Health inspection·October 3, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to provide oxygen as ordered by the physician. This affected two Residents (#2 and #26) of three reviewed for oxygen. The facility census was 86. Residents Affected - Few Findings included: 1. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including multiple myeloma not having achieved remission, generalized muscle weakness, shortness of breath, acute respiratory failure with hypoxia, and pleural effusion in other conditions classified elsewhere. Review of Resident #2's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/18/23, revealed she was cognitively intact and had an active diagnosis of respiratory failure. Further review revealed she received oxygen therapy while not a resident and while a resident. Review of Resident #2's physician order dated, 08/29/23, identified she was to have continuous oxygen at two liters/minute per nasal cannula. The staff were to check placement and record oxygen saturation every shift. Observation on 10/02/23 at 10:05 A.M. of Resident #2 with oxygen running at four liters/minute via a nasal cannula. The date on the tubing is 09/25/23. Observation on 10/02/23 at 11:05 A.M. of Resident #2 with oxygen running at four liters/minute via a nasal cannula. The date on the tubing is 09/25/23. Observation on 10/02/23 at 11:21 A.M. of Resident #2 with oxygen running at four liters/minute via a nasal cannula with Licensed Practical Nurse (LPN) #193. LPN #193 verified Resident #2's oxygen was running at four liters/minute via a nasal cannula. Interview on 10/02/23 at 11:27 A.M. with LPN #193 verified Resident #2's oxygen was not running at the correct dosage, and it should be running at two liters/minute via her nasal cannula. 2. Review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified, dependence on supplemental oxygen, and shortness of breath. Review of Resident #26's significant change MDS 3.0 assessment, dated 09/14/23, revealed she was (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: 365612 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 365612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summit Acres Nursing Home 44565 Sunset Road Caldwell, OH 43724 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)