Health inspection·July 2, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview with LVN A on 07/02/2024 at 10:36 AM, LVN A said the purpose of the humidifier was to prevent nasal and throat irritation. She said the water in the humidifier moistened the nasal passage that facilitated ease of breathing. LVN A saw the nasal cannula hanging on the wheelchair's backrest and said the nasal cannula should be bagged when not in use to prevent it from dropping on the floor or touching anything unclean. She said if the nasal cannula was not bagged, it could catch bacteria or microorganism that could eventually cause infection. LVN A said she would get a new pre-filled humidifier bottle and a new nasal cannula and would replace them. LVN A went out of the room and came back with a new nasal cannula and a pre-filled humidifier. In an interview on 07/02/2024 at 1:22 PM, CNA B stated she was the CNA assigned to Resident #1. She said she was not sure where to put the nasal cannula when the resident was using it. She said she would usually hang it on the wheelchair when she took it off from the resident. She said she did not notice that there was a plastic bag at the back of the wheelchair. She said she had been with the facility for a couple of weeks and was not sure what to be done. She said she would ask the charge nurse where to put the nasal cannula when not in use. She said she did not transfer the resident but the charge nurse did. In an interview with LVN A on 07/02/2024 at 1:30 PM, LVN A stated she did transfer the resident. She said she also took off the nasal cannula connected to the portable oxygen tank and replaced it with the nasal cannula connected to the oxygen concentrator. She said she overlooked putting it on the plastic bag. She also said the night nurse was the one changing the humidifier but said she should have checked if there was still water in it. Interview with the ADON on 07/02/2024 at 1:43 PM, the ADON stated the nasal cannula connected to the portable oxygen should be in a bag when the resident was not using it. The ADON said if the nasal cannula was not bagged, it could cause respiratory infections that would be detrimental to the health of the residents. The ADON said the humidifier should always have water to prevent any irritation on the respiratory passageway. She said this was to prevent irritation to the nose and throat. She said the nurses were responsible in ensuring the humidifier had water in it. She said the nurses and the CNAs were responsible in bagging the nasal cannula when not in use. She added the DON and the ADON were responsible in ensuring the nurses were doing the best practice regarding respiratory care. The ADON said her expectation was for the staff would be watchful in monitoring if there was water in the humidifier and if the nasal cannula was bagged when not in use. The ADON said she would do an in-service and educate the CNA about respiratory care. Interview with DON on 07/02/2024 at 2:04 PM, the DON stated the humidifier should always have water in it to prevent irritation and dryness to the lining of the nose and throat. The DON said the staff should had make sure there was water on the humidifier so the breathing of the residents would not be compromised. The DON also stated the nasal cannula should not be left hanging on the backrest of the wheelchair to prevent respiratory infections and exacerbations of respiratory issues for those residents that already had respiratory challenges. The DON said the expectation was for the staff to monitor if the humidifier had water and if the nasal cannula were bagged. She said she do an in-service about bagging the nasal cannula and would monitor their adherence to the policy. Review of facility policy, Oxygen Therapy - Discontinuation Clinical Operations revised January 12, 2020 revealed Procedures . 6. Remove nasal cannula prong or mask . place in a plastic bag if oxygen is to be administered on a PRN basis. Review of facility policy, Oxygen Therapy, Liquid - Initiation Clinical Operations revised January (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 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 676096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baybrooke Village Care and Rehab Center 8300 Eldorado Parkway West McKinney, TX 75070 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 12, 2020 revealed Procedures . 5 . fill humidifier bottle with distilled water to proper line or attached disposable humidifier. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676096 If continuation sheet Page 3 of 3