Inspection·August 17, 2022

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 needs respiratory care is provided care consistent with standards of practice and the care plan for one resident (Resident #16) of 4 reviewed for respiratory care, in that: Residents Affected - Few Resident #16's nebulizer and mask were lying on Resident #16's bed exposed (without being secured in a bag to prevent contamination) with medication in the medication delivery nebulizer. This failure could place residents who used small volume nebulizers at risk for exposure to communicable diseases and infections. The findings include: Review of Resident #16's undated Face Sheet revealed she was a [AGE] year-old female re-admitted on [DATE] with the following diagnoses: Dysphagia (difficulty swallowing) pneumonitis (pulmonary infection as a result of aspiration of food) sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and Gastro-esopheal reflux (A digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident #16's re-admission MDS assessment, dated 06/28/22 revealed she had a BIMS score of 12, indicating she was cognitively intact and able to make his needs known. Review of Resident #16's care plan dated 6/28/22 revealed: She had problems with infections and the facility was to monitor signs and symptoms of infections. The care plan did not include the process of changing the nebulizer cups or sanitary storage. Review of Resident #16's physician's orders dated 06/21/21 revealed the following: Proprium-Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% every four hours as needed for shortness of breath. During an observation and interview on 08/15/22 at 8:53 AM, revealed Resident #16 was resting in bed awake and alert, finishing her breakfast. Resident #16 had a nebulizer with a mask attached lying on her bed, which contained a small amount of medication and was uncovered and exposed to potential contamination. Further observation revealed the nebulizer was also not dated. Loose oxygen tubing was lying on her bed which was attached to the power unit that pumped air to the nebulizer creating a mist of medication. (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 5 Event ID: 675035 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 675035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Burkburnett 406 E Seventh St Burkburnett, TX 76354 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)