Health inspection·November 25, 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 such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 4 residents reviewed for respiratory care.The facility failed to ensure Resident #1's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) and nebulizer mouthpiece (device used to deliver medication in a mist form through the mouth) was properly stored when not in use on 09/30/2025.This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 09/30/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included hypertension (elevated blood pressure) and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #1's MDS (tool used to measure health status) Discharge Assessment, dated 09/21/2025, reflected a BIMS (tool used to measure cognitive status) Assessment was not completed for resident #1. The staff assessment for mental status indicated Resident #1's cognition was moderately impaired with making decisions regarding tasks of daily life. Section I (Active Diagnoses) reflected Resident #1 was treated for COPD.Record review of Resident #1's Comprehensive Care Plan, dated 07/30/2025, reflected the resident had COPD related to smoking. One intervention was continuous oxygen via nasal cannula to keep oxygen saturation at 92% - 94%.Record review of Resident #1's Comprehensive Care Plan, dated 07/30/2025, reflected Resident is at risk for infection, due to non-compliance with nasal cannula use.Frequently removes nasal cannula and drops on the floor. Date initiated 06/20/2025. The intervention was Nursing will monitor for canula placement and if found on floor will be replaced immediately. Date Initiated: 06/20/2025.Record review of Resident #1's Physician's Order, dated 07/10/2025, reflected to administer oxygen at 2-5 LPM to maintain oxygen greater than 92% every shift for shortness of breath. Record review of Resident #1's Physician's Orders, dated 07/10/2025, reflected to administer Ipratropium-Albuterol (medication that makes it easier to breathe) Inhalation Solution 0.5-2.5 (3) MG/3 ML. Inhale 1 vial orally three times a day related to COPD with acute exacerbation (sudden worsening of symptoms in chronic conditions). During an observation and interview on 09/30/2025 at 11:22 AM, Resident #1's oxygen tubing was on the resident's bed unbagged. Resident #1's mouthpiece for administration of breathing treatments was on the resident's bedside table unbagged. Resident #1 was not in her room. CNA C was in the hall and stated the charge nurse was responsible for putting the mouthpiece in the bag after the medication was finished. CNA C stated Resident #1 placed the oxygen tubing on her bed until she returned from smoking and put it back in her nose. CNA C stated the mouthpiece used for breathing treatments should have been bagged to keep it clean, but she was not sure about the nasal cannula. During an interview on 09/30/2025 at 11:28 AM, Resident #1 stated a staff member came to get her for smoke breaks. Resident #1 stated 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: 455930 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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)