Health inspection·February 12, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, interview and facility policy review the facility failed to properly maintain breathing treatment (nebulizer) tubing and medication delivery device (mask) by not changing, cleaning and securing in a bag prior to and following administration of medication. This deficient practice affected two residents (Residents #22 and #23) of two residents reviewed for respiratory care. The facility census was 36. Residents Affected - Few Findings Include: 1. A review of Resident #22's medical record revealed the initial admission date of 07/24/24 and a re-admission date of 10/15/24 with diagnoses including but not limited to opioid abuse, acute respiratory infection, anxiety and shortness of breath. Resident #22 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 11 out of a possible 15 dated 12/18/24. Resident #22 required staff assistance with activities of daily living (ADL) tasks including medication administration. A review of Resident #22's at risk for respiratory status/difficulty breathing care plan dated 08/16/24 revealed an intervention for administering medications as ordered. A review of Resident #22's signed physician orders revealed an order dated 12/28/24 for breathing treatment medication DuoNeb solution 0.5 milligrams (MG) per 2.5 milliliters (ML) (Ipratropium-Albuterol) 1 vial inhale orally via nebulizer every 4 hours as needed for shortness of breath, and an order dated 01/30/25 to clean/disinfect nebulizer machine. Change tubing (initial and date) and replace bag (initial and date) every night shift every Sunday. A review of Resident #22's Medication Administration Record (MAR) dated 02/01/25 to 02/12/25 revealed Resident #22 received a breathing treatment of DuoNeb solution on 02/01/25, 02/02/25, 02/03/25, and 02/06/23 lasting 15 minutes each. Further review of Resident #22's Treatment Administration Record (TAR) dated 02/01/25 to 02/12/25 revealed nebulizer cleaning and changing of nebulizer tubing and mask were completed on 02/03/25 and 02/10/25. An observation on 02/12/25 at 9:15 A.M. revealed in Resident #22's room, a nebulizer laying in the high backed chair on top of several items of clothing and papers. The medication delivery device was dated 02/03/25 and both the medication delivery device and the nebulizer tubing were also laying on top of the clothing items and papers and were not secured in a bag. 2. A review of Resident #23's medical record revealed an admission dated of 06/24/22 with diagnoses including but not limited to congestive heart failure (CHF), high blood pressure (HTN), and shortness of breath. Resident #23 had impaired cognition with a BIMS score of 11 out of a possible 15 dated (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 3 Event ID: 366036 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 366036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glendora Health Care Center 1552 North Honeytown Road Wooster, OH 44691 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)