Health inspection·January 20, 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, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 6 (Resident #4) reviewed for respiratory care. Residents Affected - Few Resident #4's PRN oxygen was set at 0.5 L rather than the physician's order for 1-3 L. This failure could affect residents administered oxygen and could lead to residents not receiving the therapeutic effects of oxygen; and could lead to a diminished quality of life. The findings were: Record review of Resident#4's face sheet, dated 1/19/24, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: anxiety, dysphasia (difficulty swallowing foods or liquids) , and past COVID. Resident was a female; age [AGE]. Advanced Directive was Full Code. RP was listed as: family member. Record review of Resident#4's MDS (minimum data set), dated 12/29/23 Admissions revealed: BIMS Score was 14 (cognitively intact). Record review of Resident#4's Physician' Orders, dated January 2024, read: O2 AT 1-3L/MIN VIA Nasal Cannula. Record review of Resident# 4's Care Plan, dated 1/8/24, read: OXYGEN SETTINGS: O2 via nasal prongs [at] 1-3L PRN. Humidified. Record review of Resident#4's MAR January 2024, reflected: O2 1-3L/Minute given PRN. Observation and interview on 1/19/24 at 2:16 PM, Resident #4 was in her room watching TV from bed on continuous O2 at 0.5 L [ physician's order was for 1-3 L]. The resident was not in distress. The Resident stated, .I am breathing okay . Resident was not aware of the amount of O2 ordered by the physician. During an interview on 1/19/24 at 2:29, LVN B stated: Resident #4's O2 level was at level 0.5 and should have been, PRN, at level 1-3L. LVN B stated the resident's O2 stat was at 96%. She had no explanation why the O2 was s at 0.5 at 2:26 PM. (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: 676392 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 676392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Legend Oaks Healthcare and Rehabilitation - New Br 2468 Fm 1101 New Braunfels, TX 78130 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)