Rosewood Rehabilitation And Care Center

F-F678 Quality of Life

The facility failed to provide a full code resident (Resident #1) with CPR when resident was observed without

a pulse from 10:02pm till EMS arrived at 11:23pm.

The alleged failure is as follows (summary format, bullet points)

1. Failed to initiate Full Code procedures timely when Nurse found resident unresponsive.

The Medical Director, [Physician name] was notified at 12:02pm on [DATE REDACTED]. No additional instructions or plans obtained. Facilities response was discussed.

What action was taken for the staff directly involved in the failure? Nurse was terminated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 675452 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675452 B. Wing 07/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rosewood Rehabilitation and Care Center 7700 Mesquite Pass Converse, TX 78109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Staff will be educated/trained in regard to Resident Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code. A 100% audit of Resident Code Status for all residents was Level of Harm - Immediate completed by [name], Director of Nursing in which Code status on Resident Face Sheet was verified by order jeopardy to resident health or for code status and if code status is a DNR the executed OOHDNR document was verified in Miscellaneous safety section in [EMR name] and copy verified in Resident hard chart. An audit will be completed monthly by the Director of Nursing. Residents Affected - Few Alleged Failure #1 - Failed to follow facility policy regarding code status and initiate CPR/Full Code procedures timely when resident was found unresponsive.

In-servicing/education provided in response (bullet point narrative):

Start/stop time and date:

On [DATE REDACTED] at 12:30pm education began for Nurses (LVN and RN) staff in regards to Resident Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code.

Education Code Status and Hospice: Hospice residents can elect to be a Full Code.

Resident with no pulse or respirations: Nurse will check code status in, [EMR name] call the Code Blue, initiate CPR and have another staff call 911. Flow chart of How to respond when a resident has no pulse or is unresponsive is posted at the nurses station as a reminder.

When to provide CPR. When resident has no pulse or no respirations, Nurses are to check code status in [EMR name] which will determine how to respond appropriately.

What will you do for staff not present?

Nurses that aren't present will be in-serviced before the start of their next regularly scheduled shift

What will you do with newly hired staff?

The education/in-service of facility policy regarding Code Status and Hospice Services and initiating CPR timely for resident who are a Full Code.

Who did the education/in-servicing?

The education will be completed by [name] Director of Nursing

What time did the education/in-servicing complete?

All the education on this topic will be complete [DATE REDACTED] by 5:00pm for Nurse staff present.

A 4 question post-test will be given to verify retention of knowledge related Hospice Services and Code Status and initiating CPR timely for resident who are a Full Code.

How will you monitor for effectiveness of the Plan of Removal?

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 675452 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675452 B. Wing 07/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rosewood Rehabilitation and Care Center 7700 Mesquite Pass Converse, TX 78109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Administrator will randomly issue post test regarding education/in-service on Hospice Services and Code Status and initiating CPR timely for resident who are a Full Code for 4 weeks to ensure knowledge has been Level of Harm - Immediate maintained and compliance has been achieved. jeopardy to resident health or safety Director of Nursing will randomly request a Nurse to communicate Code Status on a resident on Hospice and initiating CPR timely for resident who are a Full Code for 4 weeks to ensure knowledge has been maintained Residents Affected - Few and compliance has been achieved. Nurse responses will be documented on a Response LOG that will identify staff name, date, shift, answer/response and if correct, resident name.

The facility's POR verification was as follows:

During an interview with the DON, [DATE REDACTED] at 2:19 p.m., the DON stated LVN A was terminated from the facility on [DATE REDACTED]. The DON stated the Medical Director was notified of the incident on [DATE REDACTED] at 12:02 p.m. and the Medical Director did not give any additional instructions. The DON stated staff training was initiated

on [DATE REDACTED] and was completed on the morning of [DATE REDACTED]. The training was provided to 100% of licensed nurses and covered the topics of where to find resident code status in the resident chart, importance of verifying code status if a resident is found unresponsive, what actions to take if a resident is a full code or DNR and hospice resident's right to be full code.

During an interview with the Administrator, [DATE REDACTED] at 2:28 pm, the Administrator stated LVN A was terminated on [DATE REDACTED]. The Administrator stated the Medical Director was notified of the incident at [DATE REDACTED] at 12:02 pm and provided no further guidance. The Administrator stated training for licensed nurses was initiated on [DATE REDACTED] and was completed on the early morning on [DATE REDACTED] and the training was completed by

the DON.

