Health inspection·September 14, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 an assessment accurately reflected a resident's status for 4 of 9 residents (Resident #3 #6, #17, and #21), reviewed for accuracy of MDS assessments). Residents Affected - Few 1. The Quarterly MDS assessment of Resident #3 indicated that the resident did not have any behaviors. 2. The Quarterly MDS assessment of Resident #6 indicated that the resident did not have any, mood disorder, behaviors. 3. The Quarterly MDS assess for Resident # 17 did not document behaviors and oxygen use. 4. The Quarterly MDS assess for Resident # 21 did not document psychiatric conditions, medication use and oxygen use. This failure did not ensure accurate assessments that could affect the residents by placing them at risk of inaccurate and incomplete assessments which could result in residents not receiving care to meet their highest level of functioning and psychosocial wellbeing. Findings included: Resident #3 Record review of Resident #3's face sheet, dated 09/14/23, revealed [AGE] year-old male admitted on [DATE]. His diagnoses include Unspecified sequelae of other cerebrovascular disease (medical condition affecting blood vessels and brain), encephalopathy (chronic degenerative brain condition), unspecified dementia with agitation restlessness and cognitive decline), lack of coordination, heart failure, schizoaffective disorder (mental disorder with abnormal thoughts). A Record review of Resident #3's Quarterly MDS, dated , 08/12/23 revealed a BIMS score of 0 Page 1 of 11 675185 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating severe cognitive impairment, no history of behaviors. Functions with extensive assistance from staff for ADLs A Record review of Resident #3's Care Plan dated 08/10/23 Resident #3 sometimes becomes physically aggressive w/ otherso Anticipate and meet the resident's needs. Resident sometimes puts staff/residents' hands or arms in his mouth and bites . o Resident #3 has a behavior problem r/t Dementia. Resident #3 sometimes wanders . sometimes physically aggressive with staff. Resident sometimes puts staff/residents' hands or arms in his mouth and bites down/sucks .Resident received psychotropic medications risperidone r/t Behavior management, Potential for injury to self or others. Observation of Resident #3 on 09/14/23 revealed he was non-verbal and not interviewable. Resident #3 was observed sitting in his wheelchair at the top of the hallway reaching out as others passed by. No concerns were noted. Resident #6 Record review of Resident #6's face sheet dated an [AGE] year-old female who admitted on 0 9/28/22. Her diagnoses include dementia with anxiety (cognitive decline and tension/worry), type 2 diabetes (condition of unstable insulin levels), muscle weakness, unsteadiness on feet, lack of coordination, depression (mood disorder), unspecified glaucoma (damaged optical nerve) , hypertension (high blood pressure), osteoarthritis ( degenerative joint disease), insomnia (sleep disorder). Record review of Resident #6's Quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Section E for behaviors did not identify resident behaviors. Resident requires limited assistance with ADL's Record review of Resident #6's admission care plan dated 12/09/21 revealed resident had behaviors of resisting care and combativeness. Record review of Resident #6's care plan 07/28/23 revealed The resident has a behavior problem r/t urinating in drinking cup. The resident will have fewer episodes of behavior weekly by review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Praise any indication of the resident's, progress/improvement in behavior. The resident has impaired cognitive function/dementia or impaired thought processes, Dementia. If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately. The resident will be able to communicate basic needs on a daily basis through the review date. Consult Psychiatric/Psychiatric when verbally aggressive behaviors r/t dementia. Resident resistant to care. Record review of Resident #6's MD orders revealed MD Orders: may provide psychological services. Med Management Associates may provide Psychiatric Services. 12/16/22 behavior Monitoring Enter the code 0.None 1.Panic 2.Agitated 3.Angry 4.Anxiety 5.Biting 6.Compulsive 7.Crying 8.Pacing 9.Screaming/yelling 10.Pull IV line/tubes 11.Poor eye contact 12.Depressed withdrawn 13.Extreme fear 14.False beliefs 15.Fighting 16.Finger painting feces 17.Hallucinations/paranoia/delusion 18.Head banging 19.Insomnia 20.Jittery 21.Kicking 22.Noisy 23.Pinching 24.Restless 25.Scratching 26.Slapping 27. Suspiciousness 28.Throwing objects 29.Wandering 30.Other see progress notes dated 1/20/23 Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for mood 675185 Page 2 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disorder Pharmacy 2/2/2023 18:30 Seroquel Tablet 50 MG (quetiapine Fumarate) Give 1 tablet by mouth two times a day for agitation, aggression 3/2/2023 .trazodone tab 50mg give 1 tablet by mouth one time a day for insomnia , 090/05/23. Record review of Resident #6's progress report dated Review of behavior Note with a lock date of 08/23/23 12:32 revealed behavior of aggression and combative behaviors. 