Health inspection·March 20, 2025

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of ten residents reviewed for changes in condition. The facility failed to notify the CHF clinic or the MD of Resident #1's weight gain per providers orders. On 3/7/25 Resident #1 exhibited signs of shortness of breath and required IV Lasix a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure) to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. An Immediate Jeopardy (IJ) was identified on 03/19/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 03/19/25 at 05:36 PM. While the Administrator and DON were notified that the IJ was removed on 03/20/25 at 06:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk of a delay in medical evaluation and treatment contributing to avoidable harm such as fluid overload, respiratory distress, swelling, and increased blood pressure. Findings included: Review of Resident #1's face sheet dated 03/19/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included acute on chronic (congestive) heart failure (primary, admission)(long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), post-traumatic stress disorder-chronic (mental and behavioral disorder that develops from experiencing a traumatic event), generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), and Alzheimer's disease with early onset (condition that affects memory, thinking, and behavior). Residents face sheet also reflected she discharged to another SNF on 03/11/25. Review of Resident #1's Discharge MDS dated [DATE] reflected a BIMS score of 15 indicating cognition intact. The Discharge MDS also identified unspecified combined systolic (congestive) and diastolic Page 1 of 20 676409 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some (congestive) heart failure as an active diagnosis. Other health conditions, shortness of breath was checked for shortness of breath or trouble breathing with exertion (walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Medications also indicated Resident #1 was on a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure). Review of Resident #1's care plan last revised 02/26/25 reflected [Resident #1] is at risk for respiratory distress/SOB due to dx of CHF with goal of [Resident #1] will not exhibit or develop respiratory distress as evidence by no SOB or O2 sat (oxygen saturation, amount of oxygen in the blood) at 90% and interventions that included administer medications as ordered, monitor adverse reaction. Contact MD if noted. Review of Resident #1's physician orders reflected an order for daily weights with a start date of 02/25/25 with special instructions that revealed, CHF/Check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs overnight or 3-5 lbs in 1 week. Review of Resident #1's documented weights by LVN A and LVN B included: 03/08/25: 244.20 lbs 03/07/25: 250.00 lbs 03/06/25: 251.00 lbs 03/05/25: 250.00 lbs 03/04/25: 248.20 lbs 03/03/24: 246.00 lbs 03/02/25: 242.00 lbs 03/01/25: 241:00 lbs 02/28/25: 236.80 lbs Weight on 02/28/25 was 236.8 pounds and weight on 03/07/25 was 250 pounds which was a 13.2-pound weight gain in a week. Daily weights also reflected Resident #1 had multiple days (03/01/25, 03/03/25, 03/04/25, and 03/05/25) with a 2-pound overnight weight gain. Record review of Resident #1's O2 Saturation levels reflected: 03/06/25 O2 Saturation at 90% at 12:11 PM 03/06/25 O2 Saturation at 90% at 01:31 PM Review of Resident #1's nursing progress notes between 02/28/25 and 03/07/25 reflected no notes on notification of weight gain to the CHF facility per orders. 676409 Page 2 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #1's nursing progress notes dated 03/06/25 reflected resident called NP and stated to have SOB. 90% O2 NC. Review of Resident #1's MAR/TAR 02/27/25-03/10/25 revealed , observe for s/s of SOB or trouble breathing and reflected multiple days SOB with exertion. Included lying flat was avoided 7 of 12 days. Review of CHF clinic documents dated 03/07/25 revealed nursing note Lasix 100mg IV per mini infuser, patient up 10.7 pounds from 02/26/25. In an interview on 03/19/25 at 10:40 AM with Resident #1's family, she stated she was concerned that the facility was not managing Resident #1's weights or adjusting her Lasix as needed. She stated Resident #1 appeared like she could not breathe very well and then later she found out from the CHF clinic after her visit on 03/07/26 that Resident #1 had a lot of fluid built up. Resident #1's family stated that when she asked the CHF clinic why this was not caught earlier and if they were notified by the SNF, the CHF clinic told her they were not notified of the weight changes by the SNF which resulted in delay of care and built up of fluid in Resident #1's body. In an interview on 03/19/25 at 12:10PM with the DON, after reviewing the nursing progress notes for 02/28/25 through 03/07/25), she stated she was only able to identify a notification to the resident's physician regarding weight gain on 03/01/25 but did not see notification was made to the CHF clinic between 02/27/25-03/07/25 regarding the weight gain. She stated it was her expectation that the notification was made per the order. She stated there should have been a call by the charge nurse on duty. She stated it was important because of the possibility of fluid overload (fluid overloading the heart) and a negative outcome of not following the order could be respiratory distress (difficulty breathing). In an interview