Health inspection·November 27, 2024

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 facility policy review, the facility failed to ensure oxygen tubing was changed as ordered for residents #21 and #40. This affected two residents (#21 and #40) of four residents observed for respiratory care. The facility census was 66. Residents Affected - Few Findings include: 1. Review of Resident #21's medical record revealed an admission date of 03/23/23 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. Review of the care plan dated 11/01/24 revealed Resident #21 had alterations in respiratory function related to COPD. An intervention included administer oxygen as ordered. Review of the physician orders for November 2024 revealed Resident #21 had an order to change oxygen tubing every Sunday on night shift. Observation on 11/21/24 at 11:11 A.M. revealed Resident #21 was in bed and was wearing oxygen via a nasal cannula. Further observation revealed the oxygen tubing was dated 09/25/24. The observation was confirmed with the Director of Nursing (DON), and the DON stated oxygen tubing was to be changed weekly and also as needed. 2. Review of Resident #40's medical records revealed an admission date of 10/17/24 with a diagnoses including COPD and congestive heart failure. Review of the care plan dated 10/18/24 revealed Resident #40 had oxygen therapy related to chronic respiratory failure. Interventions included oxygen via nasal cannula at three liters per minute per nasal cannula. Review of the MDS assessment dated [DATE] revealed Resident #40 had intact cognition. Review of the physician orders for November 2024 revealed Resident #40's had an order to change oxygen tubing every Sunday on night shift. Observation on 11/21/24 at 11:30 A.M. revealed Resident #40 was in a chair in her room wearing oxygen via nasal cannula. Further observation revealed Resident #40's oxygen tubing was dated 10/31/24. (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 4 Event ID: 365667 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 365667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Medina Center for Rehabilitation and Nursing 555 Springbrook Dr Medina, OH 44256 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)