Inspection·August 23, 2018

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 record review, policy review, family and staff interview, the facility failed to ensure one resident's oxygen tank was not empty while in user by the resident. This affected one of one (#22) of one resident reviewed for respiratory care. The facility identified 19 resident's who currently receive respiratory treatments. The census was 64. Residents Affected - Few Findings include: Review of Resident #22's medical record indicated the resident was admitted to facility 07/16/14. Diagnoses included cerebral arthrosclerosis, vascular dementia, type two diabetes mellitus, hypertension, osteoarthritis, hemiplegia, anemia, insomnia, hypothyroidism, cerebrovascular, anxiety, retention of urine, neuromuscular dysfunction of bladder and dysphagia. Resident #22's quarterly minimum data set (MDS) assessment dated [DATE], indicated the resident had severe cognitive impairment and required total dependence on staff for activities of daily living including bed mobility, transfers, locomotion, dressing, hygiene and extensive assistance with eating. The resident was admitted to hospice care on 09/07/17 with the diagnosis of cerebral arthrosclerosis. The resident had physician orders for oxygen at two liters per minute continuously. Review of Resident # 22's plan of care dated 07/016/14 through 09/27/18 indicated the resident had altered respiratory status related to low energy, fatigue and shortness of breath. Interventions included provide oxygen as ordered. Interview on 08/20/18 at 6:38 P.M. with Resident #22's family member stated often when she visits, Resident #22's oxygen is not running. Observations on 08/21/18 at 7:25 A.M., revealed Resident #22 was sitting in the common area in front of the nurses station. The resident had a nasal cannula in her nose with the tubing attached to a oxygen tank. The gauge on the tank indicated the oxygen tank was empty. The resident did not appear to be in any respiratory distress. Interview with Licensed Practical Nurse (LPN) #47 on 08/21/18 at 7:25 A.M., verified the resident's oxygen tank was empty. LPN #47 stated the resident had been up for about five minutes and that the oxygen tank should of been changed when the tank was close to empty. Interview on 08/22/18 at 1:47 P.M., with the Director of Nursing (DON) stated, staff should be doing spot checks of the tanks to ensure they do not run out of oxygen. The DON identified 19 resident's who currently receive respiratory treatments. (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: 366084 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 366084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center of Eaton 1600 Park Avenue Eaton, OH 45320 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)