Avir At Lindale

F-F600 Neglect. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

All nurses will be educated on respiratory therapy for nurses, including but not limited to tracheostomy care, Trilogy care, Tracheostomy suctioning, by the respiratory therapist.

Approaches: The VP of Clinical Operations, Clinical Support Specialist, respiratory therapist and ADON will deliver in service education to nurses one on one.

If emergency items are on back order from the supplier, the facility is able to obtain said supplies from many of our sister facilities. The Director of Nursing, Administrator, ADON, and Treatment Nurse were educated by

the VP of Clinical Operations, to notify the VPCO immediately if emergency supplies are back order and are needed by the facility immediately. This in-service was completed on [DATE REDACTED].The VPCO will ensure supplies are obtained from a sister facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0600 1. The facility medical Director was informed of the IJ on [DATE REDACTED] by the VP of Clinical Operations.

Level of Harm - Immediate 2. Resident #1 remains in the hospital. jeopardy to resident health or safety 3. Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and

on the crash cart, verified by the VP of Clinical Operations on [DATE REDACTED]. Residents Affected - Some 4. Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations on [DATE REDACTED].

5. Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations on [DATE REDACTED].

6. There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility. Nurses were in serviced by the VP of Clinical Operations on [DATE REDACTED] regarding the new emergency toolboxes. All nurses will be in serviced on this new system before they are able to return to facility for their shift. All new nurses will be trained on this practice prior to starting their shift on the floor. This training will be placed in the clinical orientation packet with HR by

the VP of Clinical Operations on [DATE REDACTED].

7. All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart. The 100-hall nurse is designated to check the crash cart every night, this is included on the in-service given to nursing staff by the VP of Clinical Operations on [DATE REDACTED]. Also included on the in-service was for the nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log. This in-service was completed on [DATE REDACTED] by the VP of Clinical Operations. All nurses will be in-serviced on this system prior to returning to their shift. All new nurses will be trained on this practice prior to beginning their shift. This information is added to the clinical orientation with HR on [DATE REDACTED] by the VP of Clinical Operations.

8. All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach are at the bedside of tracheostomy residents. All nurses on staff at this time besides one that is in the hospital, h [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19401 safety Based on interview and record review the facility failed to provide basic life support, including CPR, to a Residents Affected - Some resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the residents advanced directives for 1 of 4 residents reviewed for emergency care. (Resident #1)

1. Resident #1 a full code status ( a medical code status that indicated to take all steps to save the residents life in the event of cardiac or respiratory arrest, including CPR) turned blue and had no pulse or heart rate,

the facility staff requested the crash cart (a cart with emergency medical supplies) when the cart arrived the emergency supplies were missing.

2. The crash cart did not have AED pads for the AED- defibrillator (AED pad are a vital part of the AED machine that are used to help people experiencing sudden cardiac arrest. The AED pads are place on the person's bare chest and are attached to a cable that connects to the AED to the patient body. The AED then analyzes the hearts rhythm and can deliver an electric shock or defibrillation, to help the heart re-establish normal rhythm.) and they did not have an ambu bag- bag mask ventilation ( the primary tool for resuscitation

in emergency situations such as cardiac arrest).

3. The facility failed to have emergency equipment at the Resident #1's (a tracheostomy resident) bedside as ordered by the physician to include an extra tracheostomy and an ambu bag. The facility nurses did compressions only.

4. Resident #1 was without oxygen to her brain for about 10 minutes prior to EMS arrival and remained unresponsive after she was resuscitated. Resident #1 was placed on hospice due to severe brain damage.

An Immediate Jeopardy (IJ) situation was identified on [DATE REDACTED]. While the IJ was removed on [DATE REDACTED], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

These deficient practices could place residents at risk for not receiving CPR services as needed and being at risk for death.

Findings included:

Record review of Resident #1's face sheet dated [DATE REDACTED] indicated this [AGE] year-old female was admitted to the facility on [DATE REDACTED]. Some of the diagnose were acute respiratory failure, and morbid obesity.

