Health inspection·February 20, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to obtain an electrocardiogram (EKG) services per physician orders for Resident #36. This affected one resident (#36) of three residents reviewed for change in condition. The facility census was 32. Residents Affected - Few Findings include: Review of the closed medical record of Resident #36 revealed an admission date of 02/06/25. Medical diagnoses included acute respiratory failure, nonrheumatic aortic valve insufficiency, metabolic encephalopathy, hypothyroidism, disorder bilirubin metabolism, edema, congestive heart failure, panic disorder, hepatic failure, atherosclerotic heart disease, jaundice, acute myocardial infarction, presence of coronary angioplasty, Turner's syndrome (a chromosomal disorder in which a female is born with only one X chromosome), and abnormal electrocardiogram (EKG). Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #36 dated 02/07/25 revealed the resident's cognition was moderately impaired, and she was dependent upon staff to roll left to right in bed, toileting, hygiene, and bathing. She required moderate assistance for eating and oral hygiene. She had no indwelling catheter and was not on a toileting program. She was always incontinent bowel and bladder. She received oxygen therapy. Review of the physician's telephone orders dated 02/06/25 at 4:56 P.M. revealed a diagnostic order to obtain a STAT (immediate) chest x-ray, STAT EKG related to congestive heart failure, obtain a STAT complete blood count (CBC) with differential, complete metabolic panel (CMP), thyroid stimulating hormone (TSH), T4, and a lipid profile. Review of nursing note for dated 02/06/25 at 5:25 P.M. revealed Resident #36's pulse oximeter read 77 percent on five liters of oxygen per minute of oxygen. Her lung sounds were diminished with crackles. The physician was notified and provided new orders to obtain a STAT EKG, STAT chest x-ray, STAT lab work and Lasix 10 milligrams (mg) (diuretic) intramuscular (IM) for a one-time dose. The charge nurse called mobile x-ray and the lab. Review of the Treatment Administration Record (TAR) for February 2025 revealed on the order dated 02/06/25 to obtain a STAT EKG related to congestive heart failure was marked with an x, and the order dated 02/06/25 for the STAT chest x-ray revealed the order was signed off as completed. Review of nursing note dated 02/07/25 at12:25 P.M. revealed the chest x-ray results were received and showed bilateral patchy infiltrates. The physician was called, and new orders were given. There was no documented evidence that the STAT EKG was completed and no documented evidence that the staff followed up with the physician or the mobile x-ray company regarding the order for the STAT EKG. Page 1 of 2 365748 365748 02/20/2025 White Oak Manor 1926 Ridge Avenue Warren, OH 44484

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/20/25 at 2:20 P.M. with the Director of Nursing (DON) verified that the STAT EKG was not completed for Resident #36. She also verified the record contained no documented evidence that staff followed up on the STAT EKG order and/or notified the physician that the STAT EKG was not completed. This deficiency represents non-compliance investigated under Master Complaint Number OH00162779 and Complaint Number OH00162715. 365748 Page 2 of 2