Millbrook Healthcare And Rehabilitation Center
Inspection Findings
F-Tag F0695
F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
1:02PM with LVN A revealed that she was Resident #1 and Resident #2's nurse. She stated that she was not aware that the oxygen tubing and the prefilled humidifier bottles were not dated. She stated that she usually checked the oxygen tubing to make sure they were dated. She stated that the oxygen tubing and prefilled humidifier were changed every week on Sunday night and PRN. She stated it was important to date all tubing so that everyone track when the tubing was last changed. She stated that it was important to change tubing every week, and store tubing in plastic bags and place in the drawers to prevent contamination and infections. She stated that she had been in service on infection control and oxygen tubing care.Interview 10/16/2025 at 1:34pm with LVN B revealed that oxygen tubing was supposed to be changed on Sunday night shift. She stated she usually checked the oxygen tubing and prefilled humidifier bottlers to make sure they were dated. She stated she was not aware that Resident #3's oxygen tubing and
the prefilled humidifier bottle were not dated. She stated the importance of dating oxygen tubing was to track its age so it could be replaced according to the recommended schedule. She stated that she had been in service on infection control and oxygen tubing care.Interview 10/16/2025 at 4:30PM with DON revealed her expectation was the nurse assigned should be check the oxygen tubing and prefilled humidification bottles as part of overall assessment make sure it was properly functioning. She stated oxygen tubing was changed weekly on the night shift and if the night shift were busy then any shift could change. She stated all oxygen tubing and prefilled humidification bottles should be dated. She stated that all oxygen tubing should be stored in a plastic bag. She stated the risk to the resident if tubing was not dated or stored in sanitary ways was infection control. She stated that the nurses had been in serviced on infection control and oxygen tubing care.The facility policy titled Infection Control and Policy/Procedure Reviewed July 2022 reflected:The goal of the infection control program is to:a. Decrease the risk of infection to patients and personnelb. Monitor for the occurrence of infection and implement appropriate control measuresc. Identify and correct problems relating to infection control practicesd. Ensure compliance with state and federal regulations to infection control.The facility policy titled Oxygen Equipment Revised May 2017 reflected:It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable pre-filled humidifiers, tubing, mask, and cannulas for residents receiving oxygen. The equipment is to be discarded. The facility will maintain clean tanks, connectors, and concentrators.Procedures:1. Oxygen Tanks, connectors, and concentratorsa. Oxygen tanks, connectors and concentrators must be cleaned after use.b. Gauges must be cleaned after use as a follows:1. Remove gauge from tank.2. Clean gauge with disinfectants. Allow to dry thoroughly.3. Place clean Guage in oxygen storage area.C. pre-filled humidifiers, when used, are to be dated and replaced every (7) days, according to manufacturers' recommendations, or as needed.1. Tubing should be replaced every week.2. Masks should be replaced every week.3. Cannulas should be replaced every week.4. Oxygen concentrator filters will be cleaned with water and detergent every week according to manufacturer's recommendations.D. Oxygen masks, nasal cannulas, and tubing will be used for one resident only. When used continuously or intermittently, tubing will be routinely changed to prevent the build-up of respiratory secretions, mucous, and bacterial growth.E. When a mask or cannula is temporarily not being used it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.
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Millbrook Healthcare and Rehabilitation Center in Lancaster, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lancaster, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Millbrook Healthcare and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.