The Brazos Of Waco

F-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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 676409 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 676409 B. Wing 03/20/2025

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

The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

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 0684 Record review of the undated new hire orientation packet which included an added section revealed the following: Level of Harm - Immediate jeopardy to resident health or - Respiratory care all nurses validate resident is receiving oxygen per MD orders. safety - Change of condition recognition and notification to providers. Residents Affected - Some - 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.

- 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 676409 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 676409 B. Wing 03/20/2025

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

The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

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 0684 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 Level of Harm - Immediate the DON prior to her shift. LVN E stated there was a verbal assessment to confirm understanding of the jeopardy to resident health or material presented and that she also reviewed a PowerPoint on CHF management. LVN E stated she would safety 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 Residents Affected - Some 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.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 676409