Health inspection·November 4, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for 2 (Resident #1 and Resident #8) of 3 residents reviewed for accuracy of assessments. The MDS did not address Resident #1 and Resident #8's oxygen use. This failure could place residents at risk of missed services, treatments, and overall decline in health. Resident #1Record review of Resident #1's face sheet, dated 11/04/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with other specified cough and obstructive pulmonary disease (a chronic inflammatory disease that causes obstructed airflow from the lungs). Record review of Resident #1's Comprehensive MDS Assessment, dated 10/29/2025, reflected the resident was cognitively intact with a BIMS score of 12, indicating the resident had moderately impaired cognition Section O Special treatments, procedures, and programs did not address resident oxygen treatment. Record review of Resident #1's Comprehensive Care Plan, dated 06/30/2025, reflected the resident The resident has Oxygen Therapy r/t COPD. She is at risk for shortness of breath. Resident's oxygen tubing often has discoloration r/t heavy smoking. Edited: 06/30/2025 interventions Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry (a non-invasive medical procedure that measures the oxygen saturation of the blood), Increased heart rate (Tachycardia), Restlessness, Diaphoresis (excessive sweating), Headaches, Lethargy (lack of energy), Confusion, Atelectasis (partial or complete collapse of the lung), Hemoptysis (the coughing up of blood or bloody mucus from the lungs or airways.), Cough, Pleuritic pain (sharp stabbing pain). Accessory muscle usage, Skin color. OXYGEN SETTINGS: The resident has O2 via nasal prongs (two small tubes that are placed into a patient's nostrils to deliver supplemental oxygen.) @ 2LPM PRN. Resident is a smoker and is at risk for injury. Interventions monitor PRN when smoking to ensure residents safety perform smoking assessment according to facility policy. staff to supervise during smoke breaks. Resident #8Record review of Resident #8's face sheet dated 11/04/2025 reflected he was a [AGE] year-old male that was admitted on [DATE] with diagnosis of COPD Lung Record review of Resident #8's Comprehensive MDS Assessment, dated 10/16/2025, reflected the resident was cognitively intact with a BIMS score of 13, indicating the resident had moderately impaired cognition. Section O Special Treatments, Procedures, and programs did not address his oxygen treatments. The section was left blank. Record review of Resident #8's Comprehensive Care Plan, dated 09/07/2025 reflected [Resident #8] has Oxygen Therapy r/t SOB associated with COPD.interventions administer medications as ordered, Monitor for s/sx of respiratory distress and report to MD PRN. OXYGEN SETTINGS: The resident has, O2 via nasal @ 3 LPM. Position resident to facilitate ventilation/perfusion matching: Use upright, high-Fowlers position (a medical posture where the patient is sitting upright with the head of the bed elevated at a 60-90 degree angle. ) whenever possible to allow for optimal diaphragm , When on side, the good side should be down (damaged lung should be up). Record review of Resident #8's Physician's Order dated 08/26/2025 reflected Nurse to verify 02 humidification Residents Affected - Few Page 1 of 4 455463 455463 11/04/2025 The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bottle/chamber has adequate amount of distilled water, at least every shift. every shift.Oxygen continuously via Nasal Cannula. May titrate between 2-5 LPM for shortness of breath or pulse oximetry < 90%. every shift for SOB and to maintain pulse ox > 90% . Nurse to verify 02 humidification bottle/chamber has adequate amount of distilled water, at least every shift.order dated 09/28/2025 reflected an order Check Oxygen Concentrator filter for placement and clean filter every week and PRN every night shift every Sun. Record review of Resident #8's October TAR reflected that the oxygen concentrator was checked, tubing and water was changed on 10/05/2025, 10/12/2025, 10/19/2025, and 10/26/2025. Record review of Resident #8's November TAR reflected that the Oxygen Concentrator filter was checked, tubing and water was changed on 11/02/2025 during the night shift. The water was checked for adequate distilled water on the Day, Evening, and night shift 11/01/2025, 11/02/2025, 11/03/2025, and 11/04/2025. Observation and interview on 11/04/25 at 10:50 AM revealed Resident #8 was awake, sitting in his