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F0695
E

Failure to Sanitize and Store Respiratory Equipment Properly

Round Rock, Texas Survey Completed on 11-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents requiring respiratory care received such care in accordance with professional standards of practice. Specifically, for five residents reviewed, nebulizer masks and oxygen cannulas were not stored in protective bags when not in use. Observations revealed that these respiratory devices were left exposed on side tables, beds, or even on the floor, rather than being properly bagged or stored as required for sanitation. In several cases, there were no protective bags available in the residents' rooms, and residents were not educated on the importance of proper storage. The residents involved had significant medical histories, including acute and chronic respiratory failure, COPD, heart failure, and other serious conditions requiring the use of nebulizers and oxygen therapy. Despite physician orders and care plans specifying the use of these devices, staff did not consistently ensure that the equipment was stored in a sanitary manner. Interviews with nursing staff revealed a lack of in-service training on this subject, and some staff admitted to not following proper procedures for storing respiratory equipment. One nurse acknowledged it was her mistake for not ensuring the masks were protected from contamination. The Director of Nursing confirmed that the usual practice was to store nebulizer masks in drawers, but in reality, this was rarely done, and there was no system in place to ensure compliance. The facility's policy on oxygen administration did not address the need for storing respiratory equipment in protective bags. Additionally, national guidelines reviewed by surveyors indicated that nebulizer parts should be stored in clean, dry plastic bags between uses to prevent contamination, a practice not followed at the facility.

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