Inspection·January 29, 2025

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, interview and review of the facility policy, the facility failed to correctly transcribe and record oxygen orders upon admission to ensure oxygen was administered properly. This affected one resident (#43) of three residents reviewed for oxygen. Facility census was 40. Residents Affected - Few Findings include: Review of Resident #43's closed medical record revealed an admission date of [DATE] and diagnoses including right arm humorous fracture, acute on chronic congestive heart failure, hypertensive heart disease with heart failure, hyperlipidemia, chronic obstructive pulmonary disease, type two diabetes and chronic kidney disease stage four. Resident #43 expired in the facility on [DATE]. Review of Resident #43's 5-day minimum data set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact and was dependent on staff for toileting and transfers. The assessment indicated Resident #43 expired in the facility. Review of Resident #43's hospital paperwork dated [DATE] revealed additional discharge instructions of oxygen to be administered at 2 liters/minute. Review of Resident #43's physicians' orders revealed an order dated [DATE] for apply oxygen in order to keep oxygen saturation at or above 92% as needed. The order was timed [DATE] at 1:34 P.M. and was put in by Previous Director of Nursing (PDON) #109. Review of the order audit details revealed PDON #109 created and confirmed the order on [DATE] at 2:19 P.M. No other oxygen orders were noted for Resident #43 during this admission. Review of Resident #43's Medication Administration Record (MAR) for [DATE] revealed his oxygen was not signed off as being administered on [DATE] or [DATE]. Interview on [DATE] at 8:48 A.M. with Family Member (FM) #111 revealed an autopsy was done after Resident #43 passed away and recalled they were told Resident #43 did not have oxygen supplied to him for five hours. Interview on [DATE] at 9:45 A.M. with FM #112 revealed Resident #43's death certificate reported his cause of death to be congestive heart failure for three years and cardiorespiratory failure for three hours. Interview on [DATE] at 10:44 A.M. with Licensed Practical Nurse (LPN) #110 revealed she was responsible for Resident #43's admission documentation on [DATE]. LPN #110 explained the Director of (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: 366266 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 366266 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Enniscourt Nursing Care 13315 Detroit Ave Lakewood, OH 44107 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)