08/23/23 07:35 No behavior issues during shifts .staff monitored resident and redirected back to room to decrease stimulation Review of behavior note with a Lock Date: 8/22/2023 07:55 Spit at staff, Curse at Staff, try and throw water on resident and staff intervention Directed to the resident's room to decrease stimulation. Lock Date 8/21/2023 13:00; Lock Date 8/19/2023 18:06 Resident struck another resident 8/18/2023 behavior monitoring interventions encouraged engagement in activities and assess for pain. Behavior monitoring Lock Date: 6/16/23, 5/17/2023, and 5/18/23 after incident screaming and cussing at this nurse and other residents over a saltshaker at lunch time. Interventions of assessing pain and encouraging activities. Record review of Resident #6's admission Assessment with a locked date 12/09/21 locked time 4:42 P.M. revealed behaviors of resisting care, combative behaviors. In an interview and observation of resident #6 on 09/14/23 revealed she was polite, loved to go to church and could not recall the incident of aggression, when asked she responded, No I have not became angry and hit others. Resident #17 A record Review of Resident #17 face sheet dated 09/13/2023 revealed a [AGE] year-old male that was admitted initially on 06/03/21 and again on and 09/07/23: His primary diagnosis included: Acute Chronic Diastolic (Congestive) Heart Failure (Heart failure), Acute Respiratory Failure with Hypercapnia (a condition of abnormally elevation of carbon dioxide levels in blood), Chronic Pain, and symbolic disfunction (problems in communication related to oral motor), Bipolar Disorder (mental disorder related to depression). A record review of Resident #17's MDS dated [DATE] revealed a BIMS of 13 indicating mild cognitive impairment, Section D for mood stated none of the above. Section E for Behaviors listed non- of the above. Section O for special treatment oxygen therapy was left blank. Resident requires extensive assistance for bed mobility, toileting, and personal hygiene (resident involved in activity, staff provide weight-bearing support). 4. Total dependence for transfer, (full staff performance every time during entire 7-day period). Section E listed no behaviors. Record review of Resident #17s care plan dated 08/17/23 revealed resident receives Oxygen Therapy o will have no s/sx of poor oxygen absorption through the review date. o Oxygen at __2Lpm per nasal canulao resident requires the use of CPAP/BIPAP r/t sleep apnea. The resident has potential to demonstrate verbally abusive, impulsive, and manipulative behaviors, and unable to control his temper. Focus Goal Interventions Position Freq/Resolved Mr. [NAME] sometimes yells and screams at staff when he is upset. 6/1/23 Mr. [NAME] made allegations of abuse and misappropriation against staff member. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, ensure all residents involved are 675185 Page 3 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0641 safe and staff to walk calmly away, and approach later. Date Initiated: 06/08/2023. Level of Harm - Minimal harm or potential for actual harm A record review of resident #17's TAR reflected an order to Check and clean concentrator filter every month and PRN at bedtime starting on the 15th and ending on the 16th every month for clean filter Resident may have oxygen at 2L via nasal cannula as needed for O2 sats <92% as needed for O2 sats <92%. Residents Affected - Few Record Review of Resident #17's MD orders dated 11/16/22 revealed o resident will maintain oxygen saturations 90% or greater over the next 90 days date initiated: 11/16/2022 target date: 08/17/2023o resident will use device as ordered o staff to monitor saturation as ordered. In an observation of resident #17 observation of Resident 17 on 09/13/23 at 10:38 AM revealed him asleep in bed with oxygen tubing attached to concentrator undated. Unable to interview as he was Sleep. In another attempt to interview Resident #17 on 09/14/23 at 1:50 PM revealed resident in bed on oxygen. In an attempt to interview Resident #17 resulted in him not responding to surveyors attempts and greeting. Resident #21 A record review of resident #21 face sheet dated 09/13/2023 r revealed a [AGE] year-old female admitted on [DATE] with primary Diagnosis: secondary and unspecified malignant neoplasm of axilla and upper 05/11/2021 primary admitting dx limb lymph nodes malignant neoplasm of unspecified