Health inspection·November 20, 2025

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 observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 4 residents (Resident #1) reviewed for respiratory care. 1. The facility failed to ensure Resident #1's humidifier was not empty.2. The facility failed to ensure the nasal cannula and humidifier were replaced weekly.3. The facility failed to ensure Resident #1's oxygen maintenance requirements for regular replacement of nasal cannulas and humidifiers were documented in Resident #1's orders or care plan. These failures could place residents at risk for dry nasal passages or infection.Findings include: 1. Record review of Resident #1's face sheet, dated 11/06/2025, indicated Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure), dementia (decline in cognitive functioning), and COPD (chronic obstructive pulmonary disease; inflammation and narrowing of the airways leading to breathing difficulties). Record review of Resident #1's Quarterly MDS assessment, dated 10/15/2025, indicated he was understood by others and was able to understand others. Resident #1 had a BIMS score of 03, which indicated he had severe cognitive impairment. Resident #1 received oxygen while a resident in the facility. Record review of Resident #1's Order Summary Report, dated 11/06/2025, indicated may have oxygen at 4 liters per nasal cannula every shift with a start date of 07/11/2025, and check oxygen saturation frequency every shift for hypoxia (inadequate oxygen supply) with a start date of 7/11/2025. There were no other orders related to oxygen administration. Record review of Resident #1's care plan, with a date initiated of 08/20/2025, indicated he had COPD (chronic obstructive pulmonary disease; inflammation and narrowing of the airways leading to breathing difficulties) and should avoid lying flat due to shortness of breath. The goal was for the resident to display optimal breathing patterns daily through the review date. There were no interventions related to regular replacement of the nasal cannula or the humidifier. During an observation and interview on 11/06/2025 at 10:22 AM, revealed Resident #1 was in his bed, and he had oxygen via nasal canula on and running. The nasal cannula and the humidifier were dated 10/26/25. The humidifier was completely empty. Resident #1 was not aware the humidifier was empty and did not know when it was changed or how frequently. He stated he had no issues related to the humidifier being empty and had no complaints regarding oxygen administration. During an interview on 11/06/25 at 12:28 p.m., LVN A stated nasal cannulas were to be changed on the night shift weekly and the humidifiers were to be changed weekly and/or when they were empty. LVN A stated it was the night nurse's responsibility to change the nasal cannulas and the humidifiers weekly, but any nurse could replace them. LVN A stated the failure to replace nasal cannulas and humidifiers could cause infection and failure to replace humidifiers when they were empty could restrict moisture in the tubing and cause the resident to dry up. During an interview on 11/06/25 at 12:37 p.m., ADON B stated nasal cannulas were to be changed Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455757 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Spindletop Hill Nursing & Rehab Center 1020 S 23rd St Beaumont, TX 77707 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)