Health inspection·February 27, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #1) of 6 residents reviewed for care plans. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her required need for oxygen, monitoring her for shortness of breath related to her disease process of Chronic Obstructive Pulmonary. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her required need for specialty medical appointment related to her disease process of Congestive Heart Failure. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her need for substantial/maximal assistance with her Activities of Daily Living including showering, upper and lower body dressing, and toileting hygiene. This failure could place residents at risk of not having their care and treatment needs met to ensure necessary care and services were provided for specific disease processes and activities of daily living. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] wit diagnosis of acute on chronic systolic heart failure (a condition in which the heart is too weak to pump the blood around the body to meet its needs), chronic obstructive pulmonary disease (a group of lung conditions making it difficult to breath), personal history of COVID-19, and wheezing. Record review of Resident #1's care plan dated 01/08/2025 reflected there were no care plans to reflect Resident#1's need for oxygen, disease process of COPD (Chronic Obstructive Pulmonary Disease), disease process of CHF (Congestive Heart Failure), or her ADL (activities of Daily Living) needs. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. Resident #1 required substantial/maximal assistance indicating the helper did more than half the effort or the helper lifted or held trunk or limbs and provided more Page 1 of 11 676409 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 received oxygen therapy while a resident continuously and received a diuretic medication. Record review of Resident #1s' Physician orders for February 2025 reflected an order for oxygen at 2 liters per minute via nasal cannula every shift dated 02/17/2025. The Physician orders reflected an order to assist times 2 persons with bed mobility dated 12/20/24, and for Resident #1 to have daily weights with special instructions: CHF/check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs. overnight or 3-5+ lbs. in 1 week Once A Day at 07:00 AM dated 2/25/25. Record review of Resident #1s' Physician orders history report for dated of 01/01/2025 through 02/25/25 reflected an order for oxygen at 2 liters per minute via nasal cannula every shift dated 12/20/2024. The order history report also reflected an order to check Resident #1 every hour to ensure the oxygen delivery is functioning properly. Report any complications to the DON or Administrator. This order was started on 01/10/2025 and then discontinued on 01/26/2025. Record review of facility's grievance log for January and February 2025 reflected Resident #1s RP had filed a grievance on 01/10/2025 stating when Resident #1 was at an appointment the oxygen tank was not turned on after being transported from the facility. The RP turned the oxygen on. Then later within the same day the RP was dropping off laundry and noticed the residents' eyes looking glassy and checked her oxygen tank and found the tank was full but not turned on and she had to turn it on again. The internal investigation revealed there were new oxygen regulators at the facility and had not been attached to the oxygen tank appropriately. Staff were in serviced on 1/17/25 on oxygen regulators and the grievance was closed as resolved. In an interview on 02/25/25 at 10:25 Resident #1s stated she has a constant problem with the facility not ensuring there was oxygen in the portable oxygen tanks. She stated she had a diagnosis of CHF and COPD (both disease process will cause shortness of breath) and has difficulty breathing. She stated she always uses oxygen continuously. Resident #1 stated she must see a medical specialist weekly for management of her CHF and COPD disease processes. She stated she was sent to the medical clinic the last 2 visits on 2/13/25 and on 2/21/25 with empty oxygen tanks. The specialty clinic staff changed her from her empty potable tanks (sent by the facility) to the wall oxygen unit in the medical clinic. Resident #1 stated she becomes confused, belligerent, and has severe crippling anxiety due to feeling as if she must struggle to breathe without adequate oxygen supply. Resident #1 stated she was transported to the medical clinic by ride safe a transport company. She stated the nurses do not check the oxygen tank to see if it's empty or full prior to leaving to her medical appointments. Resident #1 stated she was told to use the oxygen concentrator in her room. She stated that limits her mobility to freely move around the building and she does not like being grounded to her room it was like a punishment. Resident #1 stated she could not take her oxygen concentrator with her to the appointments