Record review of Resident # 1's baseline care plan dated [DATE REDACTED] indicated she was a full code ( CPR to be preformed) other than that the form was basically blank.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 Record review of Resident #1's care plan dated [DATE REDACTED] indicated a Focused area of Full Code. Some of the interventions were the resident would receive CPR if indicated, and to continue CPR until resident responded Level of Harm - Immediate or until EMS arrived to take over the code. A Focused area tracheostomy status and was risk for increased jeopardy to resident health or secretions, congestion, respiratory infections, and infections to tracheostomy. She required a trach safety Bovina(name brand) flex 7 humidification with air compression at 50 PSI OS at 8 liters per minute via trach collar. Some of the interventions were Ambu bag and an extra inner cannula along with 1 size smaller to be Residents Affected - Some kept at the beside. Monitor oxygen stats and apply oxygen as ordered. Monitor for needed suctioning of increased secretions, congestion assessed for relief.

Record review of Resident #1's MDS dated [DATE REDACTED] titled other was incomplete.

Record review of Resident #1's computerized physician orders indicated BiPap/APAP to be worn at night on at night off in the mornings with setting specified. An order for trach bovina flex 7 extra of that size and one size smaller to be kept in supply box at bedside dated [DATE REDACTED]. The resident required Foley catheter care every shift. May change disposable inter canula of trach daily, emergency trach supplies are to be kept at bedside to include oxygen source, suction machine, additional trach and ambu bag.

Record review of nursing notes dated [DATE REDACTED] at 7:57 p.m. indicated Resident #1 arrived at the facility via EMS. The resident was alert and oriented to self, time, place, situation, and able to make her needs known.

She was a full code. Her vital signs were within normal limits, and she voiced no pain.

Record review of a RT note dated [DATE REDACTED] at 3:41 p.m. indicated Resident #1 was placed on a speaking value and trach was suctioned. Suctioned a small amount of thin white secretions. The patient tolerated the treatment well. Nursing staff on duty instructed on how to place the speaking valve. Time spent 25 minutes.

Record review of nursing note dated [DATE REDACTED] at 3:00 a.m. indicated at 2:15 a.m. CNA called nurse to the room. LVN B went into the room and the resident stated she could not breath and wanted to be switched to her humidified oxygen. LVN B attempted to suction the resident with no secretions removed. The resident went unresponsive with no pulse and no respirations. CPR was started and the crash cart obtained, AED pads applied and 911 called. EMS arrived and CPR continued at 2:32 a.m. pulse obtained but resident continued to be unresponsive, and breaths given via ambu bag continued per EMS instructions. At 2:43 a.m.

the resident was transferred to stretcher, and continued to be unresponsive, pulse continued, continued to administer breaths via ambu bag. At 2:45 a.m. resident transferred to hospital. note signed by LVN A.

Record review the facility crash cart check off list [DATE REDACTED] indicated on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] there were no check offs for those days and the form was not initialed. The rest of the days and the days in between were checked and the form was initialed.

Record review of the facilities crash cart check off list for [DATE REDACTED] indicated there was one day that the form was not signed [DATE REDACTED] all other days were checked as if the supplies were there and signed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 Review for the facility crash cart check on [DATE REDACTED] at 11:43 a.m. of list for [DATE REDACTED] indicated on [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED] the slot for ambu bag was circled and checked. All the other dates except [DATE REDACTED] we Level of Harm - Immediate checked and initialed. On [DATE REDACTED] it was not checked or signed. jeopardy to resident health or safety Record review of an EMS report dated [DATE REDACTED] indicated they were called at 2:17 a.m. They arrived at the facility at 2:24 a.m. and they were at the patient at 2:25 a.m. The facility staff said Resident #1 had only been Residents Affected - Some at the facility for two days. They reported that they were not familiar with her. The staff reported Resident#1 hit her call light and told them she was having breathing problems. The resident had no emergency trach at bedside. All the staff members denied her being their patient and was unable to locate the patient caregiver.( LVN A) The staff reported the patient stated to turn blue before going into cardiac arrest surrounding 2:15 a. m. The fire department was requested by EMS for lift assistance and possible riders due to the patient, not fitting. The report indicated they arrived at the patient side to find [AGE] year-old female lying in bed with CPR being performed. The patient is pulseless and had her ventilator providing resume breaths. Her face appeared purple and warm and dry skin touch. A rapid assessment was performed and findings were noted

on the assessment. The patient was removed from the vent and placed on ambu bag. Staff were informed and squeeze ambu bag about every six seconds. The patient was applied to monitoring devices via stat pads and found with no heart rate. The staff were struggling when attempted to use the ambu bag on the resident.

