Health inspection·September 13, 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 review of the medical record, review of hospital discharge orders, policy review, and interview, the facility failed to ensure special respiratory equipment was available for resident use. This affected one resident (#94) of four residents reviewed for admission rights. The facility census was 93. Residents Affected - Few Findings include: Closed record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, pulmonary fibrosis, and hyperlipidemia. Review of hospital records revealed Resident #94 had been identified as having significant risk for obstructive sleep apnea and discharge orders included but were not limited to CPAP machine with adult mask and tubing while sleeping. The order stated another medication with the same name was removed, continue taking this medication and follow the directions you see here. Review of an admission minimum data set (MDS)assessment completed on 08/13/24 revealed Resident #94's cognitive status remained intact. The resident had no behaviors, and had shortness of breath or trouble breathing with exertion and when lying flat. Review of the resident's medical record revealed Resident #94 received the CPAP on 08/19/24 although it was originally ordered on 08/06/24 at the time of the resident's admission to the facility. Review of orders revealed Resident #94 had an order in place (dated 08/19/24) to encourage her to wear CPAP when sleeping and during naps with CPAP settings of 10cm H2O and a full mask. The resident had an order dated 08/19/24 for prior to putting on, to check CPAP reservoir and fill with distilled water to max fill line, after removing in the morning cleanse mask and tubing with soap and water then allow to air dry. Review of the medical record revealed Resident #94 discharged to home from the facility on 08/22/24. Interview on 09/05/24 at 11:41 A.M. with Resident #94's family revealed early in her stay, they had informed Licensed Practical Nurse (LPN) #107 that Resident #94 required a CPAP and asked if they could bring her personal CPAP in from home, which was declined due to infection control concerns. Resident #94's family stated LPN #107 stated she would take care of it but Resident #94 did not receive a CPAP until she was about to go home. Interview on 09/10/24 at 2:04 P.M. with Director of Nursing (DON) revealed the referrals from the (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: 366429 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 366429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Zanesville Inc. 4200 Harrington Drive Zanesville, OH 43701 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)