Regent Care Center Of League City

F-F678 Cardiopulmonary Resuscitation

Immediate Response:

Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker

on the expected practice of confirming all new admissions have advance directives elections indicated within

the medical record.

o 1. All residents should have a code status election physician's order in place upon admission.

o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed timely, then uploaded into the electronic health record.

o 3. Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 12 676153 Department of Health & Human Services Printed: 09/04/2025 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 676153 B. Wing 03/07/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 o 4.The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will conduct an initial

review of the admission/readmission orders to validate that the advanced directive election for code status is Level of Harm - Immediate in place. This audit will take place the next business day during the morning meeting and the RN Supervisor jeopardy to resident health or on duty will conduct the audit on the weekends. In the absence of the RN Supervisor on duty, the Director of safety Nursing or Assistant Director of Nursing will be responsible for conducting the audit to validate code status election orders are in place. Any discrepancies will be immediately clarified with the resident, authorized Residents Affected - Few representative and the appropriate order will be obtained by the attending physician.

Date completed: [DATE REDACTED]

Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate the CPR process, until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with

the required paperwork for a hospital transfer.

Date completed: [DATE REDACTED]

The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record.

o 1. All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses will receive the education regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. No nurse will be allowed to work until the in-service training has been completed.

o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced.

o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 676153 Department of Health & Human Services Printed: 09/04/2025 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 676153 B. Wing 03/07/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 o Nurses are expected to validate the code status election within the electronic health record orders to determine code status ordered, upon identifying that a resident presents with altered signs of life, i.e. Level of Harm - Immediate absence of detectable vital signs, no s/s of life. Nurse should immediately validate code status order in order jeopardy to resident health or to confirm advance directive/code status election prior to initiating CPR. After code status has been swiftly safety confirmed, the nurse should adhere to the code status election (Full Code = swiftly initiating CPR accordingly or DNR-do not resuscitate the nurse would swift proceed with notifications of no s/s of life to the physician Residents Affected - Few and representative. If full code: The available licensed nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. If you find a resident is found unresponsive, the nurse must yell for help, and then proceed to validate the code status, if the cart with the computer is at the door of the room. In the event the cart is not at the door of the room, the charge nurse must also yell for a team member to bring the computer, the crash cart, and the AED machine.

Nurses are expected to immediately review the code status orders within the electronic health record in order to identify the resident's code status. This should be immediately with the closest nurse's station computer or closest laptop available. The nurse should respond with urgency, immediately confirming code status and implementing resuscitative measures accordingly.

o Nurses are expected to document findings, interventions/response and notifications within the medical record.

o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order.

Date Completed: [DATE REDACTED]

The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses initially then re-education is provided to all licensed nurses regarding on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate CPR until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for

a hospital transfer.

Date completed: [DATE REDACTED]

Director of Nursing/Assistant Director of Nursing conducted an audit to validate all orders have been entered into [facility electronic record system] accurately and timely from [DATE REDACTED]-[DATE REDACTED].

Outcome: 1 of 123 residents did not have designated advanced directive/code status orders in place. Issue was resolved, physician provided orders as per resident/representative's code status election.

Date completed: [DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 676153 Department of Health & Human Services Printed: 09/04/2025 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 676153 B. Wing 03/07/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights. Level of Harm - Immediate jeopardy to resident health or Date completed:[DATE REDACTED] safety Going forward the identified trainings above will also be conducted with new hires accordingly. Residents Affected - Few Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.

Risk:

All residents who currently admit or re-admit to the community have the potential to be affected by this practice.

Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.

Systemic Response:

Director of Nursing/Assistant Director of Nursing conducted 100% re-education was extended to all nurses regarding the expected practice of confirming all new admissions have advance directives elections indicated within the medical record.

The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record.

o All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses educated regarding the process of reconciling physician orders into the electronic health

record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives.

o Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced.

o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record.

o Code Status Response:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 676153 Department of Health & Human Services Printed: 09/04/2025 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 676153 B. Wing 03/07/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 Upon a resident being identified with an acute change of condition; thus, presenting with no signs of life, the absence of vital signs the nurse will: Level of Harm - Immediate jeopardy to resident health or Nurses are expected to validate the code status election prior to initiating CPR by revieing the code status safety order within the electronic health record. The nurse should immediately alert staff for assistance and all available nursing staff should immediately respond to that location. The nurse will alert staff by utilizing the Residents Affected - Few call light system, phone and /or verbally calling for emergency response assistance to that location.

Upon identifying the code status election via the physician's order, the nurse should then proceed with initiating CPR. If the person is designated as Full Code as per the code status order. The available nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer.

Should the resident be designated as DNR-do not resuscitate per physician's order and as per the resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper notifications of no s/s of life to the physician and representative.