as it requires electricity to function. She stated the oxygen tank problem had been reported to the administrator previously in a grievance form in January 2025. She stated she attended an emergency care-plan meeting with her RP regarding the issue, and the facility staff began to check the oxygen more frequently. Then the staff stopped checking the oxygen. So, it did not last long them checking the tanks. In an interview on 02/25/25 at 10:25 The RP of Resident #1 stated she has found Resident #1 with either her oxygen off, attached wrong, with an empty oxygen tank, or the liter flow set to the wrong amount multiple times. She stated she did meet with the facility ADM in January and drafted an emergency plan for the facility to increase the frequency of checking Resident #1s oxygen and then they 676409 Page 2 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stopped. The RP stated Resident #1 has shown up for two appointments in the last 2 weeks with empty oxygen tanks at the specialty medical clinic. At one of those appointments her oxygen saturation was 84%, Normal range is above 90%, she said Resident #1 was belligerent and confused short of breath and having anxiety. The RP said the nurses at the clinic were able to transfer Resident #1 to their in-house oxygen unit on the wall and bring her level up to 100% but she still suffered from anxiety and not being able to breathe. She stated Resident #1 wears her oxygen continuously she is never without it unless the facility fails to ensure she has oxygen on. In an interview on 2/26/25 at 1:30pm with the MDS Coordinator she stated she has worked for the facility for 8 years. She stated she did the basic comprehensive care plan for Resident #1, and the emergency care plans were completed by the DON or the ADON. She stated she was responsible for holding the care plan meetings. She stated she did not update the comprehensive care plan at the care plan meetings. The MDS Coordinator stated she should have done a care plan for the COPD, CHF, and oxygen use. She stated It would be nice if she were able to update the care plans at the meetings, but she would have to borrow a computer and there was no way to update the care plan while in the meeting. She stated she did not think there were any negative effects for not having a care plan, in place for COPD, CHF disease processes, and ADL care for Resident #1. She stated Resident #1 was alert and oriented and she could verbalize her needs. In an interview on 2/26/25 at 1:45pm the Interim DON stated that the MDS coordinator was responsible for completing the comprehensive care plan. She stated the DON and the ADON updated the care plan with acute changes. She stated the MDS coordinator should update comprehensive care plans after each meeting. Those care plan meeting were held quarterly and as needed. The Interim DON stated the disease processes of CHF, COPD, interventions, monitoring, and use of oxygen should have been care planned. The care plan should have been updated with residents' changes in condition including the need to increase the monitoring of the oxygen, daily weights, and assistance with needs within the ADL care plan. The negative effects could be that the resident would not receive appropriate care. Record review of facility policy titled Care Plan Process Person -Centered Care dated 05/05/2023 reflected: PROCEDURES Following RAI Guidelines (a tool used by Nursing Homes to assess a resident needs and strengths) develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. For the comprehensive assessment the review will be completed with seven (7) days and no more than 21 days after admission. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development. Residents will remain actively engaged in the person-centered care planning process and has the right to participate in the development of and be informed in advance any changes to the 676409 Page 3 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0656 person-centered care plan; see the person-centered care plan and choose to sign the care plan after significant changes. Level of Harm - Minimal harm or potential for actual harm The person-centered care plan includes: Residents Affected - Few Date Problem Resident goals for admission and desired outcomes Time frames for achievement Interventions, discipline specific services, and frequency 676409 Page 4 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, 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 and the resident's goals and preferences for 1 of 6 residents (Resident#1) reviewed for respiratory care. Residents Affected - Few The facility failed to supply oxygen to Resident #1 while she was out on pass to a medical clinic appointment on 02/13/2025 and 02/21/25 resulting in increased shortness of breath, anxiety, and an inability to breath. An Immediate Jeopardy (IJ) was identified on 2/25/25 at 6:07 p.m. The IJ template was provided on 02/25/2027 at 6:07PM. While the IJ was removed on 2/27/25, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents on continuous oxygen at risk of experiencing desaturation, unconsciousness, and death. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of acute on chronic systolic heart failure (a condition in which the heart is too weak to pump the blood around the body to meet its needs), chronic obstructive pulmonary disease (a group of lung conditions making it difficult to breath), personal history of COVID-19, and wheezing. Record review of Resident #1's care plan dated 01/08/2025 reflected there were no care plans to reflect Resident#1's need for oxygen, disease process of COPD (Chronic Obstructive Pulmonary Disease), disease process of CHF (Congestive Heart Failure), or her ADL (Activities of Daily Living) needs. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. Resident #1 required substantial/maximal assistance indicating the helper did more than half the effort or the helper lifted or held trunk or limbs and provided more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 received oxygen therapy while a resident continuously. Record review of Resident #1s' Physician orders for February 2025 reflected an order for Oxygen at 2 liters per minute via nasal cannula every shift dated 02/17/2025. Record review of Resident #1s' Physician orders history report for dated of 01/01/2025 through 02/25/25 reflected an order for Oxygen at 2 liters per minute via nasal cannula every shift dated 12/20/2024. The order history report also reflected an order to check Resident #1 every hour to ensure the oxygen delivery is functioning properly. Report any complications to the DON or Administrator. This order was started on 01/10/2025 and then discontinued on 01/26/2025. Record review of the facility's grievance log for January and February 2025 reflected Resident #1's RP had filed a grievance on 01/10/2025 stating when Resident #1 was at an appointment the oxygen tank was not turned on after being transported from the facility. The RP turned the oxygen on. Then 676409 Page 5 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few later within the same day the RP was dropping off laundry and noticed the residents' eyes looking glassy so she checked her oxygen tank and found the tank was full but not turned on and she had to turn it on again. The internal investigation revealed there were new oxygen regulators at the facility and had not been attached to the oxygen tank appropriately. Staff were in serviced on 1/17/25 on oxygen regulators and the grievance was closed as resolved. Record review of Oxygen saturation Vital sign report reflected on 02/13/25 Resident #1 had her oxygen level checked at 1:18pm and it was 97% with oxygen in place at 2 pm. Record review reflected on 02/21/25 at 2:39am the facility staff checked Resident #1's oxygen level, and it was 98% with oxygen in place at 2 lpm. Record review of a Medical Clinic visit reflected that on 2/13/25 at 9:35 Resident #1 arrived at the medical clinic and she had an oxygen saturation level on room air (without oxygen flowing) of 84% but recovered up to 100% after being placed on oxygen at 2 liters per minute in the clinic. In an interview on 02/25/25 at 10:15 The Private Caregiver for Resident #1 stated there have been many times that Resident #1 was sent out to a medical appointment with an empty oxygen tank causing her shortness of breath, changes in mental status, and severe anxiety. She stated she meets the resident at the medical clinic to relay to the family if there were any changes in residents' condition or care. She stated that the resident's RP had filed a complaint with the facility back in January 2025 and had an emergency care-plan meeting with the facility staff related to the residents need for working oxygen tanks. She stated they thought the issues were resolved but this month the resident had been sent to the specialty medical clinic twice with empty portable oxygen tanks. On 2/13/25 and on 2/21/25 the resident was sent with a portable oxygen tank to the medical clinic that was reading red indicating the oxygen tank was empty. This caused the resident to have low oxygen level while at the medical clinic causing Resident #1 confusion, shortness of breath, and anxiety. The Private Caregiver stated that the medical clinic staff were able to intervene and place Resident #1 on their in-house oxygen unit and brought her oxygen levels back up. She stated the facility staff did not check the tanks prior to the resident leaving and never monitored if the tanks were full or empty. In an interview on 02/25/25 at 10:25 Resident #1 stated she had a constant problem with the facility not ensuring there was oxygen in the portable oxygen tanks. She stated she had a diagnosis of CHF and COPD (both disease process will cause shortness of breath) and has difficulty breathing. She stated she always used oxygen continuously. Resident #1 stated she must see a medical specialist weekly for management of her CHF and COPD disease processes. She