wheelchair with nasal cannula on receiving oxygen via concentrator. During an interview on 11/04/2025 at 2:00 PM, the DON stated that she reviewed and signed the completed MDSs upon completion of all the sections as the RN. She stated that if the oxygen treatment was not coded, it meant the resident did not use it during the look back period. She would have to check the resident files. She did not address the negative outcome to the resident. During an interview on 11/04/2025 at 2:20 PM, the Administrator stated it was his expectation for the comprehensive MDS assessments to be completed accurately. During an interview on 11/06/2025 at 1:30 PM with MDS, revealed she completed sections B-health speech and vision, C-Cognitive, D-Mood, E-Behaviors, and Q-participation in Assessments and goal setting. She stated the importance of the resident's comprehensive MDS being accurate was to ensure the resident received the proper care they needed. Record review of facility policy dated 03/2022 and titled Resident assessments reflected The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan.The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan. 455463 Page 2 of 4 455463 11/04/2025 The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 3 residents reviewed for respiratory care. Resident #1's NC was not replaced when dirty.Resident #8's 02 concentrator humidification bottle was not dated. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings:Resident #1Record review of Resident #1's face sheet, dated 11/04/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with other specified cough and obstructive pulmonary disease (a chronic inflammatory disease that causes obstructed airflow from the lungs). Record review of Resident #1's Comprehensive MDS Assessment, dated 10/29/2025, reflected the resident was cognitively intact with a BIMS score of 12, indicating the resident had moderately impaired cognition. Section O Special Treatments, Procedures, and programs did not address his oxygen treatments. The section was left blank. Record review of Resident #1's Comprehensive Care Plan, dated 06/30/2025, reflected the resident The resident has Oxygen Therapy r/t COPD. She is at risk for shortness of breath. Resident's oxygen tubing often has discoloration r/t heavy smoking. Edited: 06/30/2025 interventions Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry (a non-invasive medical procedure that measures the oxygen saturation of the blood), Increased heart rate (Tachycardia), Restlessness, Diaphoresis (excessive sweating), Headaches, Lethargy (lack of energy), Confusion, Atelectasis (partial or complete collapse of the lung), Hemoptysis (the coughing up of blood or bloody mucus from the lungs or airways.), Cough, Pleuritic pain (sharp stabbing pain). Accessory muscle usage, Skin color. OXYGEN SETTINGS: The resident has O2 via nasal prongs (two small tubes that are placed into a patient's nostrils to deliver supplemental oxygen.) @ 2LPM PRN. Resident is a smoker and is at risk for injury. Interventions monitor PRN when smoking to ensure residentssafety perform smoking assessment according to facility policy. staff to supervise during smoke breaks. Record review of Resident #1's Physician's Order dated 09/28/2025 reflected change O2 tubing/water every week as needed.every night shift every Sun. Change Oxygen administration device (nasal cannula, mask or collar) and humidifier bottle weekly on Sunday night. every night shifts every Sun. An order dated 09/01/2025 reflected Oxygen at 1-3 LPM via nasal cannulaas needed for SOB and to maintain pulse ox > 90% Every shift. Observation and interview on 11/04/25 at 10:45 AM revealed Resident #1 was awake, walking from the restroom. Observation revealed NC lying on her pillow with various stages of brown (dark brown, golden brown, and light brown) on the NC prongs. An oxygen concentrator machine had saltine cracker crumbs and dried liquid from food. The resident said the nurse never changed her NC tubing nor cleaned the concentrator. Resident #8Record review of Resident #8's face sheet, dated 11/04/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with Cough And Obstructive Pulmonary Disease (a chronic inflammatory disease that causes obstructed airflow from the lungs). Record review of Resident #8's Comprehensive MDS Assessment, dated 10/16/2025, reflected the resident was cognitively intact with a BIMS score of 13, indicating the resident had moderately impaired cognition. Section O Special Treatments, Procedures, and programs did not address his oxygen treatments. The section was left blank. Record review of Resident #8's Comprehensive Care Plan, dated 09/07/2025 reflected [Resident #8] has Oxygen Therapy r/t SOB associated with COPD.interventions administer medications as ordered, Monitor for s/sx of respiratory distress and report to MD PRN. OXYGEN SETTINGS: The resident has, O2 via nasal @ 3 LPM. Position resident to facilitate Residents Affected - Few 455463 Page 3 of 4 455463 11/04/2025 The Meadows Health and Rehabilitation Center 8383 Meadow Rd Dallas, TX 75231