In the event there is no identified code status / advanced directives CPR should be initiated. Resuscitative measures should then only be ceased upon the resident's representative's instruction to stop CPR, confirm

the person wished to be DNR and as instructed by physician and/or EMS-medical response team.

Director of Nurses/Assistant Director of Nurses will conduct training for licensed nurses, aids and medication aids regarding the process for confirming and implementing CPR. Nursing team members will not work until in-service training has been received.

Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts. The DNS/ADNS will determine competency by evaluating the mock emergency drill. Mock code conducted on [DATE REDACTED]. It was done correctly. All team members followed

the Code Status Process with the Mock Code. Will conduct another mock code on [DATE REDACTED] the day shift. This will be ongoing and monthly.

Date to be completed: [DATE REDACTED].

o Nurses are expected to document findings, interventions/response and notifications within the medical record.

o Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 676153 Department of Health & Human Services Printed: 09/04/2025 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 676153 B. Wing 03/07/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as Level of Harm - Immediate well as any resident without an identified code status election order. jeopardy to resident health or safety o All Staff: Any staff member should immediately respond to a code status response with the Crash Cart along with the AED to the bedside of identified resident accordingly. Residents Affected - Few Date Completed: [DATE REDACTED]

The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights.

Date completed:[DATE REDACTED]

Going forward the identified trainings above will also be conducted with new hires accordingly.

Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.

Going forward the identified trainings above will also be conducted with new hires accordingly.

Monitoring:

The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits validating the electronic health record for accurate code status orders as well as appropriate OOH-DNR form within the medical record. This audit will be conducted ,d+[DATE REDACTED] days a week for the next 2 months. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs.

The Director of nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry as well as interview nurses to review the expected practice of validating code status upon admission, validating code status order entry as well as expected process for an emergent response when a significant change in condition (absence of signs of life, no detectable vital signs) has been identified, as well as general interviews with all staff regarding expected response of responding with the crash cart to the designated room accordingly. This expected validation observations and interviews will take place ,d+[DATE REDACTED] days a week for the next 2 months.

Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts at least once a month for the next 2 months.

Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed as per required code status admission orders and will

review all orders daily in the clinical meeting to validate compliance of code status election has the appropriate code status election physician's order in place. This expected validation observations and interviews will take place ,d+[DATE REDACTED] days a week for the next 2 months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 676153 Department of Health & Human Services Printed: 09/04/2025 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 676153 B. Wing 03/07/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 HR/Director of Nurses will conduct CPR certification audit at least once a month for the next 2 months.

Level of Harm - Immediate This corrective action plan will remain in place for the next 2 months to ensure compliance or to identify any jeopardy to resident health or further training needs. Findings of those observations will be reported to the QAPI committee during monthly safety meeting for the next 2 months to establish compliance or identify additional trainings and oversight is required. Residents Affected - Few All audits will be placed in a binder and kept for review by HHSC for the revisit to validate to compliance.

The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented.

Date of ADHOC :

Monitoring of the plan of removal included the following:

Record review of In-Service for Administrative Nurses on Advance Directives dated [DATE REDACTED] revealed DON, ADON A, ADON B, MDS A, MDS B, MDS C, were provided education by Reg. RN regarding Advance Directives and CPR process.

Record review of In-Service for Administrative Nurses on Response Times dated [DATE REDACTED] revealed DON, ADON A, ADON B, MDS A, MDS B, MDS C, were provided education by Reg. RN. Licensed Nurses : Response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate CPR until

the code status is validated. The other present license nurses in the community must assist with the change

in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with

the required paperwork for a hospital transfer.

Record review of In-Service for Administrative Nurses on Code Status Response dated [DATE REDACTED] revealed ADMIN, DON, ADON A, MDS A, MDS B, MDS C were provided education by Reg. RN:

Code Status Response:

o Upon a resident being identified with an acute change of condition; thus, presenting with no

signs of life, the absence of vital signs the nurse will:

o 1. Nurses are expected to validate the code status election prior to initiating CPR by revieing

the code status order within the electronic health record. The nurse should immediately alert staff

for assistance and all available nursing staff should immediately respond to that location. The

nurse will alert staff by utilizing the call light system, phone and /or verbally calling for

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 676153 Department of Health & Human Services Printed: 09/04/2025 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 676153 B. Wing 03/07/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 emergency response assistance to that location.

Level of Harm - Immediate 2. Upon identifying the code status election via the physician's order, the nurse should then jeopardy to resident health or safety proceed with initiating CPR. If the person is designated as Full Code as per the code status

Residents Affected - Few order. The available nurses within the community should assist with the code status response by

swiftly verifying the code status order, implementing CPR according to the physician's order,

calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the

required paperwork for a hospital transfer.

o Should the resident be designated as DNR-do not resuscitate per physician's order and as per the

resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper

notifications of no sis of life to the physician and representative.

o In the even [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 676153