State inspectors discovered the violation at Cedar Hollow Rehabilitation Center on December 30 during a complaint investigation. The resident, who requires oxygen therapy through a nasal cannula and twice-daily breathing treatments for acute and chronic respiratory failure, had no idea her breathing equipment was improperly stored.
The nebulizer mask should have been sealed in a plastic bag between treatments. Instead, inspectors found it loose in the drawer with other belongings.
"I don't know if the nebulizer mask was supposed to be in a bag," the resident told inspectors when they asked for permission to open her nightstand drawer.
An empty plastic bag hung from the drawer handle.
The resident receives Budesonide inhalation treatments twice daily through the nebulizer system. Her care plan specifically requires staff to monitor for signs of respiratory distress and administer medications as ordered. At 91, she was readmitted to the facility earlier this year with diagnoses including respiratory failure and low blood oxygen levels.
RN A acknowledged the equipment storage failure when questioned by inspectors. She stated the nebulizer mask "should have been stored in a bag when not in use" and accepted responsibility as the resident's assigned nurse.
"She stated as the resident's nurse, she was responsible for ensuring it was stored in a bag when the resident was not receiving a breathing treatment," the inspection report noted.
The nurse explained the medical risk. Improper storage could lead to respiratory infection for a patient whose lungs already cannot function properly.
The facility's Director of Nursing confirmed the violation during a separate interview. Any staff member could notice improper storage and alert the nurse, she said, but ultimately the assigned nurse bears responsibility.
"She stated it was important to prevent infection," inspectors wrote.
Cedar Hollow's own infection control policy, reviewed as recently as December 2024, explicitly requires respiratory equipment storage "in plastic bag, marked with date and resident's name, between uses."
The policy addresses "Infection Control Considerations Related to Nebulizer/Continuous Aerosol" equipment. Staff had access to the proper storage protocol but failed to follow it.
For residents with compromised respiratory systems, contaminated breathing equipment poses serious health risks. Nebulizer masks deliver medication directly into the lungs through a fine mist. Any bacteria or pathogens on the equipment enter the respiratory system during treatment.
The resident's medical assessment from December 19 showed she remained cognitively intact with a perfect score of 13 on cognitive testing. She understood her medical condition but depended on staff to properly maintain her life-supporting equipment.
State inspectors classified the violation as causing "minimal harm or potential for actual harm." The finding affects respiratory care protocols for all residents who require nebulizer treatments at the facility.
The inspection occurred during a complaint investigation, though the specific nature of the complaint was not detailed in the public report. Inspectors reviewed four residents receiving respiratory care and found violations affecting one patient.
Cedar Hollow Rehabilitation Center operates at 5011 North US Highway 75 in Sherman. The facility must submit a plan of correction addressing how staff will ensure proper respiratory equipment storage going forward.
The resident continues receiving oxygen therapy and twice-daily breathing treatments. Her nebulizer mask now sits in a nightstand drawer, where contamination from personal items and environmental exposure could compromise the very treatments designed to help her breathe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Hollow Rehabilitation Center from 2025-12-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Cedar Hollow Rehabilitation Center
- Browse all TX nursing home inspections