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ventilation/perfusion matching: Use upright, high-Fowlers position (a medical posture where the patient is sitting upright with the head of the bed elevated at a 60-90 degree angle. ) whenever possible to allow for optimal diaphragm , When on side, the good side should be down (damaged lung should be up). Record review of Resident #8's Physician's Order dated 08/26/2025 reflected Nurse to verify O2 humidification bottle/chamber has adequate amount of distilled water, at least every shift. every shift.Oxygen continuously via Nasal Cannula. May titrate between 2-5 LPM for shortness of breath or pulse oximetry < 90%. every shift for SOB and to maintain pulse ox > 90% . Nurse to verify O2 humidification bottle/chamber has adequate amount of distilled water, at least every shift.order dated 09/28/2025 reflected an order Check Oxygen Concentrator filter for placement and clean filter every week and PRN every night shift every Sun. Record review of Resident #8's November 2025 TAR reflected that the Oxygen Concentrator filter was checked, tubing and water was changed on 11/02/2025 during the night shift. The water was checked for adequate distilled water on the Day, Evening, and night shift 11/01/2025, 11/02/2025, 11/03/2025, and 11/04/2025. Observation and interview on 11/04/25 at 10:50 AM revealed Resident #8 was awake sitting in his wheelchair. Observations revealed an oxygen concentrator water bottle that was not dated. The resident said the nurse checked the tubing and bottle during rounds. He could not remember when the water bottle change occurred. During an interview on 11/04/2025 at 1:04 PM with LVN-E stated Resident #1 received oxygen treatments PRN and the tubing was changed during the night shift on Sundays. LVN-E said she changed resident #8's tubing and water bottle 30 minutes after surveyor's observation. LVN-E stated that the overnight staff changes the tubing every Sunday. LVN-E said that the brown colors that were observed on the NC were due to the resident being a heavy smoker, per her Google search today. During an interview on 11/04/2025 at 2:00 PM, the DON stated the housekeeping staff were responsible for cleaning the oxygen concentrators. The DON said the oxygen tubing should be changed on Sundays during the night shift and as needed. The DON said the facility policy did not require the NC to be dated. The DON said that Resident #1's NC discoloration was due the resident excessively smoking, despite re-education from nursing staff. The DON said that she was aware of the resident's NC discoloration, however, she was could not say how long it would take for the discoloration to occur on the NC. DON said the tubing should be changed as needed when soiled. During an interview on 11/04/2025 at 2:18 PM, the ADON stated the staff were responsible for ensuring all the respiratory devices were clean during resident rounds. She said the staff should change tubing as needed, and she would educate the staff and document in the care plan frequent NC changes for Resident #1. She stated that another expectation was for the staff to ensure the humidifier bottle was dated when changed. She said she would coordinate with the DON to do an in-service regarding dating and monitoring respiratory devices and changing the tubing. During an interview on 11/04/2025 at 2:20 PM, the Administrator stated that Resident #1's tubing was changed on Sundays during the night shift, and it was the ADON and the DON responsibility to monitor clinical treatments. Record review of the facility policy undated, titled Oxygen Administration reflected PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration.Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.3. Assemble the equipment and supplies as needed.Weekly Documentation 1. Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record.Reporting.1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. 455463 Page 4 of 4