON, Staff Development Coordinator, the director of Rehab, and the MDS coordinator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Staff In-service on Code Status and Advanced Directives are ongoing and being conducted by the Staff Development Nurse at the facility. Implementation date is 02.16.2024. Initial In-service was 02.16.2024, with SW, DON, Admin, MDS. The Staff Development Nurse was in-service by the Administrator on 676364 Page 3 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 02.16.2024. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. Inservice will be completed by 02.21.2024 and ongoing. The Administrator, DON, ADON and/or the Social Worker will immediately document discussions with all residents and/or resident representative(s) regarding the residents' rights. Including but not limited to the residents' decision on code status. Implementation date is 02.17.2024 In-service on 02.17.2024 In-serviced the Administrator, DON, SW and MDS, regarding residents' rights and immediate documentation of such discussions, and this will be on-going. In-service done by DDRC and RDO on 02.17.2024. Completed on 02.17.2024 and will be ongoing. The Social Worker will review and verify code status during all care plan meetings. If the resident and/or resident representative(s) elect to change code status, Social Worker will immediately document the discussion, and inform the Administrator, DON and ADON and verify paper chart and EMAR updated accurately. Implementation date is 02.17.2024. Completed on 02.17.2024 and this will be on-going. The Administrator, DON, ADON and/or Social Worker will chart all orders and make part of the residents' medical records and care plan. Implementation 02.17.2024 The DON, ADON and any other Licensed Nurse can accept phone orders and are responsible for charting phone orders once received and accepted. Completed on 02.17.2024 and will be ongoing. Staff In-service on abuse, neglect, and exploitation with all staff. Implementation date is 02.16.2024 The Administrator in-service staff on abuse, neglect, and exploitation. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. The DDRC in-service the Administrator and DON on 02.17.2024. Inservice will be completed by 02.21.2024 and will be ongoing. .The DON, MDS, and the Social Worker were educated on 02.17.2024 by the administrator on IJ. There was an Ad Hoc Qapi meeting regarding the IJ on 02.17.2024 with the Administrator, DON, Social worker and MDS. This will be an on-going discussion at QAPI meetings indefinitely. The Medical Director was notified of the IJ on 02.17.2024 by the administrator. Verification Plan of Removal: 6. Corporate Nurse completed Inservice training to Adm, DON, and MDS nurse, who immediately started training staff on Advance directive, order transcription, Code book, and resident rights and abuse and neglect. b. of [DATE]. 7. 676364 Page 4 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0578 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Administrator was unable to confirm the current status of the resident on [DATE], but an update from the wife on [DATE] stated he was in stable condition with no anticipated discharge date . 8. DON Validated all Residents code status was up to date per paper chart, red binder with code status was created and placed at nurses' station verified as up to date, EMR was up to date, including care plans on [DATE]. Daily audits preformed on 2/18,2/19, and [DATE] verified. Random audit of 4 residents with Full code status and 4 residents with DNR status were completed and verified as correct. 9. Verified thru sign in sheets that all facility staff reporting for duty from [DATE] at 6 am thru [DATE] at 6 am had completed in-services on Abuse/neglect, Advance Directives, The new red binder at the nurse's station with code status, resident rights and transcribing physician's orders. Interview with ADM on [DATE] at 10:00 she stated that the corporate compliance nurse educated her on Abuse/neglect, advance Directives, the red binder for code status, resident rights and who is responsible for transcribing physician's orders. Interview with SW on [DATE] at 09:30 am she stated that the corporate nurse and the DON educated her on the following in services, abuse/neglect, advance directives, the red binder at the nurse's station, resident rights and the process for transcribing orders. Interview with the DON on [DATE] at 11:30 am stated that the corporate nurse educated her on the following in-service abuse/neglect, resident rights, code book at the nurse's station, and transcribing order so that she could educate her staff and be a resource for questions. c. Interviews were conducted with staff across multiple shifts on [DATE] 06:00 am Thru [DATE] 06:00 am, including Maintenance Director, Culinary Director, Culinary Associate, Lead Housekeeper revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility and what to do in a medical emergency. d. Interviews were conducted with staff across all shifts on [DATE] 06:00 am thru [DATE] at 06:00 am including 8 RCA's, 3 Agency RCA, 3 Med Techs, 1 Agency LVN, 2 LVN's and 1 RN revealed they had all been in-serviced by DON/ADON stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents rights and where to find the resident rights posted in the facility, advance directives, where to find code status, and how to transcribe physician's order. The Nurses all stated that the information on who is responsible to enter the advance directive orders was new to them, and the rest of the information was a good reminder. 