Health inspection·December 7, 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 observation, interview and record review the facility failed ensure that a resident that needed tracheostomy care was provided such care consistent with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for tracheostomy care. Residents Affected - Few The facility failed to ensure Resident #1's tracheostomy tubing was changed out within a seven-day period upon observation on 11/07/2024 at 4:13 PM. These failures could place residents at risk of cross-contamination and the development of infection. Findings include: Record review of Resident #1's face sheet, dated 12/07/2024 at 5:41 PM, reflected a [AGE] year-old resident who was admitted to the facility on [DATE]. Resident #1 had relevant diagnoses which included Moyamoya disease (blood vessel disorder that reduces blood flow to the brain,) cerebral infarction (blood supply to the brain is blocked or reduced) and tracheostomy status (hole in front of the neck into the windpipe to keep open for breathing.) Record review of Resident #1's Comprehensive Care Plan, dated 12/07/2024 , reflected Resident #1 had a tracheostomy and required his oxygen tubing, humidification bottle and mask changed weekly or as needed when visibly soiled. Record review of Resident #1's quarterly MDS , dated 11/15/2024, reflected he was not able to complete a BIMS assessment but had short- and long-term memory problems and was severely impaired in his cognitive skills for daily decision making. He had impairments on both sides in both upper and lower extremities and required a wheelchair for mobility. Resident #1 was totally dependent upon staff for hygiene, toileting, dressing and transfers. Resident #1's appliances included indwelling catheter for urinary management and ostomy for bowel management. Resident #1 had a feeding tube and received 51% or more total calories from tube feeding. He required oxygen therapy and tracheostomy care. Record review of Resident #1's Physician Orders reflected: -Change respiratory tubing, mask, bottled water every 7 days with a start date of 12/03/2024 and timed for 10 PM each Sunday. -Tracheostomy: Change oxygen tubing, bottled water for humidification, and mask weekly and as needed with a start date of 12/05/2024. No time listed as this is an as needed order. Page 1 of 3 676315 676315 12/07/2024 The Hillcrest of North Dallas 18648 Hillcrest Rd Dallas, TX 75252

F 0695 -Oxygen at 4 liters per minute via tracheostomy with a start date of 12/03/2024 and timed each shift. Level of Harm - Minimal harm or potential for actual harm -Tracheostomy care daily and as needed with a start date of 12/05/2024. Residents Affected - Few Record review of Resident #1's Progress Notes, authored by LVN A on 12/07/2024 at 2:13 PM, reflected Resident #1's tracheostomy care was completed. In observation of Resident #1 on 12/07/2024 at 4:13 PM, he was resting in bed with family at his bedside. Resident #1 had a tracheostomy present with tracheostomy tubing, oxygen tubing, tracheostomy mask, bottled water for humidification, adapter and concentrator equipment present. Resident #1's tracheostomy tubing was dated 11/26/2024 both on the bag and on the tubing. Interview with Resident #1 on 12/07/2024 at 4:13 PM was not successful due to the resident's cognitive and verbal limitations. In interview with Resident #1's family member on 12/07/2024 at 4:13 PM, revealed they were not knowledgeable of Resident #1's tracheostomy care. In interview and observation with Resident #1's nurse, LVN A, on 12/07/2024 at 4:37 PM, she stated she performed tracheostomy care and changed out Resident #1's oxygen tubing, tracheostomy mask, and bottled water for humidification earlier that day. She stated she did not change out the tracheostomy tubing at that time and stated she did not notice the date, nor did she recognize it needed to be changed at that time. She stated all the tracheostomy equipment was ordered to be changed weekly on Sunday nights and it was the night shift nurse's responsibility to complete this task. She stated if that was not completed, it was the next nurse's responsibility to ensure this was completed. She stated it was important for the respiratory tubing to be changed out weekly for infection control purposes. In interview with the facility's ADON on 12/07/2024 at 5:00 PM, she stated tracheostomy tubing and equipment needed to be changed weekly by the weekend night shift nurse or as needed by any nurse when out of date (which was determined by assessing the date listed on the equipment) or if tubing was soiled or compromised. She stated she typically did an audit and visual inspection each Monday to ensure this was completed; but she recently came back from vacation and did not think it was delegated. She stated it was important for the respiratory tubing to be changed out weekly for infection control purposes. In interview with the facility's DON on 12/07/2024 at 5:15 PM, she stated tracheostomy tubing and equipment needed to be changed out weekly by the weekend night shift nurse. She stated her expectation was if this was not completed, then the next nurse the resident had in their care would complete this task. She stated the ADON typically completed an audit on Monday, but every nurse Resident #1 had should be assessing the date on the tubing equipment each shift to ensure the tubing was not out of date and needed to be changed for infection control purposes. Record review of the facility policy Tracheostomy - Care of rev. 06/2020 reflected tracheostomy care will be performed as ordered by the Physician. Record review of the facility policy, Oxygen Administration, rev. 06/2020 reflected a Physician's Order is required to initiate oxygen therapy. All oxygen tubing, humidifiers, masks, and cannulas 676315 Page 2 of 3 676315 12/07/2024 The Hillcrest of North Dallas 18648 Hillcrest Rd Dallas, TX 75252

F 0695 used to deliver oxygen will be changed weekly and when visibly soiled. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676315 Page 3 of 3