The Brazos Of Waco

F-F695

Head to toe comprehensive assessment, including assessing the respiratory system for abnormalities, signs of distress or change in condition completed on Resident #1 by Director of Nursing/Designee on 2/25/25 with no negative effects and physician notified.

Resident #1's responsible party notified on 2/25/25.

An observation of the 6 residents currently in the facility with orders for continuous Oxygen was completed

on 2/25/25 by the Director of Nursing/Designee to validate oxygen is being delivered per physician orders. No issues identified.

Administrative Nurses were reeducated on Oxygen Administration on 2/25/25 by the Clinical Consultant including:

Validate residents are receiving oxygen per physician's orders.

Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of

the facility and document on the resident's leave of absence form.

Licensed nurses were reeducated on Oxygen Administration on 2/25/25 by the Director of Nursing/Designee including:

Validate residents are receiving oxygen per physician's orders.

Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of

the facility and document on the resident's leave of absence form.

Licensed Nurses working on 2/25/25 received this education. All nurses that have not worked will receive education by the Director of Nursing/Designee prior to their next scheduled shift. This education will also be completed in New Hire and agency orientation by the Director of Nursing/Designee.

Member of Nursing Management will interview 2 staff members per week for 4 weeks to validate comprehension of provided reeducation.

Members of Nursing Management will round daily and document on the validation tool for 5 days to validate that oxygen is being delivered per physician's orders, then 3x per week for 2 weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 676409 Department of Health & Human Services Printed: 09/07/2025 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 676409 B. Wing 02/27/2025

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

The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

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 Director of Nursing/designee will validate and document on the validation tool that the leave of absence form is completed for residents who leave the facility and have orders for continuous oxygen, including Level of Harm - Immediate documentation that the resident was sent with a full portable cylinder. This will be validated daily for 5 days, jeopardy to resident health or then 3x per week for 2 weeks. safety QAPI was held on 2/25/25. Residents Affected - Few

The Medical Director was notified of the Immediate Jeopardy on 2/25/25.

Monitoring of the plan of removal included the following:

2/27/25

10:28am-

Record Review reflected a head-to-toe comprehensive assessment including respiratory system was completed on Resident #1 on 2/25/25 by the DON with no negative finding.

Record review reflected that 6/6 residents who wore oxygen continuously were evaluated to ensure physicians orders were being followed and residents were receiving oxygen.

Record review reflected on 2/25/25 the DON and the ADON were reeducated by the Clinical Services Director on verifying oxygen was on and tank had enough for residents when going out on pass and during activities in the building.

Record review reflected that licensed nurses (10/12) have been reeducated on oxygen administration on 2/25/25 by the DON including validating residents were receiving oxygen per physicians' orders, validating residents with orders for continuous oxygen had a full tank prior to going out of the facility, and documenting

on the residents leave of absence form adequate supply of oxygen.

Record review reflected that 1 random staff member had been audited by the DON for comprehension on education provided related to oxygen dated 2/26/25 and passed.

Record Review reflected that the DON rounded daily, and documented oxygen was being delivered as ordered for those residents requiring oxygen dated 2/25/25, 2/26/25, and 2/27/25.

Record review reflected that Resident #1 was provided a leave of absence form on 2/26/25 and the oxygen tank was verified by the DON to be full prior to the resident's exit from the facility for a medical appointment.

Record review reflected that on 2/25/25 at 7:00PM a QAPI was held attended by the Medical Director, Interim Administrator, Interim DON, and the Clinical Services Director. During the meeting the IJ was discussed along with the writing of the POC.

Observation on 2/27/25 at 11:38 am rounds were completed and reflected 6/6 residents requiring continuous oxygen had oxygen in place as ordered by their physician. Their portable tanks were secured and full or almost full.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 676409 Department of Health & Human Services Printed: 09/07/2025 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 676409 B. Wing 02/27/2025

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

The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

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 Interviewed 10 nursing staff (2-night shift LVN A and LVN B, 1 agency staff nurse LVN C, 1 PRN LVN D, a Weekend Supervisor RN E, and 5-day shift nurses LVN F, LVN G, LVN H, LVN I, LVN J ) they stated they Level of Harm - Immediate had been educated on receiving oxygen orders, oxygen administration, oxygen order verification, and jeopardy to resident health or validating residents who required oxygen had it in place as ordered by the physician. They stated they were safety aware of the leave of absence form and to verify in writing on the form, that residents who were going out on pass and required oxygen, that their tanks were full. The Nurses stated the pass forms were printed from Residents Affected - Few their matrix (an electronic medical record) system and in writing the nurse validated the amount of oxygen in

the tank onto the form to ensure the resident was safe for transportation.

In an interview on 2/27/25 at 2:35 pm the Interim DON stated she was educated by the clinical services director on oxygen administration, checking oxygen, and ensuring residents were adequately equipped with oxygen prior to leaving the facility. She stated she educated the nursing staff on the above in person and by phone. There were 2 nurses that work night shift that have not worked since the IJ was called and they would be educated prior to their next shift. She stated she did do a head-to-toe full comprehensive assessment on Resident #1 with no negative findings. The DON stated an audit was completed on residents with oxygen and all residents receiving oxygen had adequate supply within their portable tanks. She stated

she has questioned 1 nurse this week so far to ensure comprehension of new oxygen plan and plans to continue audits x 4 weeks. The DON stated since Resident #1 frequently leaves for appointments and was out of her room the facility was planning on obtaining her a portable concentrator for her to take with her that will be battery operated with a backup battery in case it was needed. The portable concentrator had already been ordered at that time. The plan was for all residents to have adequate oxygen supply if needed and no negative outcomes.

In an interview on 2/27/25 at 2:50PM the Interim ADM stated the POR had been implemented as written, the nursing mangers were educated and in turn the nurses were educated by the managers. He stated that an audit was completed on residents receiving oxygen and all residents were receiving it per physicians' orders.

He stated Resident #1 had a full body assessment and there were no negative findings. He stated a QAPI meeting was help with The Medical Director for the development of the POR and all residents would receive

an out on leave form printed from their EMR. The nurses were to sign the form ensuring residents leave the facility with a full bottle of oxygen. He stated that today the facility had ordered a portable concentrator for Resident #1 to ensure she always had adequate supply of oxygen because she was out of her room often and the portable concentrator would not restrict her freedom to roam the building as she desired.

The Interim ADM and Interim DON were informed the Immediate Jeopardy was removed on 02/27/2025 at 3:45 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated 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 11 of 11 676409