10. Ad hoc QAPI meeting held with IDT team and MD on [DATE] at 3:45pm to review policy on Abuse, Neglect and exploitation, resident status, Advance Directives and Code Status, and Plan of removal/response to immediate Jeopardy Citation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to 676364 Page 5 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0578 remove the IJ after verifying the POR had been initiated and or completed. Level of Harm - Immediate jeopardy to resident health or safety The Administrator was informed the immediate jeopardy was removed on [DATE] at 10:45 am. While the IJ was removed the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. due to the facility was still monitoring the effectiveness of the Plan of removal. Residents Affected - Few 676364 Page 6 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0655 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan to include the minimum healthcare information necessary to properly care for a resident for 1 of 24 residents (Resident #1) reviewed for baseline care plans. The facility failed to update Resident #1 baseline care plan on [DATE] when his code status changed from Full code to DNR, resulting in Resident #1 receiving CPR and the use of an AED which delivered a shock on [DATE] the Resident # 1 suffered a seizure and stopped breathing. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy at a scope of isolated. This failure could place residents at risk of not receiving appropriate care to meet their current needs, prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against their wishes. Findings Include: Review of Resident # 1's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Progressive supranuclear ophthalmoplegia (an inability to look down and focus) Brain Stem Stroke syndrome (when blood supply to the base of the brain is interrupted or stopped.), other symptoms and signs involving cognitive functions and awareness ( Mild mental impairment that can include memory loss, mood swings and behavioral changes ) and palliative care. Review of Resident #1's admission MDS was in progress, and undated. Review of Resident # 1's discharge BIMs dated [DATE] reflected a score of 10 out of 15 reflecting Moderate cognitive impairment. Review of Resident #1's Base line Care plan dated [DATE] revealed full code status. Review of Resident #1's Comprehensive care plan updated [DATE] revealed DNR status. Review of Resident #1's Physicians orders revealed admission order on [DATE] of full code status. Physicians order written on [DATE] and signed on [DATE]. Review of Resident #1's Out of hospital do-not-resuscitate on chart signed by resident on [DATE] and physician on [DATE]. Review of Resident #1's progress notes dated [DATE] at 5:20 p.m., written by the DON, revealed resident was in dining room when he had a seizure, staff call the DON, CMA pulled up EMR, to obtain code status. EMR information screen showed full code status, resident was given respiratory support, transferred to room and 911 was called. Staff followed emergency operator's instructions, applied AED which advised shock. Shock given as instructed and CPR initiated per instruction. 676364 Page 7 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0655 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview [DATE] at 09:30 a.m. with SW, she stated that the Resident #1's RR came to her on [DATE] in the morning requesting resident be made a DNR, the social worker gave her an OOHDNR. Several hours later (no sure of the time but it was the same day) the RR brought the document back completed, requesting a notary, the SW found one who discovered that Resident # 1 had signed in the incorrect spot. The RR, SW and Notary then went to the room and witnessed Resident #1 sign the document in the correct place. The Charge nurse was notified, and the document was placed in the folder for the physician to sign when she came in. Interview [DATE] at 10:00 a.m., the DON said she was at the facility the day of the incident and responded to yells from the dining room. Upon arriving she saw Resident #1 having a seizure, a CMA pulled up the code status in the EMR as a Full code. The DON said Resident #1 was agonal breathing (insufficient breathing that often sounds like snoring, snorting, gasping or labored breathing), he was given respiratory support, transferred to his room, and 911 was contacted. The DON said assessment by RN given over the phone, instructed to place AED and follow instructions until paramedics arrived. AED applied, shock advised and given, after shock CPR was started per AED instructions. Paramedics arrived and took over CPR. Upon review of chart while making transfer packet it was discovered that an OOHDNR was on the chart, signed by the resident and the Physician. A signed