Health inspection·June 20, 2019

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 observation, record review and interview, the facility failed to ensure Resident #59's oxygen was implemented according to the physician's orders and failed to ensure the resident's oxygen tank was replaced timely when the tank was empty. This finding affected one (Resident #59) of one resident reviewed for respiratory care. Residents Affected - Few Findings include: Observation on 06/17/19 at 10:27 A.M. revealed Resident #59 was in bed in the resident's room, and the oxygen was infusing at six liters per minute (LPM) per nasal cannula (NC). The oxygen tubing and attached nasal cannula was connected to a portable oxygen concentrator. The physician's order indicated the oxygen should have been infusing at five LPM per NC. Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic atrial fibrillation and essential hypertension. Review of Resident #59's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #59's physician's orders revealed an order dated 03/01/19 for oxygen at five LPM via a NC every shift which was discontinued on 06/19/19. The facility obtained a new order dated 06/19/19 for oxygen at six LPM via a humidified NC. Review of Resident #59's care planned interventions included an intervention dated 03/02/19 to administer supplemental oxygen as indicated. Observation on 06/18/19 at 1:12 P.M. with Licensed Practical Nurse (LPN) #802 confirmed Resident #59 was in bed in the resident's room, and the oxygen was infusing at 5.5 LPM per NC. The oxygen tubing and attached nasal cannula was connected to a portable oxygen concentrator. The physician's order indicated the oxygen tank should have been infusing at five LPM per NC. Interview on 06/18/19 at 1:15 P.M. with LPN ##802 confirmed Resident #59's oxygen was not infusing at the correct rate of five LPM per NC as indicated in the physician's orders. Observation on 06/19/19 at 1:48 P.M. with Registered Nurse (RN) #803 revealed Resident #59 was sitting in the television lounge on the second floor in a specialized chair. The resident was observed with an oxygen tank on the back of the resident's wheelchair. The resident was observed wearing the nasal cannula, and the attached oxygen tubing was connected to the oxygen tank on the back of the resident's wheelchair infusing at six LPM per NC. The flow meter (gauge used to administer oxygen) on (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: 366127 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 366127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodlands Health and Rehab Center 6831 North Chestnut Street Ravenna, OH 44266 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)