The Plaza At Lubbock

F-F678

The resident was a 65 y/o male, admitted on [DATE REDACTED] with a diagnosis of malignant neoplasm of the

breast with secondary malignant neoplasm of other parts of the nervous system.

The facility allegedly failed to provide basic life support, including CPR, prior to the arrival of emergency.

medical personnel for 1 (Resident #1) of 1 resident. Resident #1's code status was listed as full code.

How other residents with the potential to be affected by the same deficient practice.

will be identified. Any resident with full code status have potential to be affected by the alleged.

deficient practice

What measures will be put into place or what systemic changes will be made to ensure

that the deficient practice does not recur.

DON (Director of Nursing) or designated nurse will in service all licensed nurses on policy

and procedure for identifying code status on residents by 10:00 pm on [DATE REDACTED]. No

nurses will be allowed to work until training has been completed. Any nurses who did not

receive training before 10:00 P.M. on [DATE REDACTED] will receive training prior to the start of

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 676105 Department of Health & Human Services Printed: 09/10/2025 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 676105 B. Wing 01/24/2025

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

The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

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 their next shift. This education was initiated on [DATE REDACTED].

Level of Harm - Immediate DON or designee will educate all staff on emergency policy and procedures when residents. jeopardy to resident health or safety are found to be unresponsive by 10:00 pm on [DATE REDACTED]. No nurses will be allowed to work.

Residents Affected - Few until training has been completed. Any nurses who did not receive training before 10:00

P.M. on [DATE REDACTED] will receive training prior to the start of their next shift. This education

was initiated on [DATE REDACTED].

DON or designee will monitor 10 staff members per week for 4 weeks on competency of 7

signs of death/ active signs of death, competency of nurses printing code statuses from EMR

and on person, and CNA competency on code status on POC. This monitoring was initiated.

on [DATE REDACTED].

How the corrective action(s) will be monitored to ensure the deficient practice is being

corrected and will not recur (i.e., what program will be put into place to monitor the continued

effectiveness of the system changes); and

Proof of the education will be submitted to QA committee

Involvement of Medical Director

Medical Director was notified and met with interdisciplinary team on [DATE REDACTED].

Involvement of QA

An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of

nursing, and social services director to review plan of removal.

Administrator will forward results of audits monthly to the QAPI Committee for review and/or action

and be reviewed monthly x 90 days.

Who is responsible for implementation of process?

The Director of Nursing/designee will be responsible for implementation of New Process. The New

Process/ system will be started on [DATE REDACTED] and no employee be able to return to work until they

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 676105 Department of Health & Human Services Printed: 09/10/2025 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 676105 B. Wing 01/24/2025

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

The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

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 complete the Inservice.

Level of Harm - Immediate Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on jeopardy to resident health or safety [DATE REDACTED].

Residents Affected - Few Interviews for POR:

Interviews with 1 RN, 1 LVN, 4 CNAs and 2 CMAs regarding the training they had received on signs of impeding death, and code status of a resident on [DATE REDACTED] by 2:30 PM, showed that the staff had an understanding of the education provided.

During an interview with CMA E for training for POR on [DATE REDACTED] at 11:34 AM. CMA E stated that she had received an in service training by the DON. CMA E stated that the training was about how to locate the code status of a resident. CMA E stated that the nurses are supposed to carry a printout paper of all resident's code status. CMA E stated that for CNA's can find the code status of a resident by getting into the POC and clicking on the resident's name and that will pull up the code status. CMA E stated that the CMA's are not required to print out the code status. CMA E stated that the other training that they received was for the signs of death which are pain, sleeping a lot, not able to eat or drink, not able to get out of bed. You would report

these signs through chain of command. CMA E stated that she would then step out in the hall and keep her eyes on the resident and yell for help if she noticed t [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 676105