physician's order dated [DATE] and signed [DATE] was also located in the paper chart. Updated information given to paramedics; resident was transported to hospital. The DON said per conversation with Resident # 1 RR on [DATE] resident had survived, no updates since then. The DON said the nurse who worked that day was on duty the day the order was signed, resigned the day after the incident with no notice. Interview on [DATE] at 11:45 a.m. with the ADM, her expectation is that when a physician signs an order, no matter if he wrote it, or it was a verbal or telephone order it be processed per policy which to her understanding in to place the order in the EMR. She stated that not placing orders in the EMR, can result in a potential negative outcome for the residents. She stated her expectation is the policy on advance directive and care plans be followed by staff and they are unfamiliar with what to do they ask the DON or MDS nurse for clarification. She stated not having a resident's orders and needs reflected can put the residents at risk of not receiving the care they need. Policy Care plans, comprehensive person-centered revised [DATE] 11. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's conditions change. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 02:50 p.m., and the administrator was notified at 02:50 PM. The Administrator was provided with the IJ Template on [DATE]. The following Plan of Removal was accepted on [DATE] at 02:44 PM and indicated the following. POR Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. On [DATE] an abbreviated survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. 676364 Page 8 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0655 Level of Harm - Immediate jeopardy to resident health or safety The notification of immediate threat states as follows: The facility failed to provide basic life support and CPR per the physician's order and Resident #1's advance directives. The deficient practice did result in harm to resident #1. The Medical Director has been notified of the deficient practice on 02.15.2024. Residents Affected - Few The resident #1 Code Status has been updated on Electronic Medical Records System (EMR) and on the paper chart to reflect that the resident is OOHDNR. The resident's care plan has been reviewed and updated. Implementation date is 02.16.2024 by DON. The Divisional Director of Nursing, Director of Nursing, Social Worker, and MD have done a full facility wide audit to make sure that all the residents at the facility have accurate Code Status on both the EMR and the Paper chart. Residents' care plans were reviewed during the audit. Every resident's code status is accurately documented and accurately reflected on the care plans. Implementation date is 02.16.2024 Completed on 02.16.2024 and will be ongoing. The DON has created a Code Status Binder with updated code status for every resident and made available at the nurses' stations for easy access by the staff. Changes will be reported to the DON, Administrator and ADON, and will be updated immediately by the DON or designee. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Each resident's code status and Advance Directives will be reviewed daily for 30 days by the DON and the Administrator after which there will be weekly audits for 90 days. The facility will review each resident's code status and Advance Directives during monthly QAPI meetings. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. New Admits charts will be reviewed daily during morning meetings by the IDT team led by DON, Social Worker, and the Administrator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. The DON will include code status reviews at the weekly Risk Meeting to ensure that every resident's code status will remain up to date. The Risk Meeting will be attended by the IDT team, the DON, ADON, the director of Rehab, and the MDS coordinator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. Staff In-service on Code Status and Advanced Directives are ongoing and being conducted by the DON and/or the ADON. Implementation date is 02.16.2024. Initial in-service was on 02.16.2024 with SW, DON, Admin, MDS. The Staff Development Nurse was in-service by the Administrator on 02.16.2024. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. In-service will be completed by 02.21.2024 and ongoing. The Administrator, DON, ADON and/or the Social Worker will immediately document discussions with all residents and/or resident representative(s) regarding the residents' rights. Including but not limited to the residents' decision on code status. Implementation date is 02.17.2024 In-service on 02.17.2024 In-serviced the Administrator, DON, SW and MDS, regarding residents' rights and immediate documentation of such discussions, and this will be on-going. In-service done by DDRC and RDO on 02.17.2024. Completed on 02.17.2024 and will be ongoing. 