Health inspection·November 21, 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 interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences one (Resident #1) of one resident reviewed for quality of care. The facility failed to ensure Resident #1's oxygen liter flow rate matched the physician's orders. This failure could place residents at risk of not receiving appropriate treatment and care, and decreased quality of life and overall health.Findings included: Record review of Resident #1's face sheet, dated 09/27/2025 revealed an [AGE] year-old male, originally admitted on [DATE] and readmitted on [DATE], with diagnoses including iron deficiency anemia (low blood iron levels), cerebral infarction (stroke), other symptoms and signs involving cognitive function following cerebral infarction, muscle weakness, protein-calorie malnutrition, alcoholic cirrhosis of liver without ascites (scarring and damage to the liver due to heavy alcohol consumption), vascular dementia (dementia cause by brain damage form impaired blood flow), gastro-esophageal reflux disease (chronic condition where stomach acid flows back into the esophagus), dysphagia (difficulty swallowing), apraxia (neurological condition causing difficulty to make certain movements), hypertension (high blood pressure), cognitive communication deficit, dysarthria and anarthria (difficulty using muscles for speech and producing speech sounds), paroxysmal atrial fibrillation (type of irregular heartbeat), and history of transient ischemic attack (temporary blockage of blood flow to the brain). Record review of Resident #1's MDS assessment, dated 07/20/2025, revealed he had a BIMS (brief interview for mental status) score of 04 (indicating severe cognitive impairment) and an active diagnosis of chronic obstructive pulmonary disease (lung condition caused by damage to the lungs that causes inflammation, limiting airflow). Record review of Resident #1's care plan, last review/revised on 07/18/2025 revealed the resident had the potential problem of resident has the risk for shortness of breath related to COPD, the problem start date was 12/26/2022. Record review of Resident #1's hospital discharge documents, dated 09/18/2025 and 09/19/2025, with discharge instruction summary revealed the resident had a discharge diagnosis of pneumonia. Other instructions included Disposition: Transfer to hospice facility. Oxygen: Continue NC 3 L/min for comfort. Antibiotics discontinued as focus has shifted to comfort care . Continue comfort-based measures only. Record review of Resident #1's hospital progress notes dated 09/19/2025 revealed on 09/18/2025 at 20:03 (8:03 PM), Resident #1's oxygen was changed from 3 LPM (via nasal cannula) to 2 LPM (via nasal cannula). The comment on the progress note reflected O2 Waned (weaned) RN notified RN notified RN notified - by 1L. The record showed the oxygen was kept at 2 LPM, with the last recorded time at 09/19/2025 at 18:09 (6:09 PM). Resident #1's oxygen saturation level was measured at 99-100% while he was on 2 LPM. Record review of Resident #1's progress notes on 09/19/2025 at 19:25 (7:25 PM) by LPN B reflected: Resident arrived to floor via ambulance stretcher. He is admitted LTC with diagnosis PNA. VS taken B/P 98/60 T96.9 P69 Residents Affected - Few Page 1 of 3 676215 676215 11/21/2025 Avir at Dallas 4200 Live Oak St Dallas, TX 75204

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R16 SAT 97%. Resident is wearing oxygen @ 3LNC. Record Review of Resident #1's physician's orders reflected:Order: Oxygen at [_3_] LPM via N/C; Directions: every shift for For SOB and to maintain pulse ox > 90% per protocol; Start Date: 9/20/2025 06:00. Record review of Resident #1's progress note dated 09/20/2025 and created at 05:36 (5:36 AM) reflected: Resident is on follow up for readmit back to facility. Adjusting well back to facility. Staff assist with incontinent care and ADL's Remain on O2@3L via N/C. Continues to be NPO at this time. Hospice Confirmation is pending. Record review of Resident #1's progress notes dated 09/20/2025 created at 21:20 (9:20 PM) by LPN A reflected: This nurse did rounds on resident around 1500 and saw that resident's eyes were opened and looked at this nurse when his name was called, but he did not say anything. Cont to (be) on oxygen per n/c at 2LPM. During an interview on 09/27/2025 at 3:19 PM with LPN A revealed that she had came to work on 09/20/2025 and did her rounds at 3:00 PM. She said she had seen Resident #1, and he was on oxygen at 2 L/min via nasal canula. When asked who ordered the 2 L (per min), LPN A stated she assumed the doctor did because that was what the resident was on when she got to the facility. She said when she did her rounds at (3:00 PM), Resident #1 was fine. She said she looked at him and he raised his eyes at her. She further stated he was not in distress at that time, and he had just gotten done being changed and he was fine. LPN A stated she did not check the oxygen order for the resident, when she saw it was on it (2 L/min) that was what she left it at. She stated the facility had standing orders for oxygen for anyone with low saturation (oxygen levels) and did not check to see if there were written orders for oxygen. LPN A further explained she had thought the resident was going to be on hospice and did not need to check the order because he was comfortable. When asked about Resident #1's oxygen levels, she stated she did not know how low it had gotten, but that he did not have distress, and he was comfortable. LPN A discussed that if a resident was ordered 3L/min and was only receiving 2L/min and they were gasping, there was not a good oxygen and carbon dioxide exchange, and they (facility) would have resident on oxygen mask if resident were gasping. LPN A discussed that if someone was gasping from a 1L/min difference in oxygen, that indicates there is not a good oxygen and carbon dioxide exchange. She stated the 1L/min could cause a difference if the resident had COPD, but he did not have it. She said if COPD (lungs) were not perfusing oxygen (oxygen not moving through blood), carbon dioxide (levels) goes up, causing more distress of exchange. She stated if the order said 3L/min, it (the oxygen) should have been but like she had said, she did not see the order, so it stayed on 2 L/min. LPN A said she took the vitals and did not put them in the resident's electric records but in a notebook she had, she said the oxygen was not low and proceeded to get her notebook. Record review of the vitals, recorded during rounds, in LPN A's notebook reflected Sat 09/20/25. (Resident #1) 92% (oxygen saturation), 2 LPM, 98/68 (blood pressure), 16 (respiratory rate), 97.9 (temperature). During an interview on 09/27/2025 at 5:28 PM with the ADON, she stated staff were expected to review orders when residents returned from the hospital so staff know exactly what order should be or know if there were changes to their plan of care. The ADON said the hospital discontinued the facility's medication orders and did not have an order for oxygen; she said it was supposed to be continuous. She further explained the facility had standing orders for 2 L/min or 3 L/min. The ADON stated staff were expected to follow standing orders and then see what the facility doctor would want to do from there (if there needed to be a change in the standing order and/or hospital discharge order). The ADON did not find Resident #1's oxygen saturation levels of 92% while on 2 L/min a concern, and if it was a concern, she would contact the doctor and see what they wanted to do. During an interview on 09/27/2025 at 6:09 PM with the ADM, she stated LPN A should have verified Resident #1's orders because if his oxygen was set on 2 L/min, she would check to confirm, if (the order was) 3 L/min, 676215 Page 2 of 3 676215 11/21/2025 Avir at Dallas 4200 Live Oak St Dallas, TX 75204

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (she) would bump it up to 3L/min. She further stated it was important to check orders to make sure residents got physician directive care orders. The ADM said staff were expected to check orders and verify again. Attempted interview with LPN B on 09/29/2025 at 09:25 AM, no response. Attempted interview with the DON on 09/2025 at 09:26A M and 01:31 PM, no response. Attempted interview with the facility's physician on 10/08/2025 at 9:51 AM, no response. Record review of the facility's Oxygen Administration policy, revised 10/2010, reflected: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident. General Guidelines1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. AssessmentBefore administering oxygen, and while the resident is receiving oxygen therapy, assess for the following:1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes);2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion)3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing);4. Vital signs;5. Lung sounds;6. Arterial blood gases and oxygen saturation, if applicable; and7. Other laboratory results (hemoglobin, hematocrit, and complete blood count), if applicable. Reporting1. Notify the supervisor if the resident refuses the procedure2. Report other information in accordance with facility policy and professional standards of practice. 676215 Page 3 of 3