Health inspection·May 8, 2024

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 a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #1's oxygen tubing was dated. These failures affected residents and placed them at risk of not receiving the needed services for respiratory care. Findings include: Record review of Resident #1's face sheet, revealed an [AGE] year-old female was admitted on [DATE] with a primary diagnoses of DEMENTIA,WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE; CHRONIC RESPIRATORY FAILURE (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), Record review of Resident # 1's Medication Administration Record, dated May 2024 revealed change and label O2 tubing and humidifier bottle and clean O2 concentration filter weekly, every night shift every Sunday for oxygen. Start date 03/19/2023 shift 10 pm - 6 am. Record review of Resident #1's Care Plan dated 03/02/2024 revealed Resident had FOCUS care plan for Oxygen: Resident used oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. Intervention: provide a nasal cannula for meals, as allowed by the physician. In an observation on 05/08/2024 at 10:50 A.M. revealed Resident #1 was lying in bed on her side with a nasal cannula positioned appropriately in her nostrils. The oxygen concentrator was powered on and appeared to be working properly. The nasal cannula tubing was not dated. Interview with LVN A on 05/08/2024 at 2:50 P.M reflected surveyor asked LVN A to accompany her to Resident #1's room to verify the nasal cannula tubing was not dated. LVN A declined and stated that she believed that the nasal cannula tubing was not dated. She stated that the night nurse scheduled on Sunday is responsible for dating and labeling nasal cannula tubing. Observation and interview with DON on 05/08/2024 at 3:12 P.M. reflected that the nasal cannula tubing was not labeled and dated; it was the responsibility of the Sunday night nurse to change and date nasal cannula tubing. The Nasal cannula tubing should be changed weekly to prevent the risk of (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: 455996 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 455996 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Renaissance at Kessler Park 2428 Bahama Dr Dallas, TX 75211 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)