Health inspection·February 1, 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 was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 of 5 residents (Resident #1, #3, #5, #7, #9) reviewed for respiratory care. Residents Affected - Some The facility failed to ensure Resident #1, #3, #5, #7, and #9's oxygen tubing was labeled and dated. The facility failed to ensure Resident #1, #3, and #9's CPAP tubing were dated and properly stored when they weren't in use. These failures 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, dated 01/31/24, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Bilateral primary osteoarthritis primary most common form of arthritis affecting both knees), Chronic obstructive pulmonary disease (progressive lung disease), Chronic respiratory failure (respiratory failure inadequate gas exchange), and morbid obesity (severe weight gain). Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS of 15 indicating memory intact, functions Partial/moderate assistance: helper provided less than half the effort. Assist with mobility and ADLs as needed. oxygen use under treatment Section O. Record review of Resident #1's physician orders revealed the following: Change oxygen tubing and nebulizer circuit every night shift every Sunday dated 2/4/24 .Oxygen sat rates every shift .Oxygen at 2-5 liters/minute per nasal cannula as needed .Oxygen at 2-5_ liters/minute continuously per nasal cannula. Document every shift .dated 01/30/24. Resident #1 An observation on 01/30/24 at 11:25 AM, revealed Resident #1 was lying in bed with oxygen tubing nasal cannula in his nose, oxygen concentrator operating. The oxygen tubing and bottle were not dated. Resident #1 stated that he was fine and the air from the oxygen was fine. He stated it was changed Page 1 of 6 675650 675650 02/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on yesterday, but they no longer date. Resident said no discomfort with oxygen. An interview with Resident #1 on 01/30/24 at 11:25 AM revealed the tubing was changed regularly and he could not recall the date. He said nursing changes normally on Mondays. He said that dates were used in the past when changed, however, he has not observed this practice lately. A second observation on 02/01/24 at 12:10 PM, reflected a date of 01/29/24 on Resident #1's nasal cannula tubing. Resident #3 Review of Resident #3's Face Sheet, dated 01/30/24, revealed face sheet reflected an [AGE] year-old male admitted on [DATE] with diagnoses personal history of transient ischemic attack (TIA) (mini stroke), and Cerebral infarction (stroke). Review of Resident #3's Quarterly MDS, dated [DATE] reflected BIMS of 13 indicating his memory was intact, required extensive assistance and used oxygen. Record review of Resident #3's comprehensive care plan dated 1/30/24 reflected The resident has oxygen therapy r/t Ineffective gas exchange .Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Record review of Resident #3's physician orders revealed the following: Change oxygen tubing and nebulizer circuit every night shifts every Sunday .Oxygen at 2-5liters/minute per nasal cannula as needed Oxygen at 2-5 liters/minute continuously per nasal cannula. Document every shift. An observation and interview with Resident #3 on 01/31/24 at 11:35 AM, revealed resident lying in bed with his nasal cannula in his nose, oxygen concentrator operating, and tubing undated. CPAP tubing lying on night stand undated and unbagged, while not in use. Resident #3 was interviewed, and he did not know when the tubing was changed and if staff dated the tubing. Resident #5 Review of Resident #5's Face Sheet dated 01/30/24 revealed a [AGE] year-old female admitted on [DATE] with diagnoses description: Pneumonia (inflammation of the lungs), Heart and Chronic Kidney Disease with Heart Failure Stage 1 through Stage 4 chronic kidney disease (kidney disease that caused decrease in heart function). Record review of quarterly MDS dated [DATE], indicated Resident #5 had a BIMS of 11 which indicated moderate cognitive impairment .Resident requires a 2-person transfer Staff assist with transfers and ambulation as needed, supportive care assistance and oxygen use. Record review of Resident #5's comprehensive care plan dated 12/11/23 reflected oxygen therapy resident has Congestive Heart Failure. Check breath sounds and observe for labored breathing. Observe for use of accessory muscles while breathing .Give cardiac medications as ordered . Observe and report PRN any s/sx of Congestive Heart Failure: SOB upon exertion, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation (listening to lungs) of the lungs, weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation. Resident #5 has oxygen therapy r/t dx of Chronic Respiratory Failure with Hypoxia .will have no s/sx of poor oxygen absorption 675650 Page 2 of 6 675650 02/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0695 Level of Harm - Minimal harm or potential for actual harm through the review date .Administer O2 as ordered .Give medications as ordered by physician .Observe for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color .Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, head of bed elevated. Residents Affected - Some Record review of Resident #5's active MD orders dated 10/10/23 reflected clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit every night shifts every Sun. Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at2 -5 liters/minute per nasal cannula as needed Oxygen at 2-5liters/minute continuously per nasal cannula. Document every shift. An observation on 01/31/24 at 11:50 AM, revealed Resident #5 lying in bed with nasal cannula in 1 nostril and other pointed outward and unlabeled and dated. An interview with Resident #5 revealed she did not know if the tubing was dated when changed. She does not know when the tubing was last changed. Resident #7 Record review of Resident #7's face sheet dated 01/30/245 reflected an [AGE] year-old male admitted on [DATE] with diagnoses Chronic Respiratory Failure with Hypoxia (respiratory failure affecting oxygen) Chronic Combined Systolic (caused by another cardiovascular condition that weakens the hear), Heart Failure obstructive Sleep Apnea (condition affecting cardiovascular disease in adults). Record review of Resident #7's quarterly MDS dated [DATE], BIMS score of 11 indicating Moderate cognitive impairment. Resident #7 requires Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs. Oxygen treatment and use in section O. Record review of Resident #7's Comprehensive care plan dated 01/31/24 reflected Resident #7 Resident #7is at risk for altered respiratory status/difficulty breathing r/t dx of OSA and uses CPAP at HS .Resident #7 will have no complications related to SOB though the review date .Administer medication/puffers as ordered .Administer O2 as ordered .Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to yawn .Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions .Observe for changes in orientation, increased restlessness, anxiety, and air hunger .Observe for s/sx of respiratory distress and report to MD PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Headaches; Confusion; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey .Observe/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring .Obtain BIPAP/CPAP as ordered. Record review of Resident #7's active MD orders dated 10/10/23 reflected clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit every night shifts every Sun. 675650 Page 3 of 6 675650 02/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0695 Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at2 -5 liters/minute per nasal cannula Level of Harm - Minimal harm or potential for actual harm as needed Oxygen at 2-5liters/minute continuously per nasal cannula. Document Residents Affected - Some every shift. Record review of Resident #7's electronic TAR from January 2024 reflected Clean oxygen concentrator filter with soap and water weekly every Sunday. The TAR dates reflected cleanings for the following dates: 01/07/24, 01/14/24, 01/21/24, and 01/28/24. This contradicts the date on the tubing of 1/16/24. An observation Resident #7 on 02/01/24 at 10:00 AM revealed resident lying in bed on his back with his nasal cannula in his nose properly positioned and CPAP tubing unbagged, undated, and labeled. Nasal Cannula tubing was dated 01/16/24.An interview with Resident #7 revealed he did not know when his tubing was last changed. the tubing was changed however he thought it was dated. He said staff are changing tubing regularly. Resident #9 Record review of Resident #9's face sheet dated 01/30/24 reflected an [AGE] year-old male with diagnoses of Acute Chronic Diastolic (Congestive) Heart Failure Coronary Atherosclerosis (hardening of the arteries) Due to Calcified (plaque) Coronary Lesion pneumonia (inflamed lungs affecting small air sacs). Record review of Resident #9's Quarterly MDS dated [DATE] with a BIMS score of 15, indicating he was cognitively intact. Resident #9 requires Partial/moderate assistance for ADL care .oxygen use documented on section O. Record review of Resident #9's Comprehensive care plan dated 01/24/24 reflected Resident was at risk for shortness of breath (SOB) r/t dx of COPD .will have no complications related to SOB though the review date .Administer Oxygen as ordered .Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions. Observe for breathing patterns. Report abnormalities to MD: Nasal flaring, Respiratory depth changes, altered chest excursion, Use of accessory muscles, Pursed lip breathing or prolonged expiratory phase, Increased anteroposterior chest diameter. Observe for changes in orientation, increased restlessness, anxiety, and air hunger .Observe/Report breathing abnormalities to MD . Resident with proper body alignment for optimal breathing pattern .clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit. every night shifts every Sundays .Oxygen sat rates every shift .Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at 2-5 liters/minute per nasal cannula as needed .Oxygen at 2-5 liters/minute continuously per nasal cannula. Document every shift. Record review of Resident #9's MD orders dated 10/15/23 reflected clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit every night shifts every Sundays. Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at 675650 Page 4 of 6 675650 02/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0695 2 -5 liters/minute per nasal cannula Level of Harm - Minimal harm or potential for actual harm as needed Oxygen at 2-5liters/minute continuously per nasal cannula. Document every shift. Residents Affected - Some Review record of Resident #9's treatment records for January 2024 reflected changing oxygen tubing and nebulizer circuit every night shifts every Sunday Clean oxygen concentrator filter with soap and water weekly every Sunday. The TAR dates reflected tubing change and filter cleaning on 1/7/24, 1/14/24, 1/21/24, and 1/28/24, water same dates the date on Resident #9's concentrator was 1/29/24 on 02/01/24. In an interview with Resident #9 on 01/30/24 at 11:40 AM , he stated that he uses his oxygen continuously and could not remember when his tubing was changed, however staff are changing regularly. An observation of Resident #9's oxygen concentrator on 01/30/24 reflected nasal cannula tubing undated and unlabeled while in resident nose. In an interview with RN K on 01/30/24 at 1:52 PM, revealed that night shift was responsible for changing resident respiratory tubing every Sunday. RN K said she checked resident tubing, oxygen levels, every 2 hours, and she was pretty sure she observed dates on Resident's #1, #3, #5, #7, and #9's tubing. She stated that she changed Resident #1's water bottle today. RN K said it was important to change and date resident tubing to prevent overuse that can lead to infections. RN K said all nurses are responsible for checking dates on tubing, oxygen flow, and respiratory percentage during each shift. In an interview with the DON on 02/01/24 at 11:50 AM, revealed that all nursing staff were in-serviced on 1/30/24 and 1/31/24 on changing, auditing, and monitoring resident tubing and storage while not in use. The DON said all equipment supplies should be dated to prevent overuse and communicate with the tubing was last changing. She expects nursing to change overnight weekly on Sundays, nursing assesses during rounds and check for dates, as well as change and date if undated. The DON was responsible for rounding to audit and monitor tubing change and dates daily. She said failing to change tubing or dating could lead to infections. In an interview with the ADM on 02/01/24 at 2:30 PM, revealed she expects nursing staff to monitor care and equipment according to the policy. Record review of Facility Inservice completed by the DON dated 1/30/24 at 3:30 PM addressing CPAP, oxygen support, Administration Safety, Storage, and Maintenance of Resident on oxygen. All tubing should be dated at the time of change. Nursing staff should be checking tubing during rounds. Record review of facility policy dated 9/26/23 and titled Oxygen administration/safety/storage/maintenance reflected oxygen will be administered in accordance with physician orders and current standard practice. Procedure .This facility will utilize the following [NAME], while incorporating the other elements outlined below.1. Change oxygen supplies weekly and when visibly soiled. Equipment should be dated when setup or changed out .2. Humidifier/ Aerosol bottles should be dated and replaced every 7 days regardless of H20 level .a. Prefilled humidifiers are recommended. If re-usable humidifier is used, refill, using sterile water only. Water is to be emptied and replaced daily. Re-usable humidifiers should also be replaced every 7 days. 3. Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. 4. Clean exterior of concentrators weekly with an EPA 675650 Page 5 of 6 675650 02/01/2024 Garden Terrace Healthcare Center of Fort Worth 7500 Oakmont Blvd Fort Worth, TX 76132

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some registered hospital disinfectant. a. The concentrator must be stationed where there is free air movement. B. External filter should be checked daily, and all dust should be removed. Filters should be washed with soap and water once each week and PRN. Dry with a towel and reinsert. Discard and replace when damaged. 5. If oxygen is discontinued, discard all disposable pieces including filters (replace with new). 6. If oxygen is continued post discharge of isolation precautions, dispose of all disposable a. equipment, clean all non-disposable equipment with an EPA registered hospital. 675650 Page 6 of 6