on 03/19/25 at 01:04 PM with the CHF Facility RN Supervisor (RNS), she stated that Resident #1 was seen at the facility on 02/27/25 and again on 03/07/25. She stated based on their weight records they documented the resident gained 10.7 pounds on 03/07/25 since her last visit 02/27/25. RNS stated the CHF Facility was not notified in between visit days of an increase in weight. She stated it was the expectation that they were notified by the facility of changes because they were trying to keep the resident out of the hospital and the emergency room. She stated noticing changes in weight gain was how they monitored fluids and by catching it early they were able to make changes to diuretic medications. She stated, We want to catch the problem before it becomes serious. She stated that the resident had to be administered IV Lasix as a result of the large amount of weight gain/fluids and was SOB from the large amount of fluid in her body (including around heart and lungs). In an interview on 03/19/25 at 01:36 PM with the MD, he stated it was his expectation was that nursing staff followed the orders and notify the CHF facility of weight gain. He stated the reason was the CHF clinics had the ability to track subtle changes like weight gain or breathing before they became bigger problems and would allow them to adjust diuretics. He stated a negative outcome of not following the orders had the potential to result in the resident having difficulty breathing and would end up in the hospital. In an interview on 03/19/25 at 02:15 PM with LVN A she stated the CHF facility should have been notified of Resident #1's weight gain and said she took weights for Resident #1 on the weekend and let the oncoming nurse know through report of the weight gain and not the CHF facility . She stated no follow up was made to ensure the CHF facility was made aware. She stated a negative outcome of not notifying the CHF clinic would be cardiac issues with the resident, and CHF clinic should have been 676409 Page 3 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 notified. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 03/19/25 at 2:22 PM with LVN B she stated she took weights for Resident #1 on weekdays as well as weekends. She stated she was aware of the order to notify the CHF facility if there was an increase in weight of 2 pounds per day but did not recall making the notifications to CHF center. LVN B stated the CHF facility should have been notified by the nurse on shift and did not recall why she did not make the notification. She stated a negative outcome of not notifying would be a delay in care for the resident or the required use of IV Lasix to manage the increase in fluids. She also stated the increase in weight was also a significant change in condition which also resulted in the IV administration of Lasix which was a change in Resident #1's care. Residents Affected - Some Review of facility policy Physician and Other Communication/ Change in Condition last revised 05/05/23 reflected: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. The ADM, DON, and CC were notified on 03/19/25 at 06:09 PM that an IJ was identified due to the above failures and the facility's need to take immediate action to ensure facility staff act timely to prevent a delay in treatment for residents while following providers orders. The Plan of Removal was accepted on 03/20/25 and included: Plan of Removal Problem: F684 Quality of Care On 3/19/25 an abbreviated survey was initiated at the facility. The surveyor provided an immediate jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating: The facility failed to notify the CHF clinic of Resident #1's weight gain per provider's orders. Resident #1 was exhibiting signs of shortness of breath and required IV Lasix to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. Resident #1 no longer resides in the facility. The facility activity report and the 24hour report for the past 72hours will be audited by the Director of Nursing/Designee on 3/19/25 to identify any documentation that indicates changes in 676409 Page 4 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 resident's condition and notification to provider as ordered. None were identified. Level of Harm - Immediate jeopardy to resident health or safety The Director of Nursing will be reeducated by the Clinical Consultant on 3/19/25 on following providers orders to prevent a delay in treatment and change in condition including: Prompt notifications documented in residents medical record to providers as designated in provider orders Residents Affected - Some All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath Licensed nurses, including PRN nurses, will be reeducated by 3/20/25 by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: Prompt notifications to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath Licensed Nurses, including PRN nurses not receiving this education by 3/20/25 will receive prior to their next scheduled shift and this will be completed in New Hire orientation. Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting Monday - Friday beginning 3/20/25 to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months. The Administrator will oversee the continuation of this plan. Ad Hoc QAPI will be held on 3/19/25 676409 Page 5 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 3/19/25. Level of Harm - Immediate jeopardy to resident health or safety Monitoring began 03/20/25 and included the following: Record review completed of the facility 24-hour report for previous 72 hours as of 03/20/25 . Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up. Residents Affected - Some Record review of an in-service dated 03/19/25 titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes. revealed staff were educated on: Prompt notifications documented in residents medical record to providers as designated in provider orders. All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record. Notifications to required medical staff of weight changes as ordered. Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed as completed by the DON and presented by the CC. Record review of an additional in-service dated 03/19/25 revealed: Prompt notifications to providers as designated in provider orders. 676409 Page 6 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 - Level of Harm - Immediate jeopardy to resident health or safety All attempts to notify medical staff and responsible parties will be documented in resident's medical record. Residents Affected - Some Notifications to required medical staff of weight changes as ordered. - Validating any clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. Shortness of breath. Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed by the DON and presented by the CC. Record review of in-service dated 03/20/25 titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Reflected signed by the DON and presented by the CC. Record review of a staff in-service dated 03/20/25 revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Presented by the DON and signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of a staff in-service dated 03/20/25 revealed staff were educated on: Prompt notifications to providers as designated in provider orders. All attempts to notify medical staff and responsible parties will be documented in resident's medical record. 676409 Page 7 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 Notifications to required medical staff of weight changes as ordered. Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Some - Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath. Signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record Review of training dated 03/19/25 titled: Change of Condition revealed staff were trained on: Licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: Prompt notifications to providers as designated in provider orders. All attempts to notify medical staff and responsible parties will be documented in resident's medical record. Notifications to required medical staff of weight changes as ordered. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of the Adhoc QAPI dated 03/19/25 for F684 revealed the meeting included the ADM, DON, CC, and MD. Record Review of a signed statement by the DON on 03/19/25 revealed notification to the MD regarding Immediate Jeopardy. Record review of the undated new hire orientation packet which included an added section revealed the following: Respiratory care all nurses validate resident is receiving oxygen per MD orders. 676409 Page 8 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 Change of condition recognition and notification to providers. Level of Harm - Immediate jeopardy to resident health or safety Prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record. Residents Affected - Some Notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB. Policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities. Record review of education provided to the only 2 agency nurse (LVN F and LVN G) staff working on 03/19/25-03/20/25 revealed education included change of condition and CHF education. Record review of an email from the DON to RN C dated 03/20/25 at 11:29 AM revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify. RN C stated she read the in-services and understood the material being presented. RN C was not on shift that day per the schedule and so was provided the material and in-service virtually per the DON, which was reviewed. Record review of an email from the DON to LVN B dated 03/20/24 at 11:34 AM revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure. LVN B responded that she reviewed the material and understood the topics presented. LVN B was not on shift per the schedule and the material was provided virtually per the DON , which was reviewed. Record review of text messages from the DON to LVN A from 03/20/25 at 12:53 PM, revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN A stated she acknowledged the in-services and understood the material being provided. Record review of text messages from DON to LVN D from 03/20/25 at 02:40 PM, revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN D stated she acknowledged the in-services and understood the material being provided. In an interview on 03/20/25 at 04:27 PM with LVN E, she stated she was provided the in-service training which covered changes of condition and the need to notify providers. She stated it was presented to her by the DON prior to her shift. LVN E stated there was a verbal assessment to confirm understanding of the material presented and that she also reviewed a PowerPoint on CHF management. LVN E stated she would observe for changes in behavior, weight gain, or changes in oxygen saturation and make sure she was notifying the providers and the CHF clinic as needed if identified in the orders. LVN E stated that all interventions and notifications should be