The staff member was using two hands to squeeze. EMS attempted one ventilation switch to replacing the trach. EMS was informed the patient did not have any emergency trach on standby. EMS used the adult [NAME]( a tool used to unclog trach) and forced it past the clotted mucus plug. EMS suction the place the patient back on the bag. The [NAME] was covered in thick nasty mucus. Ambu bag is now easy to squeeze without issue. Staff informed to breathe with ambu bag about every three seconds until she resumed her normal breathes. EMS quickly obtained return of spontaneous circulation ( resumed heart rate) and the fire department was called to assist. EMS interventions continued as noted above.

Record review of Resident #1 hospital records dated [DATE REDACTED] indicated per admitting providers documentation. Resident #1 was a [AGE] year-old female with a history of diabetes, high blood pressure, morbid obesity, tracheostomy, and feed tube. She presented to the emergency department via nursing facility care on [DATE REDACTED] after a cardiorespiratory arrest. Per nursing home staff, the patient complained of shortness of breath and having difficulty breathing and became unresponsive with no pulse. They initiated CPR with an approximated downtime of 10 minutes prior to EMS arrival. EMS gave one round of epinephrine (used to improve breathing and stimulate the heart.) Resident #1's heart rate resumed and she was transported to the emergency room . In the emergency department she was placed on mechanical ventilation via trach. She was admitted to the ICU after cardiorespiratory arrest. The patient was not waking up despite no sedation medications provided. On [DATE REDACTED] the patient remained on mechanical ventilation with the assisted control and possible seizure disorder. On [DATE REDACTED] and MRI of the brain was completed and indicated acute encephalopathy due to Anoxic( complete absence of oxygen in an organ or tissue) and brain injury.

During a telephone interview on [DATE REDACTED] at 10:00 a.m., LVN A said Resident #1 was her resident on the morning of [DATE REDACTED]. She said she had went to lunch and was gone about 15 minutes. When she arrived back at the facility LVN B and LVN C were performing CPR on Resident #1. She said EMS was already there when she got back. She said LVN B and LVN C did 3 or 4 rounds of just of compressions, EMS got Resident #1 suctioned. LVN A said when EMS suctioned Resident #1 a lot of blood came out. She said EMS connected the ambu bag to the trach.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 During a telephone interview on [DATE REDACTED] at 10:45 a.m., LVN A said Resident #1 did not have a trach at her bedside because she did not see one. She said she did not think EMS asked for one. She said CNA D called Level of Harm - Immediate LVN B to say Resident #1 was having difficulty breathing. LVN B told her when she arrived in the room and jeopardy to resident health or Resident #1 was talking and when she removed the Trilogy respiratory system from her and tried to suction safety her Resident #1 coded. She said then they started CPR .

Residents Affected - Some During a telephone interview on [DATE REDACTED] at 1:00 p.m., CNA D said she and CNA F were walking down the hall and Resident #1 started screaming she could not breathe. She said LVN B came into the room and tried to fix her oxygen. CNA D said that did not work, and Resident #1 was turning blue. She said LVN B screamed for LVN C to get the crash cart. She said when they got the crash chart, she knew they could not find something, but she did not know what it was.

During a telephone interview on [DATE REDACTED] at 1:05 p.m. CNA F said she and CNA D were walking down the hallway on the morning of [DATE REDACTED] about 2:00 a.m. They heard Resident#1 say she could not breath. She said LVN B came in and started checking Resident #1's tubes. She said LVN B began to try to suction Resident #1, and suctioning did not work. She said Resident started turning blue. She said LVN B began CPR and she and LVN C called for the crash cart. CNA F said there were no AED Pads and no Ambu bag

on the crash cart. She said when EMS arrived, they had those things. She did not know if EMS was looking for anything else or not.

During a telephone interview on [DATE REDACTED] at 1:09 p.m. LVN C said she was down the hall and LVN B screamed her she had a code. She said LVN B was in Resident #1's room and she was a new patient. LVN said she knew nothing about the lady. She said when she arrived in the room Resident#1 was turning blue.

She said LVN B was starting CPR and they got the crash cart. She said there were no AED Pads and no ambu bag on the crash cart. She told the other nurse to call 911. She said EMS was very quick to respond.

She said they did not go the storage room to look for an ambu bag or AED pads. She said they spent their time trying to save the residents life. LVN C said Resident #1 was a large lady it took both to do compressions and try to suction her. She said when EMS arrived, they put the Ambu bag on Resident #1.

