Inspection·December 7, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on observation, record review, staff interviews, the facility failed to ensure a base line care plan included oxygen usage and respiratory treatments. This affected one (#196) of 14 residents reviewed for care plans. The facility census was 42. Findings include: Review of medical record for Resident #196 revealed an admission date of 11/30/22, with diagnoses including: dementia with agitation, respiratory failure with hypoxia, hyperlipidemia, chronic obstructive pulmonary disease (COPD), hypotension, unspecified body in respiratory tract part unspecified causing other injury, cardiomyopathy, paralysis of vocal cords and larynx, allergic rhinitis due to animal hair and dander, atherosclerotic heart disease of native coronary artery, hypertension, depression, anxiety, personal history of malignant neoplasm of breast, insomnia, and gastro-esophageal reflux disease. Review of base line care plan dated 11/30/22 revealed no care plan for oxygen therapy or respiratory issue. Review of physician orders for Resident #196 revealed order for humidified oxygen at two to five liters (L) via nasal cannula (nc) per concentrator to keep oxygen saturation greater than 90 percent (%), albuterol sulfate (hydro fluoroalkane) HFA inhalation aerosol solution 108 (90 base) microgram (mcg)/ACT- two puffs orally every six hours as needed for shortness of breath (SOB)/wheezing, albuterol sulfate nebulization solution (2.5 milligrams (mg)/three milliliters(ml)) 0.083% take one unit dose per aerosol every four hours as needed for dyspnea (SOB), budesonide inhalation suspension 0.5 mg/2 ml inhale 2 ml orally twice daily for COPD, elevate head of bed to reduce SOB while lying flat as tolerated, and yupelri inhalation solution 175 mcg/3 ml daily for COPD. Observation on 12/04/22 at 9:49 A.M., of Resident #196 revealed the resident had on oxygen at two liters via nasal cannula. Resident #196 appeared anxious and stated I need oxygen. Interview on 12/04/22 at 4:07 P.M., with Registered Nurse (RN) #366 stated Resident #196 needed oxygen and would call out she needed oxygen often. RN #366 stated she had taken the resident's vital signs and the oxygen level was 98% on two liters. Interview on 12/05/22 at 1:21 P.M., with the Director of Nursing (DON) verified Resident #196 did not have a care plan for oxygen use or respiratory issue. DON verified resident had oxygen order on admission and respiratory treatments. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365246 Printed: 05/15/2026 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 365246 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Wert Manor 160 Fox Rd Van Wert, OH 45891 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)