The Meadows Health And Rehabilitation Center

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bottle/chamber has adequate amount of distilled water, at least every shift. every shift.Oxygen continuously via Nasal Cannula. May titrate between 2-5 LPM for shortness of breath or pulse oximetry < 90%. every shift for SOB and to maintain pulse ox > 90% . Nurse to verify 02 humidification bottle/chamber has adequate amount of distilled water, at least every shift.order dated 09/28/2025 reflected an order Check Oxygen Concentrator filter for placement and clean filter every week and PRN every night shift every Sun.

Record review of Resident #8's October TAR reflected that the oxygen concentrator was checked, tubing and water was changed on 10/05/2025, 10/12/2025, 10/19/2025, and 10/26/2025. Record review of Resident #8's November TAR reflected that the Oxygen Concentrator filter was checked, tubing and water was changed on 11/02/2025 during the night shift. The water was checked for adequate distilled water on

the Day, Evening, and night shift 11/01/2025, 11/02/2025, 11/03/2025, and 11/04/2025. Observation and

interview on 11/04/25 at 10:50 AM revealed Resident #8 was awake, sitting in his wheelchair with nasal cannula on receiving oxygen via concentrator. During an interview on 11/04/2025 at 2:00 PM, the DON stated that she reviewed and signed the completed MDSs upon completion of all the sections as the RN.

She stated that if the oxygen treatment was not coded, it meant the resident did not use it during the look back period. She would have to check the resident files. She did not address the negative outcome to the resident. During an interview on 11/04/2025 at 2:20 PM, the Administrator stated it was his expectation for

the comprehensive MDS assessments to be completed accurately. During an interview on 11/06/2025 at 1:30 PM with MDS, revealed she completed sections B-health speech and vision, C-Cognitive, D-Mood, E-Behaviors, and Q-participation in Assessments and goal setting. She stated the importance of the resident's comprehensive MDS being accurate was to ensure the resident received the proper care they needed. Record review of facility policy dated 03/2022 and titled Resident assessments reflected The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan.The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Meadows Health and Rehabilitation Center

8383 Meadow Rd 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

ventilation/perfusion matching: Use upright, high-Fowlers position (a medical posture where the patient is sitting upright with the head of the bed elevated at a 60-90 degree angle. ) whenever possible to allow for optimal diaphragm , When on side, the good side should be down (damaged lung should be up). Record

review of Resident #8's Physician's Order dated 08/26/2025 reflected Nurse to verify O2 humidification bottle/chamber has adequate amount of distilled water, at least every shift. every shift.Oxygen continuously via Nasal Cannula. May titrate between 2-5 LPM for shortness of breath or pulse oximetry < 90%. every shift for SOB and to maintain pulse ox > 90% . Nurse to verify O2 humidification bottle/chamber has adequate amount of distilled water, at least every shift.order dated 09/28/2025 reflected an order Check Oxygen Concentrator filter for placement and clean filter every week and PRN every night shift every Sun.

Record review of Resident #8's November 2025 TAR reflected that the Oxygen Concentrator filter was checked, tubing and water was changed on 11/02/2025 during the night shift. The water was checked for adequate distilled water on the Day, Evening, and night shift 11/01/2025, 11/02/2025, 11/03/2025, and 11/04/2025. Observation and interview on 11/04/25 at 10:50 AM revealed Resident #8 was awake sitting in his wheelchair. Observations revealed an oxygen concentrator water bottle that was not dated. The resident said the nurse checked the tubing and bottle during rounds. He could not remember when the water bottle change occurred. During an interview on 11/04/2025 at 1:04 PM with LVN-E stated Resident #1 received oxygen treatments PRN and the tubing was changed during the night shift on Sundays. LVN-E said she changed resident #8's tubing and water bottle 30 minutes after surveyor's observation. LVN-E stated that

the overnight staff changes the tubing every Sunday. LVN-E said that the brown colors that were observed

on the NC were due to the resident being a heavy smoker, per her Google search today. During an

interview on 11/04/2025 at 2:00 PM, the DON stated the housekeeping staff were responsible for cleaning

the oxygen concentrators. The DON said the oxygen tubing should be changed on Sundays during the night shift and as needed. The DON said the facility policy did not require the NC to be dated. The DON said that Resident #1's NC discoloration was due the resident excessively smoking, despite re-education from nursing staff. The DON said that she was aware of the resident's NC discoloration, however, she was could not say how long it would take for the discoloration to occur on the NC. DON said the tubing should be changed as needed when soiled. During an interview on 11/04/2025 at 2:18 PM, the ADON stated the staff were responsible for ensuring all the respiratory devices were clean during resident rounds. She said

the staff should change tubing as needed, and she would educate the staff and document in the care plan frequent NC changes for Resident #1. She stated that another expectation was for the staff to ensure the humidifier bottle was dated when changed. She said she would coordinate with the DON to do an in-service regarding dating and monitoring respiratory devices and changing the tubing. During an interview on 11/04/2025 at 2:20 PM, the Administrator stated that Resident #1's tubing was changed on Sundays during

the night shift, and it was the ADON and the DON responsibility to monitor clinical treatments. Record

review of the facility policy undated, titled Oxygen Administration reflected PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration.Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.3. Assemble

the equipment and supplies as needed.Weekly Documentation 1. Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record.Reporting.1.

Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice.

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