Health inspection·May 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 observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart and ensure infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and including infection control practices for mechanical ventilation/tracheostomy care including the use of humidifiers were followed by staff for 2 (Residents #1 and #2) of 5 residents reviewed for respiratory care, in that: Residents Affected - Few 1. The facility failed to ensure Resident #1's nasal cannulas and tubing and Resident #1's and 2's CPAP masks and tubing were properly stored when not in use. These failures could place residents at risk of cross-contamination and illness. Findings included: Record review of Resident #1's admission record, dated 04/30/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including other specified sepsis (a life-threatening complication of an infection), unspecified dementia, systolic congestive heart failure (a specific type of heart failure that occurs in the heart's left ventricle) and cognitive communication deficit. Record review of Resident #1's comprehensive MDS assessment, dated 04/19/24, revealed a BIMS score of 3, which indicated she had severe cognitive impairment. Resident #1 also required oxygen therapy. Record review of Resident #1's baseline care plan, dated 04/12/24, revealed she required a C-pap machine (a machine that uses mild air pressure to keep breathing airways open while a person sleeps) and oxygen therapy of two liters per minute continuously delivered by a nasal cannula. Record review of Resident #1's order summary report, dated 04/30/24, revealed Resident #1 was ordered, and started on 04/12/24, the following: -Check oxygen saturation levels q shift every shift -Oxygen: Obtain SPO2 >90% at 2-3lpm via nasal cannula every shift Page 1 of 4 675748 675748 05/01/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0695 -Change CPAP/BIPAP distilled water every night before bed at bedtime Level of Harm - Minimal harm or potential for actual harm -CPAP-Use CPAP QHS at bedtime -CPAP/BIPAP setting 5 at 30% at bedtime Residents Affected - Few Resident #1 was also ordered on 04/12/24 and started on 04/15/24 the following: -Change nebulizer mask and tubing q week every day shift every Monday Record review of Resident #2's admission record, dated 05/01/24, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including left side orbital floor fracture (when the bones of the rim of your eye socket push back), multiple left rib fractures, unspecified dysphagia (difficulty swallowing), presence of cardiac pacemaker, generalized muscle weakness, other lack of coordination, and cognitive communication deficit. Record review of Resident #2's comprehensive MDS assessment, dated 04/21/24, revealed a BIMS score of 14, which indicated he was cognitively intact . Resident #2 did not require any respiratory treatments. Record review of Resident #2's baseline care plan, dated 04/14/24, revealed he did not require respiratory treatments, had no altered respiratory status, and did not use supplemental oxygen. Record review of Resident #2's order summary report, dated 05/01/24, revealed he was ordered, and started on 04/24/24, the following: -O2 at 2-4 LPM VIA NC TO MAINTAIN SATS >95% PRN every 24 hours as needed for ABN CXR Resident #2 was also ordered on 04/14/24 and started on 04/15/24 the following: -Monitor and record Temperature and O2 sats once daily, Monitor for the following: Fever >99.0, Cough, Chest pain, Runny nose, SOB, Chills, Muscle pain, Headache, Loss of smell or taste, N/V or diarrhea and loss of appetite, or sore throat. If source of symptoms has not yet been determined or treatment implemented, follow up with MD for any positive findings. one time a day An observation on 04/30/24 at 1:05 p.m. in Resident #1's room revealed Resident #1 was sitting in her wheelchair. Resident #1's tubing and nasal cannula for her oxygen tank were hanging over her wheelchair back support. There was no plastic bag attached to the wheelchair to store the tubing and nasal cannula. Resident #1 was not using the oxygen tank at the time of the observation. A C-PAP mask was also sitting on top of a mini refrigerator that was sitting directly on top of Resident #1's night stand next to Resident #1's bed. There was no plastic bag to store the C-PAP mask. Resident #1 was not using the C-PAP machine at the time of the observation. An attempt to interview Resident #1 was made, but Resident #1 was unable to answer the surveyor's questions. During an interview on 04/30/24 at 2:08 p.m., LVN A revealed nurses were responsible for wrapping the oxygen tubing and nasal cannula in a plastic bag and hanging the plastic bag over the oxygen concentrator if a resident was not using it. LVN A did not know why Resident #1's oxygen tubing and nasal cannula were not stored away in a bag when not in use. LVN A also did not know why Resident #1's C-PAP mask was not bagged when not in use. LVN A did not know when she was last trained on oxygen 675748 Page 2 of 4 675748 05/01/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few storage. LVN A stated residents' health, safety, and wellbeing could be affected if oxygen tubing, nasal cannula, and C-PAP mask were not properly stored when not in use. During an interview on 04/30/24 at 2:48 p.m., LVN B revealed oxygen tubing and nasal cannula should be bagged, hung on a resident's concentrator, and with the resident's name and date of last tubing and nasal cannula change out, on it, when not in use. LVN B stated a resident's C-PAP mask should also be bagged when not in use. LVN B did not know why Resident #1's oxygen tubing and nasal cannula were not stored away in a bag when not in use. LVN B also did not know why Resident #1's C-PAP mask was not bagged when not in use. LVN B did not indicate when she was last trained on oxygen storage. LVN B stated residents' health, safety, and wellbeing could be affected because residents could pick up germs if staff were not properly storing oxygen supplies away when not in use. During an interview on 04/30/24 at 3:22 p.m., CNA C revealed nurses were responsible for storing oxygen tubing, nasal cannula, and C-PAP masks when not in use. CNA C stated residents' health, safety, and wellbeing could be affected if tubing, nasal cannula, and C-PAP masks were not properly stored when not in use. During an interview on 04/30/24 at 4:03 p.m., LVN D revealed if a resident's oxygen tank or machine was not in use, the oxygen tubing and nasal cannula were stored by rolling it up and placing it on the resident's bedside table or on the oxygen tank or machine. LVN D did not observe residents' oxygen tubing and nasal cannula being bagged when not in use. LVN D also stated resident's C-PAP mask was bagged when not in use. LVN D stated he did not observe Resident #1's oxygen tank and machine and C-PAP machine tubing, nasal cannula, and C-PAP mask storage. LVN D did not indicate if residents' health, safety, and wellbeing could be affected by staff not bagging and storing oxygen tubing, nasal cannula, and C-PAP mask when not in use and when he was last trained on oxygen storage. An observation on 04/30/24 at 4:55 p.m. in Resident #2's room revealed Resident #2's C-PAP mask was sitting on his bedside table. There was no bag. Resident #2 was not using his C-PAP machine at the time of the observation. During an interview on 04/30/24 at 4:55 p.m., Resident #2 revealed he last used his C-PAP machine on 04/29/24. Resident #2 stated he had no concerns or issues with his care. During an interview on 04/30/24 at 4:57 p.m., the DON revealed nurses were responsible for storing resident's oxygen tubing and nasal cannula in drawers and a bag if not in use. The DON also stated resident's C-PAP masks were to be bagged when not in use. The DON stated she last checked on residents' oxygen storage last week. The DON stated she did not document checking residents' oxygen tubing, nasal cannula, and C-PAP masks. The DON also stated residents' health, safety, and wellbeing could not be affected if oxygen tubing, nasal cannula, and C-PAP masks were not properly stored when not in use. Record review of the facility's in-services, from 02/01/24 through 04/30/24, revealed staff were in-serviced on oxygen tank storage and changing out oxygen supplies on 03/12/24 and 04/10/24. Record review of the facility's Departmental (Respiratory Therapy) Prevention of Infection policy and procedure, revised November 2011, revealed staff were required to do the following, 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use. 675748 Page 3 of 4 675748 05/01/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0695 Record review of an email sent by the DON, dated 05/01/24 at 12:57 p.m., revealed she would apply the same oxygen tubing storage policy for C-PAP storage. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675748 Page 4 of 4