site of unspecified breast other seizures. Acute embolism and thrombosis of superficial veins of unspecified (vein inflammation) unspecified dementia, (cognitive decline disease) unspecified severity, without behavioral 08/11/2022 other during stay disturbance, psychotic disturbance (disorder of the mind), mood disturbance, and anxiety (feelings of tension worry). A record review of Resident #21's MDS dated annual 07/16/23 revealed a BIMS of 13 indicating mild cognitive impairment, section for respiratory treatments was blank. Extensive assistance for bed mobility, toileting, transfer, dressing and personal hygiene (resident involved in activity, staff provide weight-bearing support). Section D was left blank not addressing resident moods. Section I was left blank not addressing psychotic disorder and anxiety. Record review of resident #21's care plan dated 08/24/23 reflected o Psychosocial wellbeing Date Initiated: 08/03/2022 Resident receives Paxil r/t Depression, Poor prognosis. Date Initiated: 05/13/2021. Record review of resident #21's MD orders revealed an order dated 04/24/23 may use oxygen o2 l/m via nasal canula every shift for o2 sats below 92% verbal active 04/24/2023 04/24/2023. Depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex sodium) give 1 capsule by mouth one time a day related to major depressive disorder, single episode, unspecified (f32.9). Paxil oral tablet 40 mg (paroxetine hcl) give 40 mg for depression. behavior monitoring enter the code - 0.none 1.panic 2.agitated 3.angry 4.anxiety 5.biting 6.compulsive 7. crying 8.pacing 9.screaming/yelling 10.pull iv line/tubes 11.poor eye contact 12.depressed withdrawn 13.extreme fear 14.false beliefs 15. fighting 16.finger painting feces 17. hallucinations/paranoia/delusion 18.head banging 19. insomnia 20.jittery 21.kicking 22.noisy 23.pinching 24.restless 25.scratching 26.slapping 27. suspiciousness 28.throwing objects 29.wandering 30.other see progress notes every shift for Paxil, Depakote if any behaviors are noted, document details in a progress note. 675185 Page 4 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #21s EMAR dated 8/16/2023 13:23 revealed eMAR - Administration Text: May use oxygen @2 L/m via nasal cannula every shift for O2 sats below 92% resident )2 at 96% with no oxygen needed at this time, Record review of Resident #21's MD notes dated 09/13/23 revealed Pulmonary consult for persistent reduced lung volume on CXR (Chest Radiography). O2 saturation remains stable. 3. Chronic leukocytosis Hemodynamically stable with no signs or symptoms of infection. Continue follow-ups with hematologist. 4. Increased confusion Urinalysis (UA) Culture and Sensitivity (C&S ) x1. 5. Stage III CKD creatinine 1.08 with baseline creatinine 0.8-1. Continue to monitor with routine lab draws 6. O2 2L- 4L via nasal canula to keep sats > 92% 7. DuoNeb's TID PRN shortness of breath Pending urology consult for urinary retention with recent AKI on CKD with treatment of renal failure in the hospital. 10. Continue medications and treatments as ordered on 8/27/23 .CXR: No acute cardiopulmonary disease is seen. Reduced right lung volume is redemonstrated with resultant right-sided mediastinal shift and elevation of the right hemidiaphragm. No change since prior study. 8/20/23 CXR: No acute findings in the chest. 2. Reduced right lung volume. No change since prior study. 8/15/2023 CBC 10.4H/8.4L/26.9L/324 CXR: Hypovolemia of the right lung. Clinical correlation and follow up is recommended if symptoms persist. 8/9/23. Signed Date: 09/13/2023 3:23:08 PM. Observation of Resident #21 on 09/13/23 at 10:45 a.m. and 3:00 p.m. resident was not in her room at the time and located in the dining room with other residents. The resident was not in her room, however, the ,her oxygen tubing nasal canula were not dated. There were no concerns with concentrator. Interview with ADON-J on 09/13/23 at 1:40 PM revealed that nursing should be documenting resident behaviors and ADON review for accuracy of orders and assessment of each resident's initial assessments to provide care to according to each resident's individual needs. Then MDS coordinators then update per nursing notes and orders for each resident. In an interview on 09/14/23 at 1:50 PM with DON revealed she has been here 3 months and have not read up on all the procedures, however she expects MDS to be accurate to give medical and care guidance to meet their needs timely, and accurately. Failing to assess and document accurately could lead to resident not receiving care and a decline in health and wellbeing. Interview with administrator on 09/14/23 at 2:05 PM revealed it was his expectation for staff to assess residents timely per, as needed, quarterly, and annual with accurate information for nursing staff to perform care duties for residents to maintain