Inspection·May 10, 2024

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 observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Resident #1) of 4 residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #1's oxygen tubing was dated. This failure placed the residents at risk for infections and respiratory related complications. The findings were: Record Review of Resident #1 admission record reflected; [AGE] year-old-female with an initial admission date of 08/07/2023 and a preliminary diagnosis of: CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED Record Review of Resident #1's MDS Optional State assessment dated [DATE] reflected; Resident #1 had a BIMS score of 07 (Severe cognitive impairment). Record Review of Resident #1's Care Plan reflected; Focus: The resident has oxygen therapy r/t Chronic Respiratory illness; Intervention: OXYGEN SETTINGS: O2 via (nasal prongs/mask) Record Review of Resident #1's Order Summary reflected active orders dated 05/10/2024 reflected Oxygen: May have oxygen at (2-4) LPM related to COPD every 24 hours as needed. Oxygen: May have oxygen at 2-4 LPM] Liters per via NASAL CANNULA; MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SOB WHILE LAYING FLAT every 6 hours for SOB Record Review of Resident #1's Care Plan reflected; Focus: The resident had oxygen therapy r/t Chronic Respiratory illness; Intervention: OXYGEN SETTINGS: O2 via (nasal prongs/mask) Record Review of Resident #1's MDS Optional State assessment dated [DATE] reflected; Resident #1 had a BIMS score of 07 (Severe cognitive impairment). Section I- Active Diagnoses- Pulmonary; Asthma, COPD, or Chronic Lung Disease (e.g. chronic bronchitis and restrictive lung diseases such as asbestosis). Section J- Health Conditions- Shortness of breath or trouble breathing when lying flat. Section O- Special Treatments, Procedures, and Programs; Oxygen therapy, performed while a resident of this facility. Record Review of Resident Priority Program check list , undated, reflected: Equipment: 24 Oxygen: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676209 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 676209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Decatur Medical Lodge 701 W Bennett Rd Decatur, TX 76234 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)