Inspection·December 11, 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 medical record review, staff interview, review of the transportation schedule, and review of the facility statement form the facility failed to ensure a resident had an adequate supply of oxygen when leaving the facility for a medical appointment. This affected one (#91) resident of three residents reviewed for respiratory care and services. The facility census was 90. Residents Affected - Few Findings include: Medical record review for Resident #91 revealed an admission date of 03/20/24. Diagnoses included hemiplegia, hemiparesis following stroke, narcolepsy, type two diabetes mellitus, chronic heart failure, hypertension, pulmonary embolism, kidney failure and a history of covid. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had significant cognitive impairment, required moderate to maximum assistance from staff for eating, toileting, transfers and bed mobility. Resident #91 had oxygen usage during the assessment period. Review of the plan of care revealed Resident #91 had shortness of breath related to acute respiratory failure. Interventions included to monitor breathing patterns and report abnormalities to the physician, position the resident with proper body alignment for optimal breathing pattern and the use of pain management as needed. Review of the physician orders for Resident #91 revealed an order dated 08/20/24 for oxygen at two to five liters per minute (l/m) via nasal cannula to keep oxygen saturation rate above ninety-two percent every day and night shift related to acute respiratory failure. Review of the facility's transportation schedule dated 11/08/24 revealed Resident #91 had an medical appointment at 10:15 A.M. and had a scheduled picked up for 9:30 A.M. Interview on 12/09/24 at 3:08 P.M. with Certified Nurse Assistant (CNA) #84 stated Resident #91 was sent to the medical appointment with an almost empty oxygen tank and without oxygen on. CNA #84 verified when Resident #91 returned from the appointment the resident did not have oxygen on and that oxygen tubing was on the back of the wheelchair, but there was no oxygen tank. CNA #84 stated Resident #91 did not appear to be short of breath and when the nurse checked Resident #91 oxygen saturation, it was in the nineties. Interview on 12/09/24 at 3:19 P.M. with CNA #34 stated she was assigned to the Resident #91 on 11/08/24. CNA #34 stated the nurse did not advise her of Resident #91's appointment and when transportation arrived Resident #91 was not ready. CNA #34 stated she rushed to get him ready for departure and (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: 366040 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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)