documented in the resident's progress 676409 Page 9 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some notes. LVN E also stated she understood weights should be taken in the morning after the resident's first bathroom break to accurately assess. She stated any weights over a 2-3 pound change overnight or a 5 pound change in a week was reportable to the providers. In an interview on 03/20/25 at 04:40 PM with LVN F, she stated she received in-services prior to starting her shift which included changes of condition and who she would notify, weight gain, CHF management including s/s and concerns to look for. She stated the material was presented to her by the DON and was given a verbal quiz to confirm understanding on the material. LVN F provided examples of what to look for and information on what was considered outside of normal parameters for oxygen and weight to confirm understanding. LVN F stated all interventions and notification of change should be documented in the resident's progress notes. In an interview on 03/20/25 at 04:57 PM with the DON, she stated training was provided to her by the CC and then she provided training to floor staff (other nurses) on changes of condition and CHF management. She stated education was provided before shift to those working 03/20/25, and virtual training was provided to those not on shift. She stated training would also be ongoing to any oncoming agency, PRN, or new staff. She stated a review was also completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review. In an interview on 03/20/25 at 05:49 PM with the ADM, he stated that 03/19/25 was the first time he was made aware of Resident #1s weight fluctuations. He stated it was his expectations that providers were notified per orders. He stated he was interim Administrator but that all documentation for the IJ would be available to the incoming Administrator and that the DON would also be at the facility to continue to provide education to new staff to ensure orders are being followed to prevent potential negative outcomes. Review of the staff training indicated above reflected that out of the 10 staff of RNs/LVNs, 8 of them were confirmed to have received the in-service for change of condition, notification of change, and CHF management meeting 80% overall compliance. Training was provided to RN's and LVN's only across all shifts as this is who was in charge of weights and notifying of changes of condition. The Administrator was notified the IJ was removed on 03/20/25 at 06:10 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. 676409 Page 10 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (Resident #1) reviewed for quality of care. Residents Affected - Some The facility failed to notify the CHF clinic of Resident #1's weight gain per providers orders. On 3/7/25 Resident #1 exhibited signs of shortness of breath and required IV Lasix a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure) to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. An Immediate Jeopardy (IJ) was identified on 03/19/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 03/19/25 at 05:36 PM. While the Administrator and DON were notified that the IJ was removed on 03/20/25 at 06:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk of a delay in medical evaluation and treatment contributing to avoidable harm such as fluid overload, respiratory distress, swelling, and increased blood pressure. Findings included: Review of Resident #1's face sheet dated 03/19/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included acute on chronic (congestive) heart failure (primary, admission)(long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), post-traumatic stress disorder-chronic (mental and behavioral disorder that develops from experiencing a traumatic event), generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), and Alzheimer's disease with early onset (condition that affects memory, thinking, and behavior). Residents face sheet also reflected she discharged to another SNF on 03/11/25. Review of Resident #1's Discharge MDS dated [DATE] reflected a BIMS score of 15 indicating cognition intact. The Discharge MDS also identified unspecified combined systolic (congestive) and diastolic (congestive) heart failure as an active diagnosis. Other health conditions, shortness of breath was checked for shortness of breath or trouble breathing with exertion (walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Medications also indicated Resident #1 was on a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure). Review of Resident #1's care plan last revised 02/26/25 reflected [Resident #1] is at risk for respiratory distress/SOB due to dx of CHF with goal of [Resident #1] will not exhibit or develop respiratory distress as evidence by no SOB or O2 sat (oxygen saturation, amount of oxygen in the blood) at 90% and interventions that included administer medications as ordered, monitor adverse reaction. 676409 Page 11 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Contact MD if noted. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's physician orders reflected an order for daily weights with a start date of 02/25/25 with special instructions that revealed, CHF/Check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs overnight or 3-5 lbs in 1 week. Residents Affected - Some Review of Resident #1's documented weights by LVN A and LVN B included: 03/08/25: 244.20 lbs 03/07/25: 250.00 lbs 03/06/25: 251.00 lbs 03/05/25: 250.00 lbs 03/04/25: 248.20 lbs 03/03/24: 246.00 lbs 03/02/25: 242.00 lbs 03/01/25: 241:00 lbs 02/28/25: 236.80 lbs Weight on 02/28/25 was 236.8 pounds and weight on 03/07/25 was 250 pounds which was a 13.2-pound weight gain in a week. Daily weights also reflected Resident #1 had multiple days (03/01/25, 03/03/25, 03/04/25, and 03/05/25) with a 2-pound overnight weight gain. Record review of Resident #1's O2 Saturation levels reflected: 03/06/25 O2 Saturation at 90% at 12:11 PM 03/06/25 O2 Saturation at 90% at 01:31 PM Review of Resident #1's nursing progress notes between 02/28/25 and 03/07/25 reflected no notes on notification of weight gain to the CHF facility per orders. Review of Resident #1's nursing progress notes dated 03/06/25 reflected resident called NP and stated to have SOB. 90% O2 NC. Review of Resident #1's MAR/TAR 02/27/25-03/10/25 revealed , observe for s/s of SOB or trouble breathing and reflected multiple days SOB with exertion. Included lying flat was avoided 7 of 12 days. Review of CHF clinic documents dated 03/07/25 revealed nursing note Lasix 100mg IV per mini infuser, patient up 10.7 pounds from 02/26/25. In an interview on 03/19/25 at 10:40 AM with Resident #1's family, she stated she was concerned 676409 Page 12 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Level of Harm - Immediate jeopardy to resident health or safety that the facility was not managing Resident #1's weights or adjusting her Lasix as needed. She stated Resident #1 appeared like she could not breathe very well and then later she found out from the CHF clinic after her visit on 03/07/26 that Resident #1 had a lot of fluid built up. Resident #1's family stated that when she asked the CHF clinic why this was not caught earlier and if they were notified by the SNF, the CHF clinic told her they were not notified of the weight changes by the SNF which resulted in delay of care and built up of fluid in Resident #1's body. Residents Affected - Some In an interview on 03/19/25 at 12:10PM with the DON, after reviewing the nursing progress notes for 02/28/25 through 03/07/25), she stated she was only able to identify a notification to the resident's physician regarding weight gain on 03/01/25 but did not see notification was made to the CHF clinic between 02/27/25-03/07/25 regarding the weight gain. She stated it was her expectation that the notification was made per the order. She stated there should have been a call by the charge nurse on duty. She stated it was important because of the possibility of fluid overload (fluid overloading the heart) and a negative outcome of not following the order could be respiratory distress (difficulty breathing). In an interview on 03/19/25 at 01:04 PM with the CHF Facility RN Supervisor (RNS), she stated that Resident #1 was seen at the facility on 02/27/25 and again on 03/07/25. She stated based on their weight records they documented the resident gained 10.7 pounds on 03/07/25 since her last visit 02/27/25. RNS stated the CHF Facility was not notified in between visit days of an increase in weight. She stated it was the expectation that they were notified by the facility of changes because they were trying to keep the resident out of the hospital and the emergency room. She stated noticing changes in weight gain was how they monitored fluids and by catching it early they were able to make changes to diuretic medications. She stated, We want to catch the problem before it becomes serious. She stated that the resident had to be administered IV Lasix as a result of the large amount of weight gain/fluids and was SOB from the large amount of fluid in her body (including around heart and lungs). In an interview on 03/19/25 at 01:36 PM with the MD, he stated it was his expectation was that nursing staff followed the orders and notify the CHF facility of weight gain. He stated the reason was the CHF clinics had the ability to track subtle changes like weight gain or breathing before they became bigger problems and would allow them to adjust diuretics. He stated a negative outcome of not following the orders had the potential to result in the resident having difficulty breathing and would end up in the hospital. In an interview on 03/19/25 at 02:15 PM with LVN A she stated the CHF facility should have been notified of Resident #1's weight gain and said she took weights for Resident #1 on the weekend and let the oncoming nurse know through report of the weight gain and not the CHF facility . She stated no follow up was made to ensure the CHF facility was made aware. She stated a negative outcome of not notifying the CHF clinic would be cardiac issues with the resident, and CHF clinic should have been notified. In an interview on 03/19/25 at 2:22 PM with LVN B she stated she took weights for Resident #1 on weekdays as well as weekends. She stated she was aware of the order to notify the CHF facility if there was an increase in weight of 2 pounds per day but did not recall making the notifications to CHF center. LVN B stated the CHF facility should have been notified by the nurse on shift and did not recall why she did not make the notification. She stated a negative outcome of not notifying would be a delay in care for the resident or the required use of IV Lasix to manage the increase in fluids. She also stated the increase in weight was also a significant change in condition which also resulted in the IV administration of Lasix which was a change in Resident #1's care. 676409 Page 13 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of facility policy Physician and Other Communication/ Change in Condition last revised 05/05/23 reflected: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. The ADM, DON, and CC were notified on 03/19/25 at 06:09 PM that an IJ was identified due to the above failures and the facility's need to take immediate action to ensure facility staff act timely to prevent a delay in treatment for residents while following providers orders. The Plan of Removal was accepted on 03/20/25 and included: Plan of Removal Problem: F684 Quality of Care On 3/19/25 an abbreviated survey was initiated at the facility. The surveyor provided an immediate jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating: The facility failed to notify the CHF clinic of Resident #1's weight gain per provider's orders. Resident #1 was exhibiting signs of shortness of breath and required IV Lasix to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. Resident #1 no longer resides in the facility. The facility activity report and the 24hour report for the past 72hours will be audited by the Director of Nursing/Designee on 3/19/25 to identify any documentation that indicates changes in resident's condition and notification to provider as ordered. None were identified. The Director of Nursing will be reeducated by the Clinical Consultant on 3/19/25 on following providers orders to prevent a delay in treatment and change in condition including: Prompt notifications documented in residents medical record to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record 676409 Page 14 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Notifications to required medical staff of weight changes as ordered Level of Harm - Immediate jeopardy to resident health or safety Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Residents Affected - Some Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath Licensed nurses, including PRN nurses, will be reeducated by 3/20/25 by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: Prompt notifications to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath Licensed Nurses, including PRN nurses not receiving this education by 3/20/25 will receive prior to their next scheduled shift and this will be completed in New Hire orientation. Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting Monday - Friday beginning 3/20/25 to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months. The Administrator will oversee the continuation of this plan. Ad Hoc QAPI will be held on 3/19/25 The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 3/19/25. Monitoring began 03/20/25 and included the following: Record review completed of the facility 24-hour report for previous 72 hours as of 03/20/25 . Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up. Record review of an in-service dated 03/19/25 titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers 676409 Page 15 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 of changes. revealed staff were educated on: Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Some - Prompt notifications documented in residents medical record to providers as designated in provider orders. All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record. Notifications to required medical staff of weight changes as ordered. Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed as completed by the DON and presented by the CC. Record review of an additional in-service dated 03/19/25 revealed: Prompt notifications to providers as designated in provider orders. All attempts to notify medical staff and responsible parties will be documented in resident's medical record. Notifications to required medical staff of weight changes as ordered. 676409 Page 16 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Validating any clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. Shortness of breath. Residents Affected - Some Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed by the DON and presented by the CC. Record review of in-service dated 03/20/25 titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Reflected signed by the DON and presented by the CC. Record review of a staff in-service dated 03/20/25 revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Presented by the DON and signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of a staff in-service dated 03/20/25 revealed staff were educated on: Prompt notifications to providers as designated in provider orders. All attempts to notify medical staff and responsible parties will be documented in resident's medical record. Notifications to required medical staff of weight changes as ordered. Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath. Signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) 676409 Page 17 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Record Review of training dated 03/19/25 titled: Change of Condition revealed staff were trained on: Level of Harm - Immediate jeopardy to resident health or safety Licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: Residents Affected - Some Prompt notifications to providers as designated in provider orders. All attempts to notify medical staff and responsible parties will be documented in resident's medical record. Notifications to required medical staff of weight changes as ordered. