Inspection·June 26, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the outside provider cardiologist notes, and policy review, the facility failed to ensure ordered oxygen was applied prior to transporting a resident, who required continuous oxygen, to an outside appointment. This resulted in Actual Harm when Resident #01 was sent to an outside provider appointment without ordered continuous oxygen, suffered hypoxemia (low oxygen levels in the blood), difficulty breathing and required supplemental oxygen prior to the resident being transported back to the facility. This affected one resident (#01) out of three residents reviewed who required oxygen. The census was 80. Residents Affected - Few Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, pulmonary embolism, heart disease, protein-malnutrition, atrial fibrillation, and hypotension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had impaired cognition, required supplemental oxygen, and was a one-person assist for Activities of Daily (ADL). Review of Resident #01's care plans dated 05/31/23 revealed a focus for respiratory function related to respiratory failure, history of pulmonary embolism, and oxygen use. Resident #01 would remove his oxygen at times. Interventions included administer oxygen per order, encourage compliance, medications per order, monitor blood oxygen levels, and observe for signs of shortness of breath. Review of Resident #01's physician orders dated 06/01/23 revealed the resident was ordered two liters of oxygen via nasal cannula continuously. Review of the cardiologist's office documentation dated 06/13/23 revealed Resident #01's chief complaint was shortness of breath. Per the document, the patient presented without nasal cannula oxygen. The patient was hypoxic with 66 percent oxygen saturation and breathing very hard. Further review of the physician documentation revealed no explanation of Resident #01 provided oxygen prior to leaving to return to the facility. Review of Resident #01's vital signs documented in the facility's medical records revealed the nurse assessed the resident upon their return to the facility on [DATE] at 4:54 P.M. and the resident's oxygen saturation was 97 percent on two liters via a nasal cannula. Interview on 06/21/23 at 2:30 P.M. with the Administrator revealed on 06/13/23 he received a call (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: 365684 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 365684 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northwood Skilled Nursing and Rehabilitation 2000 Villa Road Springfield, OH 45503 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)