Inspection·June 6, 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 recommended guidelines were followed for changing disposable respiratory equipment for Residents #12, #15, and #83. This affected three residents (#12, #15, and #83) of six residents reviewed for respiratory care. The facility census was 181. Residents Affected - Few Finding include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including pneumonia, epilepsy, heart failure, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had short-term and long-term memory problems and used oxygen daily. Review of Resident #12's physician's orders revealed an order dated 05/14/24 to change the oxygen tubing and clean the filter weekly per facility policy and change the aerosol tubing and setup and clean the filter weekly per facility policy. Review of the medication administration record (MAR) for May 2024 revealed aerosol treatments were signed off as administered as ordered, and Resident #12 required oxygen daily. Review of the treatment administration record (TAR) for May 2024 revealed Resident #12's aerosol mask and tubing and oxygen tubing was last changed on 05/29/24. Observation on 06/03/24 at 12:13 P.M. of Resident #12 revealed the resident was wearing oxygen via nasal cannula that was not dated. The aerosol mask and tubing hooked up to the nebulizer was not in a bag and was not dated. The tubing dated 05/29/24 was in a clean bag on top of the oxygen concentrator. The bag with the new aerosol tubing and mask was still in the bag sitting on top of side table, not in use. Interview on 06/03/24 at 12:14 P.M. with Licensed Practical Nurse (LPN) #916 revealed oxygen tubing, aerosol masks, and tubing were to be replaced weekly and should be dated when changed. LPN #916 verified Resident #12's oxygen tubing, aerosol mask, and tubing were not dated to indicate when they were last changed, and the new tubing, dated 05/29/24, was still in the bag, not in use. 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including dementia, heart disease, and anxiety. (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: 365706 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 365706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Lake Villa 7260 Ridge Rd Parma, OH 44129 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)