Health inspection·November 18, 2025

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 review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 6 (Residents #6, #7, #8, #9, #10, and #11) of 6 residents observed for oxygen management. The facility failed to ensure that Residents on oxygen (#6, #7, #8, #9, #10, and #11) had oxygen signs posted outside their bedrooms (Rooms 4, 14, 15, 20, 26, and 33). This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident #6Record review of Resident #6's admission record dated 10/10/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old male diagnosed with heart failure and respiratory failure. Record review of Resident #6's MDS dated [DATE], revealed a BIMS score of 3, indicating the resident had severely impaired cognition. The MDS was marked for oxygen therapy. Record review of Resident #6's order summary dated 10/10/25, revealed oxygen via nasal cannula at 2 liters per minute to maintain SpO2 (blood oxygen level) greater than 90% as needed for shortness of breath. Record review of Resident #6's care plan dated 08/08/25, revealed oxygen therapy via nasal cannula at 2 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:20 PM, revealed Resident #6 was asleep in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #6's room. Resident #7Record review of Resident #7's admission record dated 10/10/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old male diagnosed with heart failure, paraplegia (type of paralysis that affects the lower body) and COPD (chronic obstructive pulmonary disease-a lung condition caused by damage to parts of the lungs).Record review of Resident #7's MDS dated [DATE], revealed a BIMS score of 14, indicating the resident had relatively good cognitive function. The MDS was marked for oxygen therapy. Record review of Resident #7's order summary dated 10/10/25, revealed, may have O2 to keep SpO2 above 92. Record review of Resident #7's care plan dated 07/30/25, revealed O2 at 2 liters per minute per nasal cannula to maintain SpO2 at 93-100%. Observation on 10/07/25 at 1:24 PM, revealed Resident #7 was not in the room, nasal cannula connected to the oxygen port and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #7's room. Resident #8Record review of Resident #8's admission record dated 10/09/25, revealed an admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old male diagnosed with heart failure, COPD and nicotine dependence. Record review of Resident #8's MDS dated [DATE], revealed a BIMS score of 11, indicating the resident had moderate impaired cognition. The MDS was marked for oxygen therapy. Record review of Resident #8's order summary dated 10/09/25, revealed oxygen via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90% every shift for COPD. Record review of Resident #8's care plan dated 09/12/25, revealed oxygen therapy via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:26 PM, revealed Residents Affected - Some Page 1 of 2 675751 675751 11/18/2025 Focused Care at Odessa 2443 W 16th St Odessa, TX 79763

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #8 was in bed watching television, with nasal cannula on, and oxygen set at 3.5 liters per minute. No Oxygen Sign was placed outside of Resident #8's room. Resident #9Record review of Resident #9's admission record dated 10/10/25, revealed an admission on [DATE] to the facility. The admission record revealed, an [AGE] year-old female diagnosed with heart failure, pulmonary fibrosis (a lung disease that causes scarring and thickening of lung tissue) and respiratory failure. Record review of Resident #9's MDS dated [DATE], revealed a BIMS score of 13, indicating the resident had relatively good cognitive function. The MDS was marked for oxygen therapy. Record review of Resident #9's order summary dated 10/10/25, revealed oxygen via nasal cannula at 2 liters per minute to maintain SpO2 greater than 90% as needed for shortness of breath. Record review of Resident #9's care plan dated 10/08/25, revealed oxygen therapy via nasal cannula at 2 liters per minute to maintain SpO2 greater than 90%, due to poor oxygen absorption. Observation on 10/07/25 at 1:40 PM, Resident #9 was in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #9's room. Resident #10Record review of Resident #10's admission record dated 10/09/25, revealed an admission on [DATE] to the facility. The admission record revealed, an [AGE] year-old male diagnosed with COPD, pulmonary fibrosis and respiratory failure. Record review of Resident #10's MDS dated [DATE], revealed a BIMS score of 7, indicating the resident had severely impaired cognition. The MDS was marked for oxygen therapy. Record review of Resident #10's order summary dated 10/09/25, revealed oxygen via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90% as needed for pulmonary fibrosis. Record review of Resident #10's care plan dated 10/08/25, revealed oxygen therapy via nasal cannula at 2-6 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:44 PM, revealed Resident #10 was asleep in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #10's room. Resident #11Record review of Resident #11's admission record dated 10/09/25, revealed an admission on [DATE] and re-admission on [DATE] to the facility. The admission record revealed, a [AGE] year-old female diagnosed with heart disease and COPD.Record review of Resident #11's MDS dated [DATE], revealed a BIMS score of 14, indicating the resident had relatively good cognitive function. The MDS was marked for oxygen therapy. Record review of Resident #11's order summary dated 10/09/25, revealed oxygen via nasal cannula at 2-4 liters per minute to maintain SpO2 greater than 90% as needed for COPD. Record review of Resident #11's care plan dated 08/06/25, revealed oxygen therapy via nasal cannula at 2-4 liters per minute to maintain SpO2 greater than 90%. Observation on 10/07/25 at 1:47 PM, revealed Resident #11 was in bed, with nasal cannula on, and oxygen set at 2 liters per minute. No Oxygen Sign was placed outside of Resident #11's room. During an interview on 10/10/25 at 12:45 PM with the DON, she said there was not a designated staff member responsible for placing the oxygen signs on the doors when a resident was on oxygen. The DON said that the lack of oxygen signs on the appropriate doors could cause injury to the residents and the staff. During an interview on 10/10/25 at 1:10 PM with the administrator, she said she was under the impression that signs on individual resident doors was not required because the facility has a sign at the front entrance. Regarding the facility oxygen policy, the administrator said she was not aware that the policy said a sign needs to be placed outside the rooms of residents using oxygen. Record review of the facility Oxygen Therapy policy dated 04/2021, revealed, Post NO SMOKING sign on the outside of door to resident's room. 675751 Page 2 of 2