Health inspection·December 1, 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 make sure that residents receive adequate respiratory care (including tracheostomy care and tracheal suctioning) for 3 of 5 Residents (Resident#1, Resident#2 and Resident#3), reviewed for infection control. The facility failed to ensure that Resident #1, Resident #2 and Resident #3's oxygen tubing and prefilled humidifier water bottles were changed and dated. The facility failed to ensure that Resident #3's oxygen tubing was bagged in a plastic bag and stored in a drawer. The failures had the potential to affect residents receiving oxygen therapy by increasing their risk of health -associated infections.Findings included:Record review of Resident 1#'s Quarterly MDS Assessment, dated 09/01/, 2025 reflected the resident was a [AGE] year-old male, had a BIMs score of 07 indicating he was cognitively impaired. The resident had diagnoses which included Renal Insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), Diabetes Mellitus (is a condition that happens when your blood sugar is too high. It develops when your pancreas doesn't make enough insulin or any at all, or when your body isn't responding to the effects of insulin properly. Diabetes affects people of all ages. Most forms of diabetes are chronic (lifelong), and all forms are manageable with medications and/or lifestyle changes.), Non-Alzheimer's Dementia (syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control) Asthma (asthma is a condition that causes long-term (chronic) inflammation in your airways. The inflammation makes them react to certain triggers, like pollen, exercise or cold air. During these attacks, your airways narrow (bronchospasm), swell up and fill with mucus. This makes it hard to breathe or causes you to cough or wheeze. Without treatment, these flare-ups can be fatal.) Record review of Resident #1's Comprehensive Care Plan, Date Initiated: 12/18/2024 and Revision on: 12/18/2024 reflected the resident had Oxygen/BIPAP Therapy r/t Respiratory illness. Facility intervention includes: BIPAP PER ORDERS. Encourage or assist with ambulation as indicated. Give medications as ordered by physician. Monitor/document side effects and Effectiveness. Monitor for s/sx of respiratory distress and report to MD.Record review of Resident #1's Physician orders start date 01/08/2025 reflected O2 at 2 l/min continuous per nasal cannula every shift for COPD related to chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs. This limited airflow is known as obstruction. Symptoms include trouble breathing, a daily cough that brings up mucus and a tight, whistling sound in the lungs called wheezing).Record review of Resident 2#'s Quarterly MDS Assessment, dated 09/04/2025, reflected the resident was a [AGE] year-old female, had a BIMs score of 14 indicating she was cognitively intact. The resident had diagnoses which included anemia (Anemia is a blood disorder that happens when you don't have enough red Residents Affected - Some Page 1 of 3 676188 676188 12/01/2025 Millbrook Healthcare and Rehabilitation Center 1850 W Pleasant Run Rd Lancaster, TX 75146

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blood cells or your red blood cells don't work as they should. Some types of anemia are inherited, but people may also acquire or develop the condition during their lifetimes), respiratory failure (Respiratory failure is a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). You might also hear people use the term acute hypoxemic respiratory failure (AHRF) to describe it.), chronic respiratory failure with HYP (Respiratory failure is a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). You might also hear people use the term acute hypoxemic respiratory failure (AHRF) to describe it.), and asthma (Asthma is a condition that causes long-term (chronic) inflammation in your airways. The inflammation makes them react to certain triggers, like pollen, exercise or cold air. During these attacks, your airways narrow (bronchospasm), swell up and fill with mucus. This makes it hard to breathe or causes you to cough or wheeze. Without treatment, these flare-ups can be fatal).Record review of Resident #2's Comprehensive Care Plan, Date Initiated: 07/29/2025: Has Oxygen Therapy. Facility interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to the usual oxygen delivery method after the meal. Monitor for s/sx of respiratory distress and report to MD PRN. Record review of Resident #2's Physician's orders start date 05/04/2025 reflected, change O2 tubing & humidifier bottle every night shift every Sun.Record review of Resident 3#'s Quarterly MDS Assessment, dated [DATE], reflected the resident was a [AGE] year-old female, had a BIMs score of 15 indicating he was cognitively intact. The resident had diagnoses which included anemia (anemia is a blood disorder that happens when you don't have enough red blood cells or your red blood cells don't work as they should. Some types of anemia are inherited, but people may also acquire or develop the condition during their lifetimes), chronic respiratory failure with HYP((Respiratory failure is a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). You might also hear people use the term acute hypoxemic respiratory failure (AHRF) to describe it.), asthma (Asthma is a condition that causes long-term (chronic) inflammation in your airways. The inflammation makes them