Health inspection·February 20, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure respiratory treatments were administered and performed as ordered. This affected one (Resident #38) of three residents reviewed for respiratory care. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record for Resident #38 revealed an admission date of 11/29/24 with diagnoses including chronic respiratory failure with hypoxia, Rett's Syndrome (rare neurological genetic disorder that causes severe muscle movement disability), cerebral palsy (condition that affects movement and posture, epