Health inspection·December 19, 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, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for Respiratory Care. Residents Affected - Few The facility failed to ensure Resident #1's nasal cannula was properly stored when not in use. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #1's Face Sheet, dated 12/19/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #1's Quarterly MDS Assessment, dated 12/16/2024, reflected the resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated Resident #1 was on oxygen therapy while a resident of the facility. Review of Resident #1's Comprehensive Care Plan, dated 10/10/2024, reflected the resident required oxygen therapy related to COPD and one of the interventions was administer oxygen at 2 - 3 L via nasal cannula. Review of Resident #1's Physician Order, dated 03/19/2021, reflected O2 @ 2-3L/MIN CONTINUES VIA NC. Observation on 12/19/2024 at 9:49 AM, revealed Resident #1 was not inside her room. It was observed that there was an oxygen concentrator beside her bed. A nasal cannula was attached to the oxygen concentrator. The nasal cannula was hanging on top of the oxygen concentrator and was not bagged. Observation and interview with CNA B on 12/19/2024 at 9:57 AM, CNA B said she assisted Resident #1 to transfer to her wheelchair. She said she took off the nasal cannula before she transferred her and put it on top of the oxygen concentrator. She said it should be placed inside a plastic bag to keep it clean. She looked for a plastic bag behind the oxygen concentrator but did not see one. While in the process of looking for a plastic bag, CNA B placed the nasal cannula on top of the bed. She said she would call the nurse to get plastic bag. (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 3 Event ID: 676247 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 676247 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sandy Lake Rehabilitation and Care Center 1410 E Sandy Lake Rd Coppell, TX 75019 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)