stated she was sent to the medical clinic the last 2 visits on 2/13/25 and on 2/21/25 with empty oxygen tanks. The specialty clinic staff changed her from her empty potable tanks (sent by the facility) to the wall oxygen unit in the medical clinic. Resident #1 stated she became confused, belligerent, and has severe crippling anxiety due to feeling as if she must struggle to breathe without adequate oxygen supply. Resident #1 stated she was transported to the medical clinic by ride safe a transport company. She stated the nurses do not check the oxygen tank to see if it's empty or full prior to leaving to her medical appointments. Resident #1 stated she was told to use the oxygen concentrator in her room. She stated that limits her mobility to freely move around the building and she did not like being grounded to her room, it was like a punishment. Resident #1 stated she could not take her oxygen concentrator with her to the appointments as it required electricity to function. She stated the oxygen tank problem had been reported to the administrator previously in a grievance form in January 2025. She stated she attended an emergency care-plan meeting with her RP regarding the issue, and the facility staff began to check the oxygen more frequently. Then the staff stopped checking the oxygen. So, it did not last long them checking the tanks. 676409 Page 6 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 02/25/25 at 10:25 the RP of Resident #1 stated she has found Resident #1 with either her oxygen off, attached wrong, with an empty oxygen tank, or the liter flow set to the wrong amount multiple times. She stated she did meet with the facility ADM in January and drafted an emergency plan for the facility to increase the frequency of checking Resident #1's oxygen and then they stopped. The RP stated Resident #1 has shown up for two appointments in the last 2 weeks with empty oxygen tanks at the specialty medical clinic. At one of those appointments her oxygen saturation was 84%, normal range is above 90%. She said Resident #1 was belligerent, confused, short of breath, and having anxiety. The RP said the nurses at the clinic were able to transfer Resident #1 to their in-house oxygen unit on the wall and brought her level up to 100% but she still suffered from anxiety and not being able to breathe. She stated Resident #1 wears her oxygen continuously. She was never without it unless the facility failed to ensure she has oxygen on. In an interview on 02/25/25 at 11:15 am the RN Specialty Clinic Director stated it was their expectation that all residents coming from a facility should have a working portable oxygen tank with them If they were oxygen dependent. She stated Resident #1 had been to the clinic 2 times with an empty portable oxygen tank on 02/13/25 and 02/21/25. She stated when a Resident #1 arrived at the clinic the staff checked her vital signs and, on the 02/13/25, when Resident #1 came into the facility, she had a saturation level of 84% indicating a critically low oxygen level and Resident #1 was not receiving enough oxygen in her blood to function. The RN Specialty Clinic Director stated a normal oxygen level is above 90%. She stated the staff immediately hooked Resident #1 to their in-house oxygen unit on the wall and within 3 minutes Resident #1s oxygen saturation went up to 100%. She stated it was a very similar situation on 2/21/25 when the resident arrived again with an empty tank. She stated clinical staff did call the facility and addressed it with the charge nurse of Resident #1. She stated the lack of oxygen caused Resident #1 to feel like she was unable to breath, causing shortness of breath, anxiety, and confusion from hypoxia (low oxygen level). She stated Resident #1 did have anxiety, confusion, and shortness of breath at both clinical visits on 02/13/25 and 02/21/25. In an interview on 02/25/25 at 1:15 pm the Interim DON stated she has been at the facility for 2 weeks. She stated the nurses were instructed to check oxygen tanks and should check portable oxygen tanks prior to the residents leaving the facility. She stated staff should always make sure the portable oxygen tank was on and full for mobile residents. She stated the staff were educated on monitoring the tanks verbally and with written in-services. She stated the DON was responsible for providing education to the staff. She stated she was aware of a recent in-service given in January on oxygen concentrator/regulator monitoring. The Interim DON stated she was not aware of an emergency plan for Resident #1 to have increased monitoring. She stated the negative outcomes for having empty oxygen tanks in use for a resident that required oxygen while out to medical appointments could be confusion and respiratory distress due to inadequate oxygen delivery. In an interview on 02/25/25 at 1:35 pm the Interim ADM stated he was not aware of the Emergency Plan for Resident #1. He stated that Resident #1 was hardly in her room and sometimes would leave