She said at first the bag was hard to squish it because there was no airflow. She said they were able not to suction her, however, EMS had a tool to remove the mucus plug with. She said when the former DON was at

the facility, she was informed they did not have ambu bags, AED pads and supplies. She said since the new DON arrived, they have all the supplies. She said she did not know if Resident #1 had an extra trach at bedside or not. She was on the other side of the bed. She said EMS did ask if Resident # was either one of

the nurses' patients and she was not. She said Resident #1's nurse was on break.(LVN A) She said she did not know if EMS asked for a trach or not, she barely knew Resident #1's name.

During an interview on [DATE REDACTED] at 1:22 p.m. the VP of Clinical Operations said she took the position as acting DON [DATE REDACTED] and was informed that day the supplies were not on the crash chart. She said she did do an impromptu in-service about the crash cart and supplies. She said she did not conduct a formal in service because she thought the items were used on [DATE REDACTED], she did not realize they did not have them to use. The VP said she checked the crash cart to make sure it had everything in place and had since she took the position. She had found the ambu bags in a box in the storage room. Thy did not have any AED pads. The VP said she ordered them one day and they were delivered the next day. She said staff members told her

the former DON said the items were on back order, however she did not have a problem getting them. She said they now have extra everything.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 During a telephone interview on [DATE REDACTED] at 10:35 a.m., LVN B said she heard beeping and was at the nurse's station. She said she saw the call light go off and headed down the hall. She said she did not hear the Level of Harm - Immediate resident say anything she mouthed the words. She said Resident #1 said I can't breathe. She said the alarm jeopardy to resident health or on the machine was going off as well. The machine read low pressure. She said the resident asked her to safety please switch her off the ventilator. She said before she could hook the resident up to the humidifier the resident lost pulse. She said the first minute or so the resident had a faint pulse. She said they were unable Residents Affected - Some to get any air into Resident #1's airway because the airway was blocked. EMS unclogged the mucus plug and they were then able to use the ambu bag to get air into Resident #1's lungs. She said a couple of times it appeared Resident #1 took a deep breath. She did not know how long Resident #1 went without air in her system. She said she did not know if the ambu bag would have helped because the airway was completely blocked. LVN B said she could not say if the mucus plug could not have been loosened sooner with the ambu bag. She said there was no ambu bag at the bedside and no ambu bag on the cart. When the cart arrived, there were no AED pads. She said she was told a few days prior the ambu bags and AED pads were

on back order by the former DON. She said she checked the cart on the night shift and knew the supplies were not on the cart. She said they had been out of those supplies for a few weeks but were always told they were on back order. She said she had circled a few days when the supplies were not available. ( Review of

the log showed days circled were [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED].)

During an interview on [DATE REDACTED] at 12:00 a.m . the VP said she did not know what circles on the crash cart check log meant. She said she did not know how long the supplies were missing from the cart.

During an interview on [DATE REDACTED] at 11:10 a.m., LVN I said she started work at the facility on [DATE REDACTED]. She said

on [DATE REDACTED] she was shadowing LVN A. She said the nurse had left the facility and she was in the hallway when she her heard LVN B yell she needed help with CPR. She said she had went into Resident #1's room and she did not see a trach on her bedside table. She did not remember if EMS asked for a trach or not. She said when the crash cart was arrived there was no ambu bag or AED pads. She said the staff were unable to use the AED machine and they just did compressions u ntil EMS arrived. She said the resident was probably not breathing for 8 to 10 minutes with no pulse.

During a telephone interview with Resident #1's family member on [DATE REDACTED] at 4:00 p.m., the family member said they were told prior to Resident #1 coming to the facility she would only be there for a couple of weeks.

They said she was doing well with the trach and the hospital staff said she would likely be able to breathe on her own and have it removed in a few short weeks. The family member said when they arrived at the hospital

on [DATE REDACTED] they were in the room with the physician when he called the facility to ask how long Resident #1 was without oxygen to her brain. She said the physician was told by some nurse about 10 minutes. The family member said the physician was trying to determine why Resident #1 was still unresponsive. The family member said the doctor said it was due to lack of oxygen to her brain for an extended period. She said

they were basically told Resident #1 had no hope of survival and was brain dead. The family member said