and achieve their highest level of practicability. In an interview on 09/14/23 at 1:30 PM with MDS Coordinator RN-C revealed that the initial assessment are completed within 14 days. If resident care areas were not addressed residents could miss care causing declines and not provide accurate interventions and services to residents. In an interview on 09/14/23 at 1:50 PM with MDS Coordinator LVN-D revealed Nursing should chart behaviors for MDS coordinators to review during the lookback for new assessments, so that the areas of care are accurately addressed on the MDS. Failure to address behaviors, moods, treatments could lead to resident not receiving care and declining emotionally and physically. and during the lookback they would see. She was not aware that the areas were not addressed, she may have missed checking the box during the review. A request for the facility MDS policy for review was requested from MDS Coordinator RN-C, and the 675185 Page 5 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0641 policy was not provided prior to exit on 09/14/23. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675185 Page 6 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Residents #21) of 6 residents reviewed for comprehensive care plans. The facility failed to document Resident #21's oxygen use and interventions were addressed on her comprehensive care plan. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and worsening of contractures. Findings included: A record review of resident #21 face sheet dated 09/13/2023 r revealed a [AGE] year-old female admitted on [DATE] with primary Diagnosis: secondary and unspecified malignant neoplasm of axilla and upper 05/11/2021 primary admitting dx limb lymph nodes malignant neoplasm of unspecified site of unspecified breast other seizures. Acute embolism and thrombosis of superficial veins of unspecified (vein inflammation) unspecified dementia, (cognitive decline disease) unspecified severity, without behavioral 08/11/2022 other during stay disturbance, psychotic disturbance (disorder of the mind), mood disturbance, and anxiety (feelings of tension worry). A record review of Resident #21's MDS dated annual 07/16/23 revealed a BIMS of 13 indicating mild cognitive impairment, section for respiratory treatments was blank. Extensive assistance for bed mobility, toileting, transfer, dressing and personal hygiene ( resident involved in activity, staff provide weight-bearing support). Section D was left blank not addressing resident moods. Section I was left blank not addressing psychotic disorder and anxiety. Record review of resident #21's care plan dated 08/24/23 reflected Resident #21 focus of care oxygen was not addressed with interventions . Psychosocial wellbeing Date Initiated: 08/03/2022 receives Paxil r/t Depression, Poor prognosis. Date Initiated: 05/13/2021. A record review of resident # 21's MD orders revealed an order dated 04/24/23 may use oxygen o2 l/m via nasal canula every shift for o2 sats below 92% verbal active 04/24/2023 04/24/2023. Depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex sodium) give 1 capsule by mouth one time a day related to major depressive disorder, single episode, unspecified (f32.9). Paxil oral tablet 40 mg (paroxetine hcl) give 40 mg for depression. behavior monitoring enter the code - 0.none 1.panic 2.agitated 3.angry 4.anxiety 5.biting 6.compulsive 7. crying 8.pacing 9.screaming/yelling 10.pull iv line/tubes 11.poor eye contact 12.depressed withdrawn 13.extreme fear 14.false beliefs 15. fighting 16.finger painting feces 17. hallucinations/paranoia/delusion 18.head banging 19. insomnia 20.jittery 21.kicking 22.noisy 23.pinching 24.restless 25.scratching 26.slapping 27. suspiciousness 28.throwing objects 29.wandering 30.other see progress notes every shift for Paxil, Depakote if any behaviors are noted, document details in a progress note. 675185 Page 7 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record revie of Resident #21s eMAR dated 8/16/2023 13:23 revealed eMAR - Administration Text: May use oxygen @2 L/m via nasal cannula every shift for O2 sats below 92% resident )2 at 96% with no oxygen needed at this time,. Record review of MD notes dated 09/13/23 revealed Pulmonary consult for persistent reduced lung volume on CXR. O2 saturation remains stable. 3. Chronic leukocytosis Hemodynamically stable with no signs or symptoms of infection. Continue follow-ups with hematologist. 4. Increased confusion UA C&S x1. 5. Stage III CKD creatinine 1.08 with baseline creatinine 0.8-1. Continue to monitor with routine lab draws 6. O2 2L4L via nasal canula to keep sats > 92% 7. DuoNeb's tid prn shortness of breath Pending urology consult for urinary retention with recent AKI on CKD with treatment of renal failure in the hospital. 