Record review of document labeled, Employee Disciplinary Action Form, dated [DATE REDACTED], revealed the name of LVN A, type of offense is listed as violation of company policy. The document revealed LVN A as suspended on [DATE REDACTED] at 11 pm and was terminated due to the result of the event on [DATE REDACTED].

Record review of staff roster dated [DATE REDACTED] reflected 13 licensed nurses (11 full time nurses and 2 prn nurses).

Record review of an in-service training attendance roster, dated [DATE REDACTED], reflected the in-service topics included hospice resident and code status, resident rights and where to find code status. The instructor was facility DON and roster was signed by 16 nurses (3 agency employees). Documents attached to the in-service included an action tree describing how to respond when a resident is found with no pulse or unresponsive and listed the first action as go to [EMR name] and check code status.

Record review of a document titled Hospice Residents/Code Status/Resident Rights Post Test listed 4 questions which included 1. What do you immediately check when a patient is found unresponsive? 2. Can you be on hospice and still be a full code? 3. Where do you find the code status? 4. Resident has the right to decide their code status True or False?. There are 18 (13 facility nurses and 5 agency nurses) completed posttests by nurses.

Record review of a Hospice list, dated [DATE REDACTED], reflected 10 resident names. 3 residents are listed as full code.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 675452 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675452 B. Wing 07/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rosewood Rehabilitation and Care Center 7700 Mesquite Pass Converse, TX 78109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Record Review of a document labeled [facility name] Ordering Listing Report, dated [DATE REDACTED] at 8:03am, reflected a list of all facility residents and their code status. The document revealed there are 28 residents Level of Harm - Immediate with orders for DNR and 31 residents with Full code orders. jeopardy to resident health or safety Record review of resident roster, dated [DATE REDACTED], reflected 59 resident names.

Residents Affected - Few Record review of 59 resident face sheets, dated [DATE REDACTED], reflected code status on the resident face sheets matched the resident physician order for code status.

Interviews conducted with 10 of 11 full time licensed nurse employees (5 -6 a.m.-2p.m., 1- 2 p.m.-10 p.m., 1 - 10 p.m.-6 a.m., 3- double weekends 6 a.m.-10 p.m.). Interviews conducted with 2 agency LVNs (1- 6 a.m.-2 p.m. and 1- 2 p.m.-10 p.m.). 2 PRN employees were unable to be reached by phone and were not on the schedule. The employees interviewed revealed they had received training from the DON regarding where a resident's code status is located in the chart, when to verify code status, what to do if a resident is a full code or DNR and hospice patients can be a full code. The licenses nurses were all able to answer the questions correctly, validating understanding of the in-service topic.

During an interview with the Administrator, [DATE REDACTED] at 2:28 p.m., the Administrator stated the DON would provide training to new hires during the orientation process and would provide training to agency employees prior to their assigned shift. The Administrator stated random post tests would be given to licensed nurses, weekly for 4 weeks, starting on [DATE REDACTED] by the Administrator. The test would include questions regarding code status and initiating CPR timely for residents that are a full code.

During an interview with the DON, [DATE REDACTED] at 2:19 p.m., the DON stated new hires would receive training on code status, hospice and full code, and what to do when a resident is DNR or full code, during the orientation process and the DON would provide the education. DON stated agency staff would be educated on code status prior to beginning their shift and the DON would be providing the education. DON stated she had created an audit log and would conduct random audits with the licensed nurses. The audit would include asking the nurse to identify the residents code status, identify if the patient is on hospice, identify if the resident is a full code and how the nurse would respond to the code status.

Record review of a document titled Monitoring for Knowledge Retention, undated, listed the names of all facility nurses and had a section for agency staff. There are 4 forms listed as week 1, 2, 3, and 4 and stated

it will be conducted by the Administrator.

Record review of audit logs labeled Week 1, undated, listed date, shift, nurse, resident, code status, hospice y/n, correctly identified code status y/n and correct response of what to do if full code y/n. There were 5 blank audit lines per sheet. There are 3 additional correlating documents labeled Week 2, Week 3 and Week 4.

The audit would be completed by the DON.

On [DATE REDACTED] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ

after verifying their POR had been initiated and/or completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 675452 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675452 B. Wing 07/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rosewood Rehabilitation and Care Center 7700 Mesquite Pass Converse, TX 78109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 The Administrator was informed the Immediate Jeopardy was removed on [DATE REDACTED] at 4:05 p.m. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not an Level of Harm - Immediate Immediate Jeopardy and a scope of isolated, due to the facility was still monitoring the effectiveness of their jeopardy to resident health or Plan of Removal. safety

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 675452