on ride safe without checking with the nurses prior to leaving. He stated he was aware of a recent complaint related to the oxygen regulators. He stated the facility had bought new regulators and the nursing staff had to be educated on them. The Interim ADM stated all residents should be sent out on pass to medical appointments or anywhere with adequate amount of oxygen if they require continuous oxygen to prevent shortness of breath. On 02/25/25 at 2:15 pm a call was placed to The Medical Director and a message was left for a return call. 676409 Page 7 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0695 In a record review of facility policy titled Oxygen Therapy dated 02/12/2024 reflected: Level of Harm - Immediate jeopardy to resident health or safety Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. Residents Affected - Few PRECAUTIONS: The administration of oxygen to patients/residents with Chronic Obstructive Pulmonary Disease (COPD), especially a carbon dioxide retainer, must be carefully monitored as too much oxygen can cause a decrease in respirations due to Carbon dioxide narcosis. Special Considerations: Maintain the patient's/resident's target oxygen saturation level within the provider's recommended range. If the patient/resident has COPD or another risk factor for hypercapnic respiratory failure, a saturation of 88%-92% may be necessary. DOSAGE: Oxygen therapy will be used to administer a FI02 (Fraction of Inspired Oxygen) (the amount of air a person is breathing in) greater than 21 % by means of various administration devices. Oxygen therapy will be used to raise the patient's/resident's Pa02 (Partial Pressure of Oxygen in the arterial blood flow) to an acceptable baseline using the lowest FI02. Preparation of Equipment: The licensed nurse is to check the oxygen outlet port to verify flow in accordance with provider's order. An Immediate Jeopardy was identified on 2/25/25 at 6:07 p.m. and an IJ template was provided to the Interim ADM and Interim DON. The following Plan of Removal submitted by the facility was accepted on 02/27/2025 at 7:48 a.m. Plan of Removal for F695 Head to toe comprehensive assessment, including assessing the respiratory system for abnormalities, signs of distress or change in condition completed on Resident #1 by Director of Nursing/Designee on 2/25/25 with no negative effects and physician notified. Resident #1's responsible party notified on 2/25/25. An observation of the 6 residents currently in the facility with orders for continuous Oxygen was completed on 2/25/25 by the Director of Nursing/Designee to validate oxygen is being delivered per physician orders. No issues identified. Administrative Nurses were reeducated on Oxygen Administration on 2/25/25 by the Clinical Consultant including: 676409 Page 8 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0695 Validate residents are receiving oxygen per physician's orders. Level of Harm - Immediate jeopardy to resident health or safety Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of the facility and document on the resident's leave of absence form. Residents Affected - Few Licensed nurses were reeducated on Oxygen Administration on 2/25/25 by the Director of Nursing/Designee including: Validate residents are receiving oxygen per physician's orders. Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of the facility and document on the resident's leave of absence form. Licensed Nurses working on 2/25/25 received this education. All nurses that have not worked will receive education by the Director of Nursing/Designee prior to their next scheduled shift. This education will also be completed in New Hire and agency orientation by the Director of Nursing/Designee. Member of Nursing Management will interview 2 staff members per week for 4 weeks to validate comprehension of provided reeducation. Members of Nursing Management will round daily and document on the validation tool for 5 days to validate that oxygen is being delivered per physician's orders, then 3x per week for 2 weeks. Director of Nursing/designee will validate and document on the validation tool that the leave of absence form is completed for residents who leave the facility and have orders for continuous oxygen, including documentation that the resident was sent with a full portable cylinder. This will be validated daily for 5 days, then 3x per week for 2 weeks. QAPI was held on 2/25/25. The Medical Director was notified of the Immediate Jeopardy on 2/25/25. Monitoring of the plan of removal included the following: 2/27/25 10:28amRecord Review reflected a head-to-toe comprehensive assessment including respiratory system was completed on Resident #1 on 2/25/25 by the DON with no negative finding. Record review reflected that 6/6 residents who wore oxygen continuously were evaluated to ensure physicians orders were being followed and residents were receiving oxygen. Record review reflected on 2/25/25 the DON and the ADON were reeducated by the Clinical Services