Health inspection·June 5, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview the facility failed to complete routine respiratory assessments for residents requiring continuous supplement oxygen and aerosolized respiratory medications. This affected two (Residents #61 and #47) of three residents reviewed for oxygen use. The facility identified 14 residents (Residents #3, #5, #6, #9, #22, #25, #28, #40, #43, #46, #47, #51, #54 and #58) currently on continuous supplemental oxygen therapy. Residents Affected - Few Findings include: 1. Review of Resident #61's closed medical record revealed an admission date of 03/15/24 with diagnoses that included chronic obstructive pulmonary disease and diabetes mellitus. Upon admission the physician ordered Resident #61 supplemental oxygen at three liters per minutes (lpm) via nasal cannula continuously. Additional physician's orders on 03/16/24 revealed ipratropium bromide and albuterol solution (bronchodilator medication to improve breathing) 0.5-2.5 milligram (mg) per 3 milliliter (ml) three ml every four hours as needed by nebulizer. Review of the Medication Administration Record (MAR) revealed oxygen to be administered as ordered by the physician. Further review of the medical record and MAR revealed no evidence of routine respiratory assessments including oxygen saturation monitoring (determines oxygen content of blood). Review of the medical record revealed oxygen saturation levels only monitored on 03/15/24 at 4:27 P.M., 03/16/24 at 10:40 A.M. and 03/19/24 at 12:39 A.M. Review of Resident #61's Care Pathways indicated a problem of chronic obstructive pulmonary disease which indicated a focus of impaired gas exchange with a goal of maintain oxygenation saturation within personal goal range and intervention of evaluation of pulse oximetry (oxygen saturation). 2. Review of Resident #47's medical record revealed an admission date of 05/21/24 with diagnoses that included pulmonary fibrosis with dependence on supplemental oxygen and hypertension. Physician's orders revealed the Resident #47 was on 10 lpm of oxygen continuously via nasal cannula. Additional physician's orders revealed the use of ipratropium bromide and albuterol solution 0.5-2.5 mg per three ml three times daily via nebulizer. Further review of the medical record and MAR revealed no evidence of routine respiratory assessments including oxygen saturation monitoring. Review of the medical record revealed oxygen saturation levels only monitored on 05/26/24 at 10:35 A.M., 05/23/24 at 9:22 A.M., 05/22/24 at 12:23 A.M., 05/21/24 at 6:30 P.M. and 05/21/24 at 6:22 P.M (continued on next page) 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 2 Event ID: 365417 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 365417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Center I 860 Iron Avenue Dover, OH 44622 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)