Inspection·May 7, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/02/24 at 2:01 P.M. revealed Resident #9 was lying on her bed in her room. Resident #9 stated she had oxygen and CPAP but she did not know where it was. Resident #9 indicated she should have respiratory therapy coming to the facility to assist with her CPAP, BiPAP. Observation on 05/02/24 at 2:31 P.M. with Assistant Director of Nursing (ADON) #137 of Resident #9's room revealed her bedside table had CPAP, BiPAP supplies inside a zipped bag. ADON #137 stated she did not know Resident #9 had a CPAP or if she needed oxygen and she would look into it. Review of Resident #23's verbal physician orders dated 05/06/24 at 9:18 A.M. revealed to discontinue overnight polysonogram ordered on 03/06/24 due to it was an unnecessary test. Interview on 05/06/24 at 10:02 A.M. with Medical Director #139 revealed Medical Director #139 stated she knew Resident #9 was on BiPAP, but she did not think she wrote orders for her BiPAP. Medical Director #139 stated orders should be written for BiPAP if Resident #9 was using it. Medical Director #139 stated Resident #9 was readmitted to the facility from the hospital and there were no orders for CPAP or BiPAP. Medical Director #139 stated she was asked about Resident #9 having a sleep study during the care conference on 02/22/22 and she ordered it, but Resident #9 did not have signs and symptoms of issues relating to no BiPAP. Medical Director #139 stated she would be happy to reorder the sleep study, and she only discontinued it because it was never scheduled by the facility. Medical Director #139 indicated she did not think the order for the sleep study was put in the system. Medical Director #139 stated she would think it should have been scheduled if it was ordered. Medical Director #139 stated she said the sleep study was an unnecessary appointment only because she thought it was not ordered. Interview on 05/06/24 at 10:35 A.M. with POA #141 revealed she had Resident #9's BiPAP in her care because it was sitting on the floor in Resident #9's Assisted Living room, and she picked it up and brought it home with her. POA #141 stated Resident #9 had been using BiPaP for about 15 to 20 years and used oxygen with her BiPAP. POA #141 stated Resident #9 had not used BiPAP since she was admitted to the skilled nursing facility. POA #141 indicated Resident #9 slept really well at night if she used her BiPAP, and she noticed she was sleeping a lot during the day now. POA #141 stated not using the BiPAP might be a problem because Resident #9 started smoking again. POA #141 stated Medical Director #139 was asked about Resident #9's BiPAP and a sleep study during Resident #9's care conference on 02/22/24. Interview on 05/06/24 at 12:49 P.M. with Social Services Designee (SSD) #108 revealed Resident #9's care conference was on 02/22/24 and staff present were herself, Clinical Manager (CM) #142, the Administrator, Medical Director #139 attended via phone, and POA's #140 and #141. SSD #108 revealed Resident #9's sleep study was discussed and POA's #140 and #141 brought Resident #9's BiPAP from her Assisted Living room. SSD #108 stated Resident #9's sleep study was not discontinued and she was trying to arrange it so Resident #9 could have it at the facility and would not have to leave to have it completed. SSD #108 stated there was a physician order for Resident #9's sleep study, she scheduled resident appointments, but she was not informed by the nurses that Resident #9's sleep study needed scheduled. Interview on 05/06/24 at 3:19 P.M. with ADON #137 revealed she was trying to find sleep study center for Resident #9's sleep study. ADON #137 stated Medical Director #139 said the sleep study was an unnecessary test because Resident #9 did not have issues or respiratory distress. ADON #137 stated she recently started working at the facility and was not present for Resident #9's 02/22/24 care conference. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 2 of 3 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 365874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled CPAP, BiPAP Support revised 03/2015 included the purpose was to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. Review the resident's medical record to determine his or her baseline oxygen saturation or arterial blood gasses, respiratory, circulatory and gastrointestinal status. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP and EPAP) for the machine. Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery. BiPAP delivered CPAP but allowed separate pressure settings for expiration (EPAP) and inspiration (IPAP). Attach pulse oximeter to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00152906. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365874 If continuation sheet Page 3 of 3