Inspection·October 19, 2023

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 was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #1 had oxygen concentrator filters free of sediment and debris. This failure could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings Included: Review of Resident #1's face sheet on 10/19/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. Relevant diagnoses included stroke, difficulty swallowing and speaking, muscle wasting, asthma, and dementia. Review of Resident #1's annual MDS assessment dated [DATE] revealed her cognition was severely impaired with a BIMS score was 6. Review of Resident #1's Comprehensive Care Plan revealed: Respiratory: [Resident #1] is at risk for aspiration .Goal: [Resident #1] will not . experience SOB, chest congestion . Interventions: 6. Apply O2 for SOB [Resident #1] has asthma . Goal: [Resident #1] will remain free from complications of asthma . Interventions: Advise resident to minimize contact with known offending allergens . Encourage prompt treatment of any respiratory infection . Monitor for s/sx of impending asthma attack: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath, tightness of neck or chest muscles, malaise or fatigue. Review of Resident #1's physician orders on 10/19/2023 at 11:00am. revealed, Continuous oxygen @ 2 l/m via nasal cannula .every shift . with a start date of 06/15/2023 at 2:00PM. There were no orders related to care or maintenance of resident's oxygen concentrator and/or filters. In an observation of Resident #1 on 10/19/2023 at 11:18 am, revealed she was resting in bed with (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: 675113 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 675113 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Park IN Plano 3208 Thunderbird LN Plano, TX 75075 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)