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of the Adhoc QAPI dated 03/19/25 for F684 revealed the meeting included the ADM, DON, CC, and MD. Record Review of a signed statement by the DON on 03/19/25 revealed notification to the MD regarding Immediate Jeopardy. Record review of the undated new hire orientation packet which included an added section revealed the following: Respiratory care all nurses validate resident is receiving oxygen per MD orders. Change of condition recognition and notification to providers. Prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record. Notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB. 676409 Page 18 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 - Level of Harm - Immediate jeopardy to resident health or safety Policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities. Residents Affected - Some Record review of education provided to the only 2 agency nurse (LVN F and LVN G) staff working on 03/19/25-03/20/25 revealed education included change of condition and CHF education. Record review of an email from the DON to RN C dated 03/20/25 at 11:29 AM revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify. RN C stated she read the in-services and understood the material being presented. RN C was not on shift that day per the schedule and so was provided the material and in-service virtually per the DON, which was reviewed. Record review of an email from the DON to LVN B dated 03/20/24 at 11:34 AM revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure. LVN B responded that she reviewed the material and understood the topics presented. LVN B was not on shift per the schedule and the material was provided virtually per the DON , which was reviewed. Record review of text messages from the DON to LVN A from 03/20/25 at 12:53 PM, revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN A stated she acknowledged the in-services and understood the material being provided. Record review of text messages from DON to LVN D from 03/20/25 at 02:40 PM, revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN D stated she acknowledged the in-services and understood the material being provided. In an interview on 03/20/25 at 04:27 PM with LVN E, she stated she was provided the in-service training which covered changes of condition and the need to notify providers. She stated it was presented to her by the DON prior to her shift. LVN E stated there was a verbal assessment to confirm understanding of the material presented and that she also reviewed a PowerPoint on CHF management. LVN E stated she would observe for changes in behavior, weight gain, or changes in oxygen saturation and make sure she was notifying the providers and the CHF clinic as needed if identified in the orders. LVN E stated that all interventions and notifications should be documented in the resident's progress notes. LVN E also stated she understood weights should be taken in the morning after the resident's first bathroom break to accurately assess. She stated any weights over a 2-3 pound change overnight or a 5 pound change in a week was reportable to the providers. In an interview on 03/20/25 at 04:40 PM with LVN F, she stated she received in-services prior to starting her shift which included changes of condition and who she would notify, weight gain, CHF management including s/s and concerns to look for. She stated the material was presented to her by the DON and was given a verbal quiz to confirm understanding on the material. LVN F provided examples of what to look for and information on what was considered outside of normal parameters for oxygen and weight to confirm understanding. LVN F stated all interventions and notification of change should be documented in the resident's progress notes. 676409 Page 19 of 20 676409 03/20/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0684 Level of Harm - Immediate jeopardy to resident health or safety In an interview on 03/20/25 at 04:57 PM with the DON, she stated training was provided to her by the CC and then she provided training to floor staff (other nurses) on changes of condition and CHF management. She stated education was provided before shift to those working 03/20/25, and virtual training was provided to those not on shift. She stated training would also be ongoing to any oncoming agency, PRN, or new staff. She stated a review was also completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review. Residents Affected - Some In an interview on 03/20/25 at 05:49 PM with the ADM, he stated that 03/19/25 was the first time he was made aware of Resident #1s weight fluctuations. He stated it was his expectations that providers were notified per orders. He stated he was interim Administrator but that all documentation for the IJ would be available to the incoming Administrator and that the DON would also be at the facility to continue to provide education to new staff to ensure orders are being followed to prevent potential negative outcomes. Review of the staff training indicated above reflected that out of the 10 staff of RNs/LVNs, 8 of them were confirmed to have received the in-service for change of condition, notification of change, and CHF management meeting 80% overall compliance. Training was provided to RN's and LVN's only across all shifts as this is who was in charge of weights and notifying of changes of condition. The Administrator was notified the IJ was removed on 03/20/25 at 06:10 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. 676409 Page 20 of 20