Las Alturas de Penitas: Oxygen Failures Risk Resident - TX
The resident in that room, identified in inspection records as Resident 69, had a tracheostomy and was on continuous oxygen. She could not use a call light to summon help. LVN A, the nurse assigned to her hall at Las Alturas de Penitas, told inspectors she had checked the oxygen setting at the start of her 2:00 p.m. shift on May 26, raised the level to 5LPM, and assumed it had stayed there. She had not noticed the flow meter ball was malfunctioning. She confirmed she had not been back to check on Resident 69 since the start of her shift.
LVN A told inspectors herself why that mattered: not checking on Resident 69 often could lead to not catching her in respiratory distress.
The CNA assigned to the same hall told inspectors she had also started her shift at 2:00 p.m. and had not yet checked on Resident 69 by the time inspectors spoke with her at 3:28 that afternoon. CNA C said she knew the resident was on continuous oxygen. She said she understood that residents who couldn't use call lights needed to be checked more frequently than every two hours, because they could be in distress and no one would know. She had received training on caring for residents on oxygen.
The broken concentrator was only part of what inspectors found. The humidifier bottle attached to Resident 69's oxygen equipment was dated May 18. The inspection took place May 26. That bottle had been sitting there for eight days.
LVN A explained that the tubing and humidifier bottle were supposed to be changed every Sunday during the night shift. When she checked the oxygen tubing in the room, every piece of tubing showed a date of May 24, the most recent Sunday. The humidifier bottle had been missed.
LVN B, the nurse who worked the night shift that Sunday, told inspectors he had been aware the humidifier bottle needed to be changed. When he gathered supplies, he said, he must have forgotten to get it. He said it was important to change it to prevent bacteria from building up and to prevent infection.
The director of nursing confirmed the night shift nurse was responsible for the change and that nurses were supposed to verify the concentrator was functioning properly and that all oxygen settings matched physician's orders. She confirmed nurses received quarterly and annual training on caring for trach patients.
What the inspection captured, in a single afternoon, was a cascade of small failures surrounding one resident who had no way to signal that anything was wrong. A machine that looked like it was working but wasn't. A supply change that was mostly completed. A check-in that hadn't happened yet, more than an hour into a shift, for a patient whose care plan required frequent monitoring precisely because she couldn't ask for help herself.
LVN A, after inspectors raised the issue, said the concentrator machine was faulty and would be swapped out.
Resident 69 remained in that room, on that equipment, until someone decided to act.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Alturas De Penitas from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
LAS ALTURAS DE PENITAS in PENITAS, TX was cited for violations during a health inspection on May 28, 2026.
The resident in that room, identified in inspection records as Resident 69, had a tracheostomy and was on continuous oxygen.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.