Health inspection·December 4, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed medical record review, staff interviews, and review of the facility policy, the facility failed to administer appropriate respiratory care, administration of a ventilator at night, as ordered for Resident #10, who had a compromised respiratory status. This resulted in Immediate Jeopardy when the ventilator was not applied, and Resident #10 was found unresponsive, and required cardiopulmonary resuscitation (CPR) and hospitalization. This affected one (Resident #10) of five residents reviewed for ventilator use in the last three months. The census was 62 residents. Residents Affected - Few On [DATE] at 11:06 A.M., the Administrator, Director of Nursing (DON), [NAME] President of Clinical (VPC) #900 and Regional Director of Operations (RDO) #901 were notified the Immediate Jeopardy began on [DATE] at bedtime when Resident #10 was not placed on a ventilator as ordered by physician from the hospital to apply a vent at hour of sleep and to wean as tolerated. On [DATE] at 6:04 P.M., Respiratory Therapist (RT) #400 transcribed the order for the ventilator at night to the resident's electronic medical record (EMR). Staff did not apply the ventilator to Resident #10 on [DATE] at bedtime and the resident was found unresponsive on [DATE] at 8:07 A.M. Staff initiated cardiopulmonary resuscitation (CPR) until emergency medical services (EMS) personnel arrived and took over CPR. The EMS personnel stopped CPR on [DATE] at 8:28 A.M. when Resident #10 regained a pulse and was transported to the hospital and was admitted with a diagnosis of acute respiratory failure. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], the DON or designee(s) evaluated all residents with ventilators to ensure the residents with ventilators had proper orders and ventilator settings and care plans in place. No issues were identified at that time. The facility identified two residents with ventilators (Residents #16 and #20). • On [DATE], the DON or designee reviewed all physician's orders for all residents residing in the facility to ensure that there were no orders in queue or pending confirmation status. The review revealed Resident #21 had an order for physical therapy/occupational (PT/OT) which was pending confirmation, and the DON confirmed the order. • Page 1 of 4 365675 365675 12/04/2024 Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150

F 0695 On [DATE], the DON/designee visually observed all residents in house with ventilators (Residents #16 and #20) to ensure the ventilators were in place and functioning per physician's orders. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE], the DON/designee reviewed new/readmission resident charts for residents admitted on [DATE] to [DATE] (Residents #10, #22, #23) to ensure all orders were transcribed appropriately. No concerns were identified. • On [DATE], the DON/designee began education of licensed nurses and respiratory therapists (RTs) on ensuring orders were transcribed correctly and confirmed with the physician and were not left in queue or pending confirmation status. Education also included that all changes in condition were reported to the nurse, responsible party and physician, that assessments were to be completed and documented in the EMR, and if there was a change in condition to complete a change in condition assessment in the EMR. On [DATE] three of six RTs on staff were educated, 14 of 14 Licensed Practical Nurses (LPNs) on staff were educated, and seven of seven Registered Nurses (RNs) on staff were educated. On [DATE] the DON/designee completed education of the other three RTs which completed education for all staff. The facility does not use agency staff, and none of the staff are currently on leave. • On [DATE], the DON/designee began audits of all new physician's orders for residents on ventilators. On [DATE] the audits continued to be completed five times per week to ensure all orders were transcribed appropriately and confirmed by the physician. The audits will continue for four weeks. Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. • On [DATE], the facility had an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to discuss the incident involving Resident #10. The facility will forward all audits to the QAPI Committee to determine the need for further monitoring. The Administrator, the DON and the Medical Director were in attendance. • On [DATE], the DON/designee will audit ventilator/tracheostomy assessment/documentation for up to five residents weekly for four weeks. Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. • On [DATE], the DON/designee will review all new admission/readmission orders Monday through Friday to ensure that all ventilator orders are in place and transcribed appropriately for four weeks. • 365675 Page 2 of 4 365675 12/04/2024 Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150