they removed Resident #1 from life support on [DATE REDACTED] and the moved her to hospice inpatient services on [DATE REDACTED]. The family member said Resident #1 was still breathing and that was all. The family member said Resident #1 did not respond in anyway, she was just lying in the bed breathing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 Record review of the facility's, emergency crash cart and automated extended defibrillators policy, dated [DATE REDACTED], indicated it was the policy of the facility to ensure that the facility would maintain at least one Level of Harm - Immediate emergency cart per nursing care floor with additional carts added as deemed necessary in the case of the jeopardy to resident health or need for basic life support. In addition, the facility would ensure that at least one AED was available for use safety in the case of cardiac emergencies. The purpose of this policy was to ensure that all supplies critical to basic life support were readily available on the emergency cart. The facility would store the emergency cart in a Residents Affected - Some location that was readily accessible outside of the office. Equipment supplies for the emergency crash cart or used only when an emergency was provided. Emergency supplies used for an emergency from the crash cart are noted and replace promptly. The emergency cart would be checked every 24 hours and after every use. Missing or expired items were replaced when applicable. The AED was authorized for personal certified

in CPR and use of the AED. The AED will be checked every night shift and the battery replace according to manufacturer's recommendations. Follow manufacturer instructions to use of the AED. Clinical staff would be educated on the location use of the emergency cart and the AED. Nursing staff should be familiar with the contents located on and within the emergency card.

Record review of the facility's cardiopulmonary resuscitation policy, dated [DATE REDACTED], indicated it was the policy of the facility to adhere to resident rights to formulate advance directives in accordance with those rights this facility would implement guidelines regarding CPR. The facility will follow American Heart Association guidelines regarding CPR.

The website for the American Heart Association indicated reflected performing lifesaving CPR procedures include chest compressions, AED- defibrillator, Ambu- bag mask ventilation, intubation that can produce aerosols.

This was determined to be an Immediate Jeopardy (IJ) on [DATE REDACTED] at 4:00 PM. The Administrator and VP of Clinical Operations were notified. The ----- was provided with the IJ template on [DATE REDACTED] at 4:05 p.m.

The following Plan of Removal submitted by the facility was accepted on [DATE REDACTED] at 1:22 p.m.:

Problem:

F-F678 Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advanced directives.

Goal: Facility will be in compliance with federal health, safety, and/or quality regulations.

All nurses will be educated on the crash cart policy and where to find emergency medical equipment to perform CPR. All equipment required, including but not limited to, Ambu bag, AED,

AED pads, and emergency tracheostomy cannulas, (size according to the resident orders), will be available for use in the facility, and at the bedside of tracheostomy residents, and on the crash cart.

Approaches: The VP of Clinical Operations, Clinical Support Specialist, and ADON will deliver in service education to nurses one on one.

1. The facility medical Director was informed of the IJ on [DATE REDACTED] during an Ad Hoc QAPI meeting, by the VP of Clinical Operations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 2. Resident #1 remains in the hospital.

Level of Harm - Immediate 3. Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and jeopardy to resident health or on the crash cart, verified by the VP of Clinical Operations on [DATE REDACTED]. safety 4. Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black Residents Affected - Some tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations on [DATE REDACTED] .

5. Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations on [DATE REDACTED]. There are currently 2 residents in house with tracheostomy's .

6. There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility. Nurses were in serviced by the VP of Clinical Operations on [DATE REDACTED] regarding the new emergency toolboxes. All nurses will be in serviced on this new system before they are able to return to facility for their shift.

7. All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart. Also included on the in-service was for the nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log. This in-service was initiated on [DATE REDACTED] by the VP of Clinical Operations. All nurses will be in-serviced on this system prior to returning to their shift.

8. All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach care at the bedside of tracheostomy residents. The facility respiratory therapist educated all nurses on the use of the Ambu bag in case of respiratory distress during the on site training on [DATE REDACTED]. All nurses will be in-serviced on this policy before

they return to facility for their next shift by the facility respiratory therapist or RN trained by the facility respiratory therapist before beginning their next shift.

9. All nurses on staff at this time besides one that is in the hospital, have been in-serviced by the VP of Clinical Operations on [DATE REDACTED]. All nurses will be in-serviced on this policy before they return to facility for their next shift.

Monitoring: All new nurses will be educated on the policy for crash cart and emergency tracheostomy supply boxes prior to starting their shift. This information will be included in the orientation packet. Will review for compliance monthly in QAPI X3 months.

The DON/designee will monitor daily to ensure all items are present on crash cart and the nurse who checked the crash cart initials are on the crash cart log. Nurses call the DON with any missing items.

