Health inspection·August 15, 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 that residents who needed respiratory care were provided with care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure Resident #1 had an order indicating an oxygen flow rate via his trach collar while on his room concentrator and portable oxygen unit as needed for hypoxia from 06/06/25 through 08/15/25. These failures could place residents at risk for symptoms and manifestations of hypoxia, the decreased perfusion of oxygen to the tissues and a decreased quality of care.Findings include: Review of Resident #1's face sheet dated 08/15/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen in body tissues), dependance on renal dialysis (medical procedure used to remove waste products and excess fluid from the blood when kidneys are no longer able to perform the function effectively), generalized anxiety disorder (excessive uncontrollable worry about every day issues), major depressive disorder (characterized by persistently low mood and loss of interest), and tracheostomy status (having surgical hole in the windpipe that helps with breathing when the usual way is blocked or reduced). Review of Resident #1's Quarterly MDS assessment reflected a BIMS score of 14 indicating cognition intact. Section I for active diagnosis indicated respiratory failure marked and active tracheostomy status. Section O of the MDS reflected Resident #1 received oxygen therapy and was marked for tracheostomy care. Review of Resident #1's care plan reflected a focus last revised 08/10/25 Resident #1 has Tracheostomy r/t impaired breathing mechanics with interventions that included give humidified oxygen as prescribed. Review of Resident #1's physician orders reflected a discontinued order with a start date of 04/10/25 and discontinued date of 06/06/25 for oxygen at 3L/min every day and night shift for acute respiratory failure. Review of Resident #1's physician orders reflected no active order for oxygen indicating flow rate between 06/06/25 and 08/11/25. Review of Resident #1's physician orders reflected an active order with a start date of 08/11/25, oxygen at LPM via trach collar every shift trach/oxygen maintenance and as needed for hypoxia. The order did not reflect a flow rate. In an observation and interview on 08/15/25 at 10:59 AM with Resident #1, he was observed in his room receiving oxygen from the room concentrator via his tracheostomy and it was observed to be set at 5.5 LPM. Resident #1 stated that he prefers his oxygen at 6 LPM and that the room concentrator will usually remain at 6 LPM. Resident #1 stated when he is ambulating or out of his room, he is moved to the portable oxygen tank and that staff will set it at 4 LPM. Resident #1 stated the flow rate was never consistent when he goes from his room oxygen concentrator to the portable oxygen. He stated he has consistently received oxygen and that he did not have a problem not getting it but that it was just never a consistent flow rate. He stated staff have also attempted getting him to lower the flow rate. In an observation and interview on 08/15/25 at 11:13 AM Residents Affected - Some Page 1 of 3 455862 455862 08/15/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with LVN A she stated the flow rate for Resident #1 is supposed to be between 3-4 LPM but can go up to 5 LPM if needed for his room concentrator. She stated he can have it higher if he feels his chest closing in. LVN A then stated that the portable oxygen was set to 4 LPM by staff when he was moving around. Surveyor asked LVN A what the provider prescribed order was for Resident #1 and LVN A stated she would have to look; LVN A was then observed reviewing Resident #1's orders on the EMR. LVN A stated she did not see that a new order was ever entered for Resident #1's oxygen indicating what the flow rate should be, and the existing order did not indicate the flow rate. She stated there should be an order for oxygen indicating the flow rate to be used for the concentrator and the portable oxygen tank. She stated the last order she could find was the order discontinued 06/06/25 where Resident #1 had a flow rate of 3 LPM. She stated Resident #1 has been receiving oxygen and that they just know what to keep it at. She stated it was the nurse's responsibility to connect and set the flow rate. She stated it was also nursing responsibility to ensure there was an order in place if they know he was receiving oxygen. LVN A stated that a negative outcome of not having the order in place was staff that don't normally work with him would not know what to set the flow rate to, and a negative outcome of giving too little oxygen could result in dyspnea (shortness of breath) and giving too much could cause other negative effects. In an observation and interview on 08/15/25 at 12:15 PM with the DON she stated Resident #1's flow rate should be at 4 LPM and that they were working on titrating Resident #1 lower to get him on room air as the goal. Surveyor asked DON what the order was in the EMR and DON was observed reviewing Resident #1's EMR, she then stated the order in the system did not indicate a flow rate. The DON stated it was her expectation that residents receiving oxygen have an order in place with the flow rate required. She stated the flow rate should also be consistent whether on the room concentrator or on the portable oxygen. The DON stated she believed the old order was discontinued when Resident #1 had a hospital visit and the new order was added but missed the flow rate. She stated she was new to the facility and was still working on fixing things. The DON stated it was nursing responsibility (the charge nurse and hers) to ensure orders were correct in the system. She stated a potential negative outcome was shortness of breath if not getting enough oxygen. The DON stated she would then contact the provider to confirm the order and update Resident #1's order for oxygen and flow rate. In an interview on 08/15/25 at 01:09 PM with the ADM, she stated it was her expectation that if a resident was receiving oxygen that there was an order in the chart for oxygen administration indicating the flow rate. The ADM stated that if there was no order in place residents could not be getting the proper amount of oxygen flow that the require. The ADM stated it would be the responsibility of the charge nurse and the DON of ensuring orders were correct in the resident chart. In an interview on 08/15/25 at 01:33 PM with the NP, he stated he was a provider that oversaw the care provided to Resident #1. The NP stated, there is supposed to be an order in the residents' chart to direct the flow of oxygen. He stated the order would apply to both the in-room concentrator and the portable tank because they should be the same flow rate. The NP stated a negative outcome of not having an order in place for someone on oxygen if they are not getting enough it could result in hypoxia, respiratory issues, weakness or feeling tired. If they are getting too much depending on their medical condition could negatively impact their carbon dioxide retention in their system which could cause altered mental status, weakness, and confusion. The NP stated it was the responsibility of the charge nurse and ultimately the DON/ ADON to ensure the correct order was in place as ordered by the provider. The NP stated Resident #1's flow rate was supposed to be 4-6 LPM with the goal of lowering him down be able to use room air. Review of the facility Oxygen Administration policy last revised October 2010 reflected: The purpose of this procedure is to provide guidelines 455862 Page 2 of 3 455862 08/15/2025 Coral Rehabilitation and Nursing of Austin 6909 Burnet LN Austin, TX 78757

F 0695 for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 455862 Page 3 of 3