F 0695 On [DATE], the DON/designee began to observe for completion of walking rounds at the change of shift between RTs to be completed three times per week for four weeks. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE], the oncoming RT will audit the previous shift to ensure all ventilator settings are accurate for four weeks. • On [DATE] at 11:30 A.M., LPN #250 verified she was educated on policies and procedures for Code Blue, admission orders, and reporting change in condition, refusal of care, and assessments. • Interviews on [DATE] at 10:25 A.M. with RN #100, at 10:30 A.M. with LPN #220, and at 11:00 A.M. with RN #110 confirmed they received education on [DATE] on physician orders, change in condition, and ventilators. • Interview on [DATE] at 12:40 P.M. with RT #430 confirmed he received education on [DATE] on physician's orders, change in condition, and ventilators. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #10 revealed an initial admission date of [DATE] and a readmission date of [DATE] with diagnoses including respiratory disorder, dependence on respiratory, chronic obstructive pulmonary disease (COPD), diabetes mellitus type two, and congestive heart failure. Review of the care plan for Resident #10 dated [DATE] revealed the resident was ventilator dependent related to respiratory failure with interventions which included the following: maintain ventilator settings as ordered, observed or report to the physician as needed any signs or symptoms of upper respiratory infection or pneumonia, suction per orders and as needed. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated [DATE] revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs). Review of the hospital continuity of care orders for Resident #10 dated [DATE] revealed an order to apply a ventilator to the resident at the hour of sleep. Review of the progress note for Resident #10 dated [DATE] timed at 5:18 P.M. revealed the resident was admitted to the facility from a local hospital. Resident #10 was placed on continuous aerosol 365675 Page 3 of 4 365675 12/04/2024 Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150

F 0695 tracheostomy collar (CATC) with oxygen running at eight liters per minute (LPM). Level of Harm - Immediate jeopardy to resident health or safety Review of the admission physician's orders for Resident #10 dated [DATE] revealed the order for the ventilator at night was not confirmed by the physician and had not been placed in the resident's Medication Administration Record (MAR.) Residents Affected - Few Review of the MAR for Resident #10 dated [DATE] revealed the order for the ventilator at night was not included in the MAR. Review of the progress note for Resident #10 dated [DATE] timed at 8:20 P.M. per RT #410 revealed the resident had the tracheostomy with oxygen in place. There was no documentation regarding application of the ventilator for the resident. Review of the progress note for Resident #10 dated [DATE] timed at 8:20 A.M. per RT #400 revealed the resident had no pulse, staff called a code blue, and initiated CPR. Review of the physician's orders for Resident #10 revealed the order for the ventilator at night for the resident was confirmed with the physician and entered into the resident's MAR on [DATE] per LPN #200. Interview on [DATE] at 1:38 P.M. with RT #410 confirmed she cared for Resident #10 on the night of [DATE]. RT #410 confirmed she did not place or offer to place the ventilator on the resident at any time during the shift. RT #410 confirmed prior to Resident #10's readmission from the hospital on [DATE] the resident had been on a ventilator continuously. RT #410 confirmed there was no order entered into Resident #10's MAR for application of a ventilator at hour of sleep. RT #410 confirmed the last time she saw Resident #10 was on [DATE] at 5:30 A.M., and the resident was wearing a tracheostomy with oxygen in place and was breathing normally. RT #410 confirmed when she arrived home after work the morning of [DATE], RT #400 called her home and notified her Resident #10 had coded and been taken to the hospital. RT #410 confirmed RT #400 questioned if RT #410 had seen an order for a ventilator at night and RT #410 confirmed she told RT #400 she had not seen a valid order for the ventilator at night. Interview on [DATE] at 10:40 A.M. with the DON and the Administrator confirmed Resident #10 had been on a ventilator continuously prior to her readmission to the facility on [DATE]. Further interview confirmed the hospital COC form ordered Resident #10 to have a ventilator placed at night and RT #400 had entered the order in the EMR. The DON confirmed Registered Nurse (RN) #100 had confirmed the admitting medication orders with the physician on [DATE] but had not confirmed the order for the ventilator at night with the physician or entered the order into the MAR. The Administrator confirmed the facility began implementing corrective action on [DATE] after Resident #10 had coded and was transferred to the hospital after not having the ventilator placed at night as ordered. The DON and the Administrator confirmed staff should have placed a ventilator on Resident #10 at night on [DATE]. Review of the facility policy titled Ventilator Unit-Mechanical Ventilation: Setup and Monitoring dated [DATE], revealed staff should verify that there was a physician's order for use of a mechanical ventilator and should review the physician's orders and care plan for any special needs of the resident. This deficiency represents noncompliance investigated under Complaint Number OH00159870. 365675 Page 4 of 4