Health inspection·June 20, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's Treatment Administration Record from 06/1/2024 - 06/20/2024 reflected, Change respiratory concentrator water, clean filter q7d every night shift every Sun and indicated it was completed on Sunday, 06/02/2024, Sunday, 06/09/2024, and Sunday, 06/16/2024. Observation on 06/20/2024 at 12:00 PM, Resident #1 was in her bed receiving oxygen via nasal cannula from an air concentrator. A check of her oxygen tubing and concentrator revealed the humidifier bottle had 6-10-24 recorded on the top of it, with no date present on the tubing. Resident #1 was receiving air from the concentrator at 2L per minute and a check of the filter on the back of it revealed it was covered in dust and debris particles. Interview and observation on 06/20/2024 at 2:56 PM, Resident #1 had her tubing and nasal cannula hanging off the side of her bed side table and stated it was off because she just received a bath. Resident #1's humidifier bottle had the same date as earlier observation and had not been changed. Resident #1 stated that her oxygen tubing and cannula were not changed on 06/20/2024 but stated they do change it out. Resident #1 stated that she could not recall in days or weeks when the last time was that they changed out her oxygen tubing with cannula. B) Review of Resident #2's Face Sheet dated 06/20/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Athetoid Cerebral Palsy (movement disorder cause by damage to the developing brain characterized by abnormal, involuntary movement), Cystic Fibrosis (disease that causes thick, sticky mucus to build up in the lungs, digestive tract, and other areas of the body), and Unspecified Dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain). Review of Resident #2's Quarterly MDS Assessment, dated 05/23/2024 revealed Resident #2 had a BIMS Score of 00, which indicated severe cognitive impairment. Resident #2's MDS indicated for Respiratory Treatments that she was under C1. Oxygen therapy, which occurred while she was a resident. Review of Resident #2's Comprehensive Care Plan revealed The resident has impaired cognitive function r/t dementia dx with an intervention for Administer meds as ordered, with both revised on 08/28/2023. Resident #2's Comprehensive Care Plan did not specifically address the use of her nebulizer. Review of Resident #2's Order Summary Report reflected an order on 08/15/2023 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML with directions for 1 dose via trach every 4 hours. Review of Resident #2's Treatment Administration Record from 06/1/2024 - 06/20/2024 reflected, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 dose via trach every 4 hours as needed for Shortness of Breath; Wheezing documented as PRN with no indication of treatment for dates reviewed. The Treatment Administration Record further reflected Change Nebulizer Tubing and Delivery Device every 8 hours as needed related to UNSPECIFIED TRACHEOSTOMY COMPLICATION documented as PRN with no notations of completion for the dates reviewed. Observation on 06/20/2024 at 12:04 PM, revealed that Resident #2 was in her bed with a nebulizer present on her nightstand, with a plastic bag in front of it. The bag had Resident #2's last name recorded on the front of it as well as 6/3. The bag contained tubing and a mask with attached nebulizing chamber, none of which had a date recorded on them. Interview and observation on 06/20/2024 at 2:58 PM, revealed that Resident #2's nebulizer mask with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 2 of 3 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 676385 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crossroads Nursing & Rehabilitation 611 Rose Marie Blvd Hearne, TX 77859 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few chamber and tubing remained bagged at her bedside with a date of 6/3. Resident #2 was not interviewable but acknowledged with a smile that she was alright when questioned. Interview on 06/20/2024 at 3:22 PM, LVN B stated all respiratory equipment including mask, cannulas, tubing, and humidifier bottles are to be changed out every seven days by a nurse on Sunday night. LVN B stated they are also supposed to clean the filter on the residents' air concentrator at the same time. LVN B stated they normally record the date of change on the humidifier bottle for concentrated air and on the mask or the outside of the bag for nebulizer equipment. LVN B stated that failure to properly change and maintain oxygen / nebulizer equipment increases a resident's chance of respiratory infection. Interview on 06/20/2024 at 3:35 PM, RN A stated oxygen and nebulizer equipment are to be changed out every Sunday night by a nurse or more frequently if they become soiled. RN A stated oxygen tubing with cannulas have the date recorded on a piece of tape that is stuck to the tubing or have the date recorded on the humidifier bottle, because they are supposed to be changed at the same time. RN A stated dates for nebulizer equipment can be placed on the mask itself or the outside of the bag. RN A stated failure to properly change out oxygen equipment could lead to respiratory issues for the resident. Interview and observation on 06/20/2024 at 3:37 PM, the ADON stated mask, tubing, cannulas, and humidifier bottles are to be changed out every seven days by the night nurse on Saturday to Sunday. The ADON stated the filters on air concentrators are also to be cleaned every seven days or more often if necessary. The ADON stated when they change out oxygen tubing with cannulas and the humidifier bottle, they will record the date on the bottle or will place the date on the tubing at the concentrator port. The ADON stated failure to properly change and maintain respiratory equipment could result in illness or worsen a resident's condition. At 3:39 PM, the ADON entered the room of Resident #1 and checked her oxygen concentrator and equipment. The ADON stated it was not correct because it had not been changed out within the past seven days. The ADON stated the filter on the concentrator had also not been cleaned in over seven days based off the dust and debris build up on it. At 3:45 PM, the ADON entered the room of Resident #2 and checked her nebulizer and equipment. The ADON stated that Resident #2's nebulizer equipment was not correct and had not been changed out every seven days per their procedures. Interview on 06/20/2024 at 4:00 PM, the Administrator stated her expectation was for all respiratory equipment to be changed out weekly or more often if soiled. The Administrator stated that the documented observations were not within policy and could result in illness. Review of the facility's Respiratory Policies and Procedures Manual dated 6/1/2006 revealed, POLICY TITLE: 10.0 Respiratory Equipment/Supply Disinfection/Cleaning, 9. In addition to surface disinfection, perform the following: 9.4 Oxygen Concentrators: Rinse and dry the external filter weekly and prn when visibly dusty. 11. Schedule for Supply Changes, Item, Nebulizers/Aerosols/Humidifiers, Frequency, Every 7 days. POLICY TITLE: 10.1 Oxygen Concentrators, PROCESS 9. Label, date and attach water bottle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676385 If continuation sheet Page 3 of 3