10. Continue medications and treatments as ordered on 8/27/23 .CXR: No acute cardiopulmonary disease is seen. Reduced right lung volume is redemonstrated with resultant right-sided mediastinal shift and elevation of the right hemidiaphragm. No change since prior study. 8/20/23 CXR: No acute findings in the chest. 2. Reduced right lung volume. No change since prior study. 8/15/2023 CBC 10.4H/8.4L/26.9L/324 CXR: Hypovolemia of the right lung. Clinical correlation and follow up is recommended if symptoms persist. 8/9/23. Signed Date: 09/13/2023 3:23:08 PM In an observation of Resident #21 on 09/13/23 at 10:35 AM revealed Resident was out of the room for activities, and nasal cannula was lying across snacks and personal room decoration on the nightstand, the tubing was not bagged or dated. Interview with ADON-J on 09/13/23 at 1:40 PM revealed that nursing should be documenting resident behaviors and the ADON reviews for accuracy. Nursing also consults with MD and IDT team regarding changes to update the care plan. In an interview on 09/14/23 at 1:50 PM with the DON revealed it was her expectation for resident care plans to be developed accurately with interventions to assure timeliness of care and needs to prevent a decline in care. The IDT team and MD often address the resident needs and focus of care that should be reflected in the care plan. In an interview on 09/14/23 at 1:55 PM with DON and MD revealed Resident #21 was ordered oxygen after testing positive for COVID--19 coronavirus (COVID is short for Corona Virus Disease- would we not need to explain to the reader that it is, a sever acute respiratory syndrome aka SARS-COV-2.) the risk of re-infections caused a decline in her oxygen levels, so it was ordered for PRN use. Interview with the administrator on 09/14/23 at 2:05 PM revealed it was his expectation for staff to update resident care plans when changes occurred, admissions, quarterly and annually to and ADON and DON monitor for accuracy for residents to maintain and achieve their highest level of practicability. In an interview on 09/14/23 at 1:30 PM with MDS Coordinator RN-C revealed that the initial care plans are updated as needed, admissions, quarterly and annually to provide updates in care and interventions. He said an inaccurate comprehensive care plan can lead to resident's not receiving care and declining health and wellbeing. As well as not communicate to staff the care needs. A request for MDS policy was requested from MDS Coordinator RN-C , and the policy was not provided prior to exit on 09/14/23. 675185 Page 8 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

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 residents who needed respiratory care were provided such care, consistent with professional standards of practice for 2 of 9 residents (Resident #17 and Resident #21) reviewed for respiratory care in that: Residents Affected - Few The facility failed to ensure Resident #17, and 21's oxygen tubing was labeled and dated. These deficient practices could affect residents who received oxygen therapy and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Resident #17 A record Review of Resident #17 face sheet dated 09/13/2023 revealed a [AGE] year-old male that was admitted initially on 06/03/21 and again on and 09/07/23: His primary diagnosis included: Acute Chronic Diastolic (Congestive) Heart Failure (Heart failure), Acute Respiratory Failure with Hypercapnia (a condition of abnormally elevation of carbon dioxide levels in blood), Chronic Pain, and symbolic dysfunction (problems in communication related to oral motor), Bipolar Disorder (mental disorder related to depression). A record review of Resident #17's MDS dated [DATE] revealed a BIMS of 13 indicating mild cognitive impairment, Section D for mood stated none of the above. Section E for Behaviors listed non- of the above. Section O for special treatment oxygen therapy was left blank. Resident requires extensive assistance for bed mobility, toileting, and personal hygiene (resident involved in activity, staff provide weight-bearing support). 4. Total dependence for transfer, (full staff performance every time during entire 7-day period). Section E listed no behaviors. Record review of Resident #17's care plan dated 08/17/23 revealed resident receives Oxygen Therapy O will have no s/sx of poor oxygen absorption through the review date. Oxygen at __2Lpm per nasal cannula resident requires the use of CPAP/BIPAP r/t sleep apnea. A record review of resident #17's ETAR reflected an order to Check and clean concentrator filter every month and PRN at bedtime starting on the 15th and ending on the 16th every month for clean filter Resident may have oxygen at 2L via NC as needed for O2 sats <92% as needed for O2 sats <92%. Record Review of Resident #17's MD orders dated 11/16/22 revealed resident will maintain oxygen