react to certain triggers, like pollen, exercise or cold air. During these attacks, your airways narrow (bronchospasm), swell up and fill with mucus. This makes it hard to breathe or causes you to cough or wheeze. Without treatment, these flare-ups can be fatal) , and shortness breathe (Shortness of breath can be a sign of some medical conditions, including asthma, COPD and heart failure, as well as anxiety or panic attacks. The long-term lung effects of smoking may first be noticed as worsening shortness of breath).Record review of Resident #3's Comprehensive Care Plan, Date Initiated 10/10/2025 Has Oxygen Therapy. Facility includes Give medications as ordered by physician. Monitor/document side effects and effectiveness. Revision on: 10/10/2025: Has Oxygen Therapy. Facility interventions: Give medications as ordered by physician. Give medications as ordered by physician. Monitor/document side effects and effectiveness, Oxygen per MD orders.Record review of Resident #3's Physician orders start date 10/12/2025 reflected, change O2 tubing & humidifier bottle every night shift every Sun.Observation on 10/16/2025 at 11:05AM of Resident# 2 revealed the oxygen tubing was not dated or labeled. Observation 10/16/2025 at 11:17AM of Resident# 3 revealed the oxygen tubing and prefilled humidification bottle were not dated. Interview with Resident #3 revealed that sometimes they changed oxygen tubing, but it had not been changed the past week.Observation 10/16/2025 at 11:30AM of Resident# 1 revealed the oxygen tubing and prefilled humidification bottle were not dated and oxygen tubing was on the floor. Interview 10/16/2025 at 676188 Page 2 of 3 676188 12/01/2025 Millbrook Healthcare and Rehabilitation Center 1850 W Pleasant Run Rd Lancaster, TX 75146

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1:02PM with LVN A revealed that she was Resident #1 and Resident #2's nurse. She stated that she was not aware that the oxygen tubing and the prefilled humidifier bottles were not dated. She stated that she usually checked the oxygen tubing to make sure they were dated. She stated that the oxygen tubing and prefilled humidifier were changed every week on Sunday night and PRN. She stated it was important to date all tubing so that everyone track when the tubing was last changed. She stated that it was important to change tubing every week, and store tubing in plastic bags and place in the drawers to prevent contamination and infections. She stated that she had been in service on infection control and oxygen tubing care.Interview 10/16/2025 at 1:34pm with LVN B revealed that oxygen tubing was supposed to be changed on Sunday night shift. She stated she usually checked the oxygen tubing and prefilled humidifier bottlers to make sure they were dated. She stated she was not aware that Resident #3's oxygen tubing and the prefilled humidifier bottle were not dated. She stated the importance of dating oxygen tubing was to track its age so it could be replaced according to the recommended schedule. She stated that she had been in service on infection control and oxygen tubing care.Interview 10/16/2025 at 4:30PM with DON revealed her expectation was the nurse assigned should be check the oxygen tubing and prefilled humidification bottles as part of overall assessment make sure it was properly functioning. She stated oxygen tubing was changed weekly on the night shift and if the night shift were busy then any shift could change. She stated all oxygen tubing and prefilled humidification bottles should be dated. She stated that all oxygen tubing should be stored in a plastic bag. She stated the risk to the resident if tubing was not dated or stored in sanitary ways was infection control. She stated that the nurses had been in serviced on infection control and oxygen tubing care.The facility policy titled Infection Control and Policy/Procedure Reviewed July 2022 reflected:The goal of the infection control program is to:a. Decrease the risk of infection to patients and personnelb. Monitor for the occurrence of infection and implement appropriate control measuresc. Identify and correct problems relating to infection control practicesd. Ensure compliance with state and federal regulations to infection control.The facility policy titled Oxygen Equipment Revised May 2017 reflected:It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers, tubing, mask, and cannulas for residents receiving oxygen. The equipment is to be discarded. The facility will maintain clean tanks, connectors, and concentrators.Procedures:1. Oxygen Tanks, connectors, and concentratorsa. Oxygen tanks, connectors and concentrators must be cleaned after use.b. Gauges must be cleaned after use as a follows:1. Remove gauge from tank.2. Clean gauge with disinfectants. Allow to dry thoroughly.3. Place clean Guage in oxygen storage area.C. pre-filled humidifiers, when used, are to be dated and replaced every (7) days, according to manufacturers' recommendations, or as needed.1. Tubing should be replaced every week.2. Masks should be replaced every week.3. Cannulas should be replaced every week.4. Oxygen concentrator filters will be cleaned with water and detergent every week according to manufacturer's recommendations.D. Oxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth.E. When a mask or cannula is temporarily not being used it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly. 676188 Page 3 of 3