676364 Page 9 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0655 Level of Harm - Immediate jeopardy to resident health or safety Staff In-service on abuse, neglect, and exploitation with all staff. Implementation date is 02.16.2024 The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. The DDRC in-service the Administrator and DON on 02.17.2024. Inservice will be completed by 02.21.2024 and ongoing. The DON, MDS, and the Social Worker were educated on 02.17.2024 by the administrator on IJ. Residents Affected - Few There was an Ad Hoc QAPI meeting regarding the IJ on 02.17.2024 with the Administrator, DON, Social worker and MDS. This will be an on-going discussion at QAPI meetings indefinitely. The Medical Director was notified of the IJ on 02.17.2024 by the administrator. Verification Plan of Removal: 1. Corporate Nurse completed Inservice training to Adm, DON, and MDS nurse, who immediately started training staff on Advance directive, order transcription, Code book, and resident rights and abuse and neglect. a. of [DATE]. 2. The Administrator was unable to confirm the current status of the resident on [DATE], but an update from the wife on [DATE] stated he was in stable condition with no anticipated discharge date . 3. DON Validated all Residents code status was up to date per paper chart, red binder with code status was created and placed at nurse's station verified as up to date, EMR was up to date, including care plans on [DATE]. Daily audits preformed on 2/18, 2/19, and [DATE] verified. Random audit of 4 residents with Full code status and 4 residents with DNR status were completed and verified as correct. 4. Verified thru sign in sheets that all facility staff reporting for duty from [DATE] at 6 am thru [DATE] at 6 am had completed in-services. a. Interviews were conducted with staff across multiple shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am, including Maintenance Director, Culinary Director, Culinary Associate, Lead Housekeeper revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility, and what to do in a medical emergency. 676364 Page 10 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0655 b. Level of Harm - Immediate jeopardy to resident health or safety Interviews were conducted with staff across all shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am including 8 RCAs, 3 Agency RCAs, 3 Med Techs, 1 Agency LVN, LVNs and 1 RN revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility, advanced directives, where to find code status, and how to transcribe physician's orders. Residents Affected - Few 5. Ad hoc QAPI meeting held with IDT team and MD on [DATE] at 3:45pm to review policy on Abuse, Neglect and exploitation, resident status, Advance Directives and Code Status, and Plan of removal/response to immediate Jeopardy Citation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying the POR had been initiated and or completed. The Administrator was informed the immediate jeopardy was removed on [DATE] at 10:45 am. While the IJ was removed the facility remained out of compliance at a severity level of no Actual harm that was not immediate jeopardy and scope was isolated, due to the facility was still monitoring the effectiveness of the Plan of removal. 676364 Page 11 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0678 Level of Harm - Immediate jeopardy to resident health or safety 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 observation, interview, and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 35 residents (Resident #1) whose records were reviewed for DNR code status. Residents Affected - Few The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #1, who had a DNR in place, CPR started after the resident had a seizure and stopped breathing, according to professional standards of practice. On [DATE] Resident # 1 had a seizure and stopped breathing, was listed as a full code in the EMR. Life saving measures were initiated. Upon review of the medical record order signed by the physician on [DATE] out-of- hospital do not resuscitate. Resident #1 had an out of hospital do not resuscitate singed on [DATE] and signed by the physician on [DATE] in the medical record. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. These deficient practices could contribute to a resident's prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against their wishes. Findings Include: Review of Resident #1's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses that include Progressive supranuclear ophthalmoplegia (an inability to look down and focus) Brain Stem Stroke syndrome (when blood supply to the base of the brain is interrupted or stopped), other symptoms and signs involving cognitive functions and awareness, (Mild mental impairment that can include memory loss, mood swings and behavioral changes), and palliative care. Review of Resident #1's admission MDS was in progress, and undated. Review of Resident # 1's discharge BIMs dated [DATE] reflected a score of 10 out of 15 reflecting Moderate cognitive impairment. Review of Resident #1's Base line Care plan dated [DATE] revealed full code status. and was not updated to reflect the physician's order of [DATE] for OOH-DNR Review of Resident #1's Comprehensive care plan updated [DATE] revealed DNR status. Review of Resident #1's Physicians orders revealed admission order on [DATE] of full code status. Physicians order written on [DATE] and signed on [DATE]. Review of