During observations on [DATE REDACTED] at 7:15 a.m. with the VP revealed the crash cart was full stocked with AED pads and two ambu bags, and the crash cart check off list was signed. The DNR list was completed on [DATE REDACTED] .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 During an interview on [DATE REDACTED] at 1:15 p.m., the VP of Clinical Operations said she conducted a training with

the Administrator, ADON, and the MDS nurse about the supplies being available for emergency use. They Level of Harm - Immediate were informed if the supplies were low to order them. If there was a problem with receiving the order to notify jeopardy to resident health or her. She said they should have the trach at the bedside to give to EMS so they could replace it or take it to safety the hospital with the residents. She said the staff were in serviced on the crash cart, checking it, making sure supplies were available. They were informed if supplies were not there to notify the DON. Residents Affected - Some

During an interview on [DATE REDACTED] at 1:29 p.m., the Administrator said she was in serviced on the crash cart and missing supplies. She said if anyone told her they were out of supplies and were unable to order them. She would report to the VP immediately. She said she assumed the role of administrator of the facility on [DATE REDACTED].

She said they had the former DON at that time. She said the staff never reported to her anything about being out of supplies. She said it was the policy of the facility that the DON ordered the supplies. She said she did not check the cart but was educated on the general aspects of the system. She said they did the ad hop QAPI. She said she was still acclimating to the facility, was relatively new to the building and no one made her aware of any issues.

Record review of a facility clinical meeting plan indicated ad hoc QAPI meeting dated [DATE REDACTED] indicated the medical Director was present via phone, emergency supplies at the bedside, emergency supplies being available, and inspection of the crash cart.

During observations on [DATE REDACTED] at 7:15 a.m. with the VP revealed the crash cart was full stocked with AED pads and two ambu bags, and the crash cart check off list was signed. The DNR list was completed on [DATE REDACTED] .

Record review of the crash cart and check off list on [DATE REDACTED] at 8:00 a.m. with the VP indicated it had been checked for the appropriate days and the supplies were present.

Record review of trainings dated [DATE REDACTED] indicated education was provided on emergency equipment and a test on what equipment could consist of, when to order, who to notify if the equipment need to be ordered, where the equipment was kept and where ventilator patient supplies were kept.

Interviews were conducted with facility staff on [DATE REDACTED].

At 1:57 p.m. ADON RN

At2:23 p.m. LVN H worked 6 to 6 p

At 2:39 LVN I worked 6a to 6p

At 2:48 p.m. RN J worked 6a to 6p

At 3:46 p.m. LVN K worked 6p to 6a

At 9:14 p.m. LVN L worked 6p to 6a

At 9:25 p.m. LVN B worked 6p to 6a

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 745021 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 745021 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lindale Specialty Care Center 13905 Fm 2710 Lindale, TX 75771

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 0678 Interviews were conducted with facility staff on [DATE REDACTED].

Level of Harm - Immediate At 7:25 a.m. LVN G worked form 6a to 6 p jeopardy to resident health or safety At 7:30 LVN E worked from 6a to 6p.

Residents Affected - Some Interviews with nurses indicated they were knowledgeable about the in-services provided regarding CPR and ensuring supplies were on the cart and available. They said if they used emergency supplies, they would replace them, and notify the DON. If they checked the crash cart and supplies were not there, they would not just initial the check list. They would notify the DON, let the Administrator know and if need be, notify the VP of Clinical operations. They were knowledgeable about the black boxes at the bedside of trach residents that contained an extra trach and ambu bag. The nurses said they were not to replace a trach if it became dislodged to call 911 and have the trach for the EMS staff.

Record review of a facility clinical meeting plan indicated ad hoc QAIP meeting, dated [DATE REDACTED], indicated the Medical Director was present via phone, emergency supplies at the bedside, emergency supplies being available, and inspection of the crash cart.

Record review of the crash cart and check off list, on [DATE REDACTED] at 8:00 a.m., with the VP indicated it had been checked for the appropriate days and the supplies were present.

Record review of trainings, dated [DATE REDACTED], indicated education was provided on emergency equipment and a test on what equipment could consist of, when to order, who to notify if the equipment need to be ordered, where the equipment was kept and where ventilator patient supplies were kept.

The Administrator and VP of Clinical Operations were informed the IJ was removed on [DATE REDACTED] at 8:05 a.m.; however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate

the effectiveness of the corrective systems that were put into place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 745021