saturations 90% or greater over the next 90 days date initiated: 11/16/2022 target date: 08/17/2023 resident will use device as ordered staff to monitor saturation as ordered. In an observation of resident #17 observation of Resident #17 on 09/13/23 at 10:38 AM revealed him asleep in bed with oxygen tubing attached to concentrator undated. Unable to interview as he was sleeping. In another attempt to interview Resident #17 on 09/14/23 at 1:50 PM revealed resident was in bed on oxygen . In an attempt to interview Resident #17 resulted in him not responding to surveyors attempts and greeting. The tubing was undated. Resident #21 675185 Page 9 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of Resident #21 face sheet dated 09/13/2023 revealed a [AGE] year-old female admitted on [DATE] with primary Diagnosis: secondary and unspecified malignant neoplasm of axilla and upper 05/11/2021 primary admitting dx limb lymph nodes malignant neoplasm of unspecified site of unspecified breast other seizures. Acute embolism and thrombosis of superficial veins of unspecified (vein inflammation) unspecified dementia, (cognitive decline disease) unspecified severity, without behavioral 08/11/2022 other during stay disturbance, psychotic disturbance (disorder of the mind), mood disturbance, and anxiety (feelings of tension worry). A record review of Resident #21's MDS dated annual 07/16/23 revealed a BIMS of 13 indicating mild cognitive impairment, section for respiratory treatments was blank. Extensive assistance for bed mobility, toileting, transfer, dressing and personal hygiene (resident involved in activity, staff provide weight-bearing support). MDS did not address resident oxygen and anxiety. Record review of resident #21's MD orders revealed an order dated 04/24/23 may use oxygen O2 l/m via nasal cannula every shift for O2 sats below 92% verbal active 04/24/2023 04/24/2023. Record review of Resident #21's EMAR dated 8/16/2023 13:23 revealed EMAR - Administration Text: May use oxygen @2 L/m via nasal cannula every shift for O2 sats below 92% resident )2 at 96% with no oxygen needed at this time., Record review of Resident #21's MD notes dated 09/13/23 revealed Pulmonary, Consult for persistent reduced lung volume on CXR. O2 saturation remains stable. Chronic leukocytosis Hemodynamically stable with no signs or symptoms of infection. Continue medications and treatments as ordered on 8/27/23 .CXR: No acute cardiopulmonary disease is seen. Reduced right lung volume is redemonstrated with resultant right-sided mediastinal shift and elevation of the right hemidiaphragm. No change since prior study. 8/20/23 CXR: No acute findings in the chest. 2. Reduced right lung volume. No change since prior study. 8/15/2023 CBC 10.4H/8.4L/26.9L/324 CXR: Hypovolemia of the right lung. Clinical correlation and follow up is recommended if symptoms persist. 8/9/23. Signed Date: 09/13/2023 3:23:08 PM Observation of Resident #21 on 09/13/23 at 10:45 a.m. and 3:00 p.m. resident was not in her room at the time. Her oxygen tubing and nasal cannula was observed unbagged and updated. Resident was later observed in the dining room with other residents. Interview with LVN-J on 09/13/23 at 10:49 AM revealed that she was in the process of training a new staff and did not observe the tubing being cloudy, discolored, and undated. She said it was all facility staff's responsibility when entering the room to assess and the condition of equipment and report to nursin g. She said she would change the oxygen tubing for Resident's #17 and #21. Interview with ADON-J on 09/13/23 at 1:40 PM revealed that nursing staff are expected to change tubing and date weekly during the overnight shift, however she did not know the date. She stated all nurses should be conducting checks in the ETAR, and during rounds and if tubing was not dated, change the tubing, date and label, and document in resident records. She said failing to change tubing could lead to infections and affect resident oxygen administration. In an interview on 09/14/23 at 1:50 pm with DON she expected nursing to assess tubing for proper administrator of oxygen during rounds and if undated change and date to prevent infections. Interview with the administrator on 09/14/23 at 2:05 PM revealed it was his expectation for staff to follow oxygen procedures for care of resident treatment devices. 675185 Page 10 of 11 675185 09/14/2023 Longmeadow Healthcare Center 120 Meadowview Dr Justin, TX 76247

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of facility policy for Oxygen therapy dated February 2007 reflected oxygen includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident?s bed or concentrator. All sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely. Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. February 2007. 675185 Page 11 of 11