Inspection·November 21, 2025

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 residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident #6) reviewed for respiratory care. The facility failed on 09/23/2025 to ensure Resident #6's oxygen was administered at the correct setting of 4 liters per minute per physician's orders when Resident's oxygen was set at 1 LPM.This failure could place residents at risk of developing respiratory complications. Findings included:Record review of Resident #6's admission record, dated 09/23/2025, revealed an [AGE] year-old male who admitted to the facility on [DATE] with a primary diagnosis of Pneumonia (infection in one or both lungs). Other diagnoses included Acute and chronic respiratory failure with hypoxia (condition when there is not enough oxygen in the tissues in the body), and Chronic Obstructive Pulmonary Disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #6's admission MDS, dated [DATE], revealed a BIMS of 11, indicating moderate cognitive impairment. Record review of Resident #6's care plan, dated 09/01/2025, revealed the following: -The Resident has COPD with intervention of Head of bed elevated while in bed to tolerable/preferred level or out of bed upright in a chair during episodes of difficulty breathing.-The Resident Has altered respiratory status/difficulty breathing r/t COPD, Acute respiratory failure. On Oxygen via nasal cannula with interventions of Monitor for s/sx of respiratory distress and report to MD PRN. and O2 via nasal cannula per physician orders.Record review of Resident #6's Active physician's order summary revealed, O2 at 4 L/min via NC every day and night shift with start date of 09/01/2025.Observation and interview on 09/23/2025 at 3:13 PM revealed Resident #6 lying in bed with nasal cannula on. The oxygen concentrator was on and set at 1 LPM. Resident #6 stated they [staff] had been running it at 4 [LPM]. Resident #6 did not appear to be in respiratory distress. Interview on 09/23/2025 at 4:03 PM, CNA B stated that Resident 6's oxygen was supposed to be set at 2 LPM. She stated she had not checked with the nurse, but when they had another resident on oxygen, the nurse told her to put it on 2 LPM. CNA B stated if oxygen was not at the right setting the resident could have breathing problems. She stated she had not seen Resident #6 have any problems breathing. Observation and interview on 09/23/2025 at 4:23 PM, in Resident #6's room, LVN A stated Resident #6's concentrator was set at 1 LPM. LVN A went to verify the order on the computer and brought the vital sign monitor with her back to the room. Resident #6's oxygen saturation level read 95%. She stated she would check with Therapy about the setting and maybe the knob on the concentrator was bumped. LVN A stated if the setting was incorrect, the risk was the resident could go hypoxic. She said the nurse and everybody else involved in care was responsible for ensuring the setting was correct. She stated the nurses were responsible to monitor and follow the physician order.In a follow up interview on 09/23/2025 at 4:58 PM, CNA B stated she had not changed the setting on the concentrator. She stated when she switched the O2 from the Residents Affected - Few (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: 676489 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 676489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Legacy Midtown Park 8280 Manderville Lane Dallas, TX 75231 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)