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. • (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: 365675 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 365675 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbors at Milford 5900 Meadowcreek Drive Milford, OH 45150 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)