Inspection·January 11, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #34's physician orders dated January 2023 indicated O2 at 3-5 LPM per nasal cannula every shift related to high blood pressure and chronic obstructive lung disease with a start date of 01/09/2023. A record review of Resident #34's MDS dated [DATE] indicated she waswas cognitively moderately impaired cognitive [NAME] impaired with BIMS score of 7 and received oxygen therapy during the last 14 days while she was at the facility. A record review of Resident #34's care plan dated 10/25/22 indicated altered respiratory status/difficulty, chronic obstructive lung disease with interventions included continuous oxygen therapy per orders and provide oxygen as ordered. During an observation on 01/09/2023 at 9:38 a.m., Resident #34 was in her bed and was receiving oxygen at 3 lpm via nasal cannula per 02 concentrator, the humidifier bottle was dated 1/9/2023 and the filter was covered with a thick layer of dust. During an interview on 01/09/2023 at 10:00 a.m., LVN A said the filters on Resident #11 and Resident #34 concentrators were covered with dust and should have been cleaned. She said the night nurse changes out the humidifier bottle and tubing every Sunday night and said she was unsure if the filters were to be cleaned at that time. She said all nurses are responsible. She said the concentrators might not work right if filters are not kept clean . During an interview on 01/09/23 at 10:45 a.m., the Administrator said the maintenance department services the concentrators. During an interview on 1/9/23 at 11:00 a.m., the Maintenance supervisor and Maintenance assistant said they only clean the filters when the concentrators are not in use. During an interview on 1/9/23 at 11:05 a.m., Housekeeper B said she works on Hall 300 and said she had never been told to clean the filters on the concentrators. During an interview on 1/9/23 at 11:45 a.m., the administrator said the cleaning of oxygen filters was not assigned to a certain department, he said now it was being assigned and the staff will be retrained. 3. Record review of physician orders dated January 2023 indicated Resident #53, admitted [DATE], was [AGE] years old with diagnosis of chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort breathing) and chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Orders indicated may use oxygen at 2-4 liters per minute. Record review of the most recent significant change MDS dated [DATE] indicated Resident #53 was cognitively moderately impaired, had diagnosis of chronic obstructive pulmonary disease and respiratory failure, and was receiving oxygen therapy. Record review of a care plan updated 01/06/23 indicated Resident #53 was receiving oxygen therapy related to chronic obstructive pulmonary disease. During an observation and interview on 01/09/23 at 9:49 a.m. Resident #53 was lying in bed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Ridge Health Care LLP 1620 US 59 N Livingston, TX 77351 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some oxygen being administered via a nasal cannula. The oxygen concentrator flow rate was set at 4.5 liters per minute and the filter on the machine appeared gray in color from the amount of dust and particles stuck to the filter. Resident said he was not having any difficulty breathing. During observation and interview on 01/09/23 at 10:40 a.m. LVN C said she was the nurse caring for Resident #53 today. LVN looked at the oxygen concentrator and said the flow rate was set too high and adjusted the flow rate to 4 liters per minute. She said the oxygen concentrator filter appeared dusty and dirty and looked like it needed to be changed. She said she did not know show was responsible for cleaning/changing the filters, but she would find out and get it changed. LVN said she received training on respiratory therapy yearly at the facility and the training was given by a respiratory therapist. She said she normally checked on Resident #53 after breakfast each day, but she had not checked on him yet today. During an observation on 01/09/23 at 12:05 p.m. Resident #53's oxygen concentrator flow rate was set at 4 liters per minute and the filter appeared black/clean with no particles of dust. During an interview on 01/11/22 at 8:25 a.m. the DON said before surveyor intervention maintenance workers were responsible for servicing oxygen concentrators including changing or cleaning the filters, but she did not think they were being changed regularly. DON said cleaning/changing the filter had been added to the weekly tasks of nurses. She said she was not aware that Resident #53's flow rate had been set at 4.5 liters per minute on 01/09/22, but his flow rate should have been 2-4 liters per minute per the physician orders. She said that only nurses are allowed to adjust the flow rate on the oxygen concentrators, and she expected nurses to check the flow rate every shift when they assessed the resident. She said a respiratory therapy company gives training to all nurses on respiratory therapy including oxygen administration yearly at the facility. During an interview on 01/11/23 at 11:45 a.m. the administrator said cleaning/changing the filter on the oxygen concentrators had been added to nurse's weekly tasks. He said his expectation was the filters would be changed weekly and new filters had been ordered to ensure these changes would be completed. He said the DON was the direct supervisor of all nurses. Record review of facility policy Oxygen Concentrator implemented 01/11/23 indicated, The nurse shall verify the physician's order for rate of flow and route of administration. And Check and clean the filter every week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676000 If continuation sheet Page 3 of 3