Health inspection·September 13, 2022

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 residents who need respiratory care are provided and consistent with professional standards of practice and the resident's care plan for 1 (Resident #10) of 2 resident reviewed for oxygen use, in that, Residents Affected - Few Resident #10 received oxygen at 5 Liters Per Minute trach collar instead of 2 LPM as per physician's order. This deficient practice could place residents receiving respiratory care and services at risk of respiratory complications. The findings included: Record review of Resident #10's admission Record, dated 09/13/22, revealed Resident #10 was a [AGE] year old female, who was admitted to the facility on [DATE], diagnoses included: Acute respiratory failure (breathing is affected) with hypercapnia (too much carbon dioxide in the bloodstream, usually caused by inadequate respiration), and tracheostomy status (incision into the trachea that forms a permanent or temporary opening). Record review of Resident #10's Quarterly MDS, dated [DATE], revealed Resident #10: -was rarely/never understood, -was rarely/never able to understand others -used oxygen therapy -had an active diagnoses of tracheostomy status Record review of Resident #10's Care plan revealed: Date Initiated: 05/25/22, revised on 06/21/22 Tracheostomy r/t impaired breathing mechanics secondary to traumatic brain injury An intervention was to give humidified oxygen as prescribed. Record review of Resident #10's Order Summary Report, dated 09/13/22 revealed: Cool aerosol at 2 liters FiO2 via trach-collar every shift (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 3 Event ID: 745000 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 745000 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Las Alturas DE Penitas 414 Liberty Blvd. Penitas, TX 78576 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)