Director on verifying oxygen was on and tank had enough for residents when going out on pass and during activities in the building. Record review reflected that licensed nurses (10/12) have been reeducated on oxygen administration 676409 Page 9 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0695 Level of Harm - Immediate jeopardy to resident health or safety on 2/25/25 by the DON including validating residents were receiving oxygen per physicians' orders, validating residents with orders for continuous oxygen had a full tank prior to going out of the facility, and documenting on the residents leave of absence form adequate supply of oxygen. Record review reflected that 1 random staff member had been audited by the DON for comprehension on education provided related to oxygen dated 2/26/25 and passed. Residents Affected - Few Record Review reflected that the DON rounded daily, and documented oxygen was being delivered as ordered for those residents requiring oxygen dated 2/25/25, 2/26/25, and 2/27/25. Record review reflected that Resident #1 was provided a leave of absence form on 2/26/25 and the oxygen tank was verified by the DON to be full prior to the resident's exit from the facility for a medical appointment. Record review reflected that on 2/25/25 at 7:00PM a QAPI was held attended by the Medical Director, Interim Administrator, Interim DON, and the Clinical Services Director. During the meeting the IJ was discussed along with the writing of the POC. Observation on 2/27/25 at 11:38 am rounds were completed and reflected 6/6 residents requiring continuous oxygen had oxygen in place as ordered by their physician. Their portable tanks were secured and full or almost full. Interviewed 10 nursing staff (2-night shift LVN A and LVN B, 1 agency staff nurse LVN C, 1 PRN LVN D, a Weekend Supervisor RN E, and 5-day shift nurses LVN F, LVN G, LVN H, LVN I, LVN J ) they stated they had been educated on receiving oxygen orders, oxygen administration, oxygen order verification, and validating residents who required oxygen had it in place as ordered by the physician. They stated they were aware of the leave of absence form and to verify in writing on the form, that residents who were going out on pass and required oxygen, that their tanks were full. The Nurses stated the pass forms were printed from their matrix (an electronic medical record) system and in writing the nurse validated the amount of oxygen in the tank onto the form to ensure the resident was safe for transportation. In an interview on 2/27/25 at 2:35 pm the Interim DON stated she was educated by the clinical services director on oxygen administration, checking oxygen, and ensuring residents were adequately equipped with oxygen prior to leaving the facility. She stated she educated the nursing staff on the above in person and by phone. There were 2 nurses that work night shift that have not worked since the IJ was called and they would be educated prior to their next shift. She stated she did do a head-to-toe full comprehensive assessment on Resident #1 with no negative findings. The DON stated an audit was completed on residents with oxygen and all residents receiving oxygen had adequate supply within their portable tanks. She stated she has questioned 1 nurse this week so far to ensure comprehension of new oxygen plan and plans to continue audits x 4 weeks. The DON stated since Resident #1 frequently leaves for appointments and was out of her room the facility was planning on obtaining her a portable concentrator for her to take with her that will be battery operated with a backup battery in case it was needed. The portable concentrator had already been ordered at that time. The plan was for all residents to have adequate oxygen supply if needed and no negative outcomes. In an interview on 2/27/25 at 2:50PM the Interim ADM stated the POR had been implemented as written, the nursing mangers were educated and in turn the nurses were educated by the managers. He stated that an audit was completed on residents receiving oxygen and all residents were receiving it per 676409 Page 10 of 11 676409 02/27/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few physicians' orders. He stated Resident #1 had a full body assessment and there were no negative findings. He stated a QAPI meeting was help with The Medical Director for the development of the POR and all residents would receive an out on leave form printed from their EMR. The nurses were to sign the form ensuring residents leave the facility with a full bottle of oxygen. He stated that today the facility had ordered a portable concentrator for Resident #1 to ensure she always had adequate supply of oxygen because she was out of her room often and the portable concentrator would not restrict her freedom to roam the building as she desired. The Interim ADM and Interim DON were informed the Immediate Jeopardy was removed on 02/27/2025 at 3:45 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 676409 Page 11 of 11