HOUSTON, TX – LEGEND OAKS HEALTHCARE AND REHABILITATION – NORTH / WILLOWBROOK

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide necessary care and services to allow the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of 45 residents (CR#138) reviewed for quality of life.

-The Facility failed to follow CR #138’s physician orders [REDACTED].

-Facility Staff failed to assess and monitor CR 138’s vital signs, and inform the residents’ physician of a significant change in his vital signs and change of condition after several reported complaints of shortness of breath and chest pains.

-Facility Staff failed to communicate to the next shift staff of CR#138’s change in condition, to assess, and monitor the resident for change of condition, which resulted in the death of CR #138 on [DATE].

Record review of CR #138’s face sheet dated [DATE] revealed a [AGE] year-old male admitted from an acute care hospital to the facility on [DATE]. CR #138’s [DIAGNOSES REDACTED]. CR #138’s was pronounced dead in the facility on [DATE].

Interview on [DATE] at 10:43 a.m. CNA A confirmed she had worked on [DATE] in the AM with CR #138. CNA revealed the Resident was fine when she did her initial rounds around 6:00 a.m. that morning. She said she gave CR #138 his breakfast and he then complained he could not breathe. CNA A said she said immediately to LVN A about CR #138’s complaint. She said she saw LVN A go into his room, and she continued with other resident’s care. CNA A said she went back CR #138’s room before lunch and he continued to complain that he could not breathe. CNA A said she said this immediately to LVN A who instructed her to assist the resident up into his wheelchair. She then saw CNA B answer CR #138’s call light and she was by CNA B that he was still complaining he could not breathe. CNA A said she and CNA C assisted CR #138 up into his wheelchair. She said he continued to complain of not being able to breathe. She adjusted the air conditioning in the room and applied his oxygen. CNA A said she had gone to LVN A about 4 times that morning to let her know about CR #138’s complaints. She said the therap department had also been in his room and he was complaining to them about chest pain. She revealed she did see he had a bloody nose during one of her times in the room and she had said that to LVN A. CNA A said CR #138 ate the fruit cup only from his lunch tray and did not want the lunch because he did not feel good. CNA A said she had worked on Sunday [DATE] and the resident had no shortness of breath or complaints on that day. CNA A said when she had received report from the night CNA on the morning of [DATE] CR #138 had had a good night and there were no complaints or concerns. She said when she had left her shift at 2:00 p.m. on [DATE] she had said to the on-coming CNA about CR #138 complaining of shortness of breath and not feeling well. CNA A said she had only witnessed LVN A go into CR #138’s room one time during her shift. CNA A said she felt like LVN A should have checked on CR #138 more often.