Health inspection·January 6, 2026

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 residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #1) reviewed for respiratory care.The facility failed to ensure Resident #1's breathing mask (used to receive medication by breathing in mist through the nose and mouth) was not on the nightstand unbagged on 01/06/2026.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 01/06/2026, reflected a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure) and COPD (lung condition that makes it difficult to breathe).Record review of Resident #1's Quarterly MDS (tool used to measure health status) Assessment, dated 12/24/2025, reflected moderately impaired cognition with a BIMS (tool used to measure cognitive status) score of 10. Section I (Active Diagnoses) reflected the resident was treated for COPD. Record review of Resident #1's Baseline Care Plan, dated 12/18/2025, reflected the resident was treated for COPD. Interventions included Monitor and report signs of respiratory distress.monitor oxygen saturation as ordered.administer medications per order. Record review of Resident #1's Physician's Orders reflected Ipratropium-Albuterol 0.5 mg - 2.5 mg/ml. 1 vial every 8 hours for wheezing x 2 days. Start date 01/01/2026. End date 01/02/2026. Record review of Resident #1's Medical Administration Record revealed the last breathing treatment was administered on 01/02/2026. During an observation and interview on 01/06/2026 at 10:18 AM, Resident #1 was lying in bed awake. The bed was placed against the wall, and the foot of the bed was near the door. The nightstand was placed parallel to the bed, approximately three feet from the head of the bed. The side of the nightstand was visible upon entering the room. The nebulizer machine was on top of the nightstand. The mask and tubing were connected to the nebulizer and hung from the side of the nightstand. It was not in a bag. Resident #1 stated she did not remember when she had the last breathing treatment. During an observation and interview on 01/06/2026 at 10:23 AM, LVN B went to Resident #1's room. He stated it looked like someone had given a breathing treatment and did not put the nebulizer mask in a bag. He stated he had not provided a breathing treatment to Resident #1 and had not noticed it on her nightstand. LVN B stated it should be bagged up when not in use to prevention respiratory infection. LVN B stated he would remove the nebulizer mask and tubing and discard it. During an interview on 01/06/2026 at 12:13 PM, the Administrator stated all respiratory items should be bagged when not in use. She stated it was for infection control. During an interview on 01/06/2026 at 1:08 PM, the DON stated a nebulizer mask should be stored in a bag and dated when not in use. The DON opened her tablet and stated the resident had an order to receive a breathing treatment every eight hours for two days. She stated the order ended 01/02/2026. She stated the nurse who gave the breathing treatment was primarily responsible for ensuring the mask was Residents Affected - Few Page 1 of 2 675902 675902 01/06/2026 Avir at Pilot Point 208 N Prairie St Pilot Point, TX 76258

F 0695 Level of Harm - Minimal harm or potential for actual harm placed in a bag after the treatment was completed. The DON stated the nebulizer mask should not have been left on Resident #1's nightstand unbagged. She stated it was important for staff to monitor those items to ensure they were stored properly. She stated it was important to prevent respiratory infection.The facility did not have a policy specifically related to storing breathing masks and tubing. Residents Affected - Few 675902 Page 2 of 2