Resident #1's Out of hospital do-not-resuscitate on chart signed by resident on [DATE] and physician on [DATE]. Review of Resident #1's progress notes dated [DATE] at 5:20 p.m., written by the DON, revealed resident was in dining room when he had a seizure, staff call the DON, CMA pulled up emr, to obtain code 676364 Page 12 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few status. EMR information screen showed full code status, resident was given respiratory support, transferred to room and 911 was called. Staff followed emergency operator's instructions, applied AED which advised shock. Shock given as instructed and CPR initiated per instruction. Interview on [DATE] at 09:30 a.m., the SW stated that the Resident #1's RR came to her on [DATE] in the morning requesting resident be made a DNR, the social worker gave her an OOHDNR. Several hours later (not sure of the time but it was the same day) the RR brought the document back completed, requesting a notary, the SW found one who discovered that Resident #1 had signed in the incorrect spot. The RR, SW and Notary then went to the room and witnessed Resident #1 sign the document in the correct place. The charge nurse was notified, and the document was placed in the folder for the physician to sign when she came in. Interview [DATE] at 10:00 a.m., the DON said she was at the facility the day of the incident and responded to yells from the dining room. Upon arriving she saw Resident #1 having a seizure, a CMA pulled up the code status in the EMR as a Full code. The DON said Resident #1 was agonal breathing (insufficient breathing that often sounds like snoring, snorting, gasping or labored breathing), he was given respiratory support, transferred to his room, and 911 was contacted. The DON said assessment by RN given over the phone, instructed to place AED and follow instructions until paramedics arrived. AED applied, shock advised and given, after shock CPR was started per AED instructions. Paramedics arrived and took over CPR. Upon review of chart while making transfer packet it was discovered that an OOHDNR was on the chart, signed by the resident and the Physician. A signed physician's order dated [DATE] and signed [DATE] was also located in the paper chart. Updated information given to paramedics; resident was transported to hospital. The DON said per conversation with Resident #1's RR on [DATE] resident had survived, no updates since then. The DON said the nurse who worked that day was on duty the day the order was signed, resigned the day after the incident with no notice. Interview [DATE] 11:45 am She was not in the building when the incident occurred, but she was made aware of it and the IDT met the next morning to evaluate the event and identify the root causes, Review of Policy Medication and treatment orders [DATE] 12:30 PM dated [DATE] revealed All orders must be charted and made part of the resident medical record and plan of care. Review of Policy Advanced Directive [DATE] at 12:45 PM Revised [DATE] 20. The Director of Nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 02:50 p.m., and the administrator was notified at 02:50 PM. The Administrator was provided with the IJ Template on [DATE]. The following Plan of Removal was accepted on [DATE] at 02:44 PM and indicated the following. POR Preparation and submission of this Plan of removal does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of removal is prepared and submitted solely because of requirements under state and federal laws. On [DATE] an abbreviated survey was initiated. On [DATE] the surveyor provided an Immediate 676364 Page 13 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0678 Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Level of Harm - Immediate jeopardy to resident health or safety The notification of immediate threat states as follows: The facility failed to provide basic life support and CPR per the physician's order and Resident #1's advance directives. Residents Affected - Few The deficient practice did result in harm to resident #1. The Medical Director has been notified of the deficient practice on 02.15.2024. The resident #1 Code Status has been updated on Electronic Medical Records System (EMR) and on the paper chart to reflect that the resident is OOHDNR. The resident's care plan has been reviewed and updated. Implementation date is 02.16.2024 by DON. The Divisional Director of Nursing, Director of Nursing, Social Worker, and MD have done a full facility wide audit to make sure that all the residents at the facility have accurate Code Status on both the EMR and the Paper chart. Residents' care plans were reviewed during the audit. Every resident's code status is accurately documented and accurately reflected on the care plans. Implementation date is 02.16.2024 Completed on 02.16.2024 and will be ongoing. The DON has created a Code Status Binder with updated code status for every resident and made available at the nurses' stations for easy access by the staff. Changes will be reported to the DON, Administrator and ADON, and will be updated immediately by the DON or designee. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. Each resident's code status and Advance Directives will be reviewed daily for 30 days by the DON and the Administrator after which there will be weekly audits for 90 days. The facility will review each resident's code status and Advance Directives during monthly QAPI meetings. Implementation Date is 02.16.2024. Completed on 02.16.2024 and will be ongoing. New Admits charts will be reviewed daily during morning meetings by the IDT team led by DON, Social Worker, and the Administrator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. The DON will include code status reviews at the weekly Risk Meeting to ensure that every resident's code status will remain up to date. The Risk Meeting will be attended by the IDT team, the DON, ADON, the director of Rehab, and the MDS coordinator. Implementation date is 02.16.2024. Completed on 02.16.2024 and will be on-going. Staff In-service on Code Status and Advanced Directives are ongoing and being conducted by the DON and/or the ADON. Implementation date is 02.16.2024. Initial in-service was on 02.16.2024 with SW, DON, Admin, MDS . The Staff Development Nurse was in-service by the Administrator on 02.16.2024. The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. In-service will be completed by 02.21.2024 and ongoing. The Administrator, DON, ADON and/or the Social Worker will immediately document discussions with all residents and/or resident representative(s) regarding the residents' rights. Including but not 676364 Page 14 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few limited to the residents' decision on code status. Implementation date is 02.17.2024 In-service on 02.17.2024 In-serviced the Administrator, DON, SW and MDS, regarding residents' rights and immediate documentation of such discussions, and this will be on-going. In-service done by DDRC and RDO on 02.17.2024. Completed on 02.17.2024 and will be ongoing. Staff In-service on abuse, neglect, and exploitation with all staff. Implementation date is 02.16.2024 The Administrator and DON will continue in-service with non-present/prn/agency staff and future staff, which will be on-going. The DDRC in-service the Administrator and DON on 02.17.2024. Inservice will be completed by 02.21.2024 and ongoing. The DON, MDS, and the Social Worker were educated on 02.17.2024 by the administrator on IJ. There was an Ad Hoc QAPI meeting regarding the IJ on 02.17.2024 with the Administrator, DON, Social worker and MDS. This will be an on-going discussion at QAPI meetings indefinitely. The Medical Director was notified of the IJ on 02.17.2024 by the administrator. Verification Plan of Removal: 1. Corporate Nurse completed Inservice training to Adm, DON, and MDS nurse, who immediately started training staff on Advance directive, order transcription, Code book, and resident rights and abuse and neglect. a. of [DATE]. 2. The Administrator was unable to confirm the current status of the resident on [DATE], but an update from the wife on [DATE] stated he was in stable condition with no anticipated discharge date . 3. DON Validated all Residents code status was up to date per paper chart, red binder with code status was created and placed at nurse's station verified as up to date, EMR was up to date, including care plans on [DATE]. Daily audits preformed on 2/18, 2/19, and [DATE] verified. Random audit of 4 residents with Full code status and 4 residents with DNR status were completed and verified as correct. 4. Verified thru sign in sheets that all facility staff reporting for duty from [DATE] at 6 am thru [DATE] at 6 am had completed in-services on Abuse/neglect, Advance Directives, The new red binder at the nurse's station with code status, resident rights and transcribing physician's orders. Interview with ADM on [DATE] at 10:00 she stated that the corporate compliance nurse educated her on Abuse/neglect, advance Directives, the red binder for code status, resident rights and who is responsible for 676364 Page 15 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0678 Level of Harm - Immediate jeopardy to resident health or safety transcribing physician's orders. Interview with SW on [DATE] at 09:30 am she stated that the corporate nurse and the DON educated her on the following in services, abuse/neglect, advance directives, the red binder at the nurse's station, resident rights and the process for transcribing orders. Interview with the DON on [DATE] at 11:30 am stated that the corporate nurse educated her on the following in-service abuse/neglect, resident rights, code book at the nurse's station, and transcribing order so that she could educate her staff and be a resource for questions. Residents Affected - Few a. Interviews were conducted with staff across multiple shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am, including Maintenance Director, Culinary Director, Culinary Associate, Lead Housekeeper revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents' rights and where to find the resident rights posted in the facility, and what to do in a medical emergency. b. Interviews were conducted with staff across all shifts on [DATE] from 06:00 am thru [DATE] at 06:00 am including 8 RCAs, 3 Agency RCAs, 3 Med Techs, 1 Agency LVN, LVNs and 1 RN revealed they had all been in-serviced by the DON/ADON. Staff stated they were educated on abuse, neglect and exploitation, who to report abuse to, types of abuse, residents rights and where to find the resident rights posted in the facility , advanced directives, where to find code status, and how to transcribe physician's orders The Nurses all stated that the information on who is responsible to enter the advance directive orders was new to them, and the rest of the information was a good reminder. 5. Ad hoc QAPI meeting held with IDT team and MD on [DATE] at 3:45pm to review policy on Abuse, Neglect and exploitation, resident status, Advance Directives and Code Status, and Plan of removal/response to immediate Jeopardy Citation. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ after verifying the POR had been initiated and or completed. The Administrator was informed the immediate jeopardy was removed on [DATE] at 10:45 am. While the IJ was removed the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. Due to the facility was still monitoring the effectiveness of the Plan of removal. 676364 Page 16 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for each resident that are complete, accurately documented, readily accessible, and systemically organized for one (Resident #1) of 35 residents reviewed for medical records. The facility failed to ensure Resident #1 had the most current physician's order in the EMR for code status that was changed by a written physician's order in the paper chart. This failure could place residents at risk of having records that do not reflect their current status resulting in potential prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against physicians' orders. Findings Included: Review of Resident #1's progress notes dated [DATE] at 5:20 p.m., written by the DON, revealed resident was in dining room when he had a seizure, staff call the DON, CMA pulled up EMR, to obtain code status. EMR information screed showed full code status, resident was given respiratory support, transferred to room and 911 was called. Staff followed emergency operator's instructions, applied AED which advised shock. Shock given as instructed and CPR initiated per instruction. Interview on [DATE] at 09:30 a.m., the SW stated that the Resident #1's RR came to her on [DATE] in the morning requesting resident be made a DNR, the social worker gave her an OOHDNR. Several hours later (not sure of the time but it was the same day) the RR brought the document back completed, requesting a notary, the SW found one who discovered that Resident #1 had signed in the incorrect spot. The RR, SW and Notary then went to the room and witnessed Resident #1 sign the document in the correct place. The Charge nurse was notified, and the document was placed in the folder for the physician to sign when she came in. Interview [DATE] at 10:00 a.m., the DON said she was at the facility the day of the incident and responded to yells from the dining room. Upon arriving she saw Resident #1 having a seizure, a CMA pulled up the code status in the EMR as a Full code. The DON said Resident #1 was agonal breathing (insufficient breathing that often sounds like snoring, snorting, gasping or labored breathing), he was given respiratory support, transferred to his room, and 911 was contacted. The DON said assessment by RN given over the phone, instructed to place AED and follow instructions until paramedics arrived. AED applied, shock advised and given, after shock CPR was started per AED instructions. Paramedics arrived and took over CPR. Upon review of chart while making transfer packet it was discovered that an OOHDNR was on the chart, signed by the resident and the Physician. A signed physician's order dated [DATE] and signed [DATE] was also located in the paper chart. Updated information given to paramedics; resident was transported to hospital. The DON said per conversation with wife on [DATE] resident had survived, no updates since then. The DON said the nurse who worked that day was on duty the day the order was signed, resigned the day after the incident with no notice She stated her expectation was that all physician's orders be updated in the EMR by the nurse receiving the order, written or telephone. She is currently in servicing her staff and auditing orders daily to ensure they are being put in EMR and identifying an additional staff training needed. 676364 Page 17 of 18 676364 02/20/2024 Morada Temple 4312 S 31st St Temple, TX 76502

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 11:45 am with ADM stated her expectations are that LVN's and RN's update the EMR when they obtain an order, they are the only discipline in the building that can do that. She is aware of the issue and working with the DON to conduct in servings and additional training if needed. Review of Policy Medication and treatment orders dated [DATE] revealed All orders must be charted and made part of the resident medical record and plan of care. Review of Policy Advanced Directive Revised [DATE] 20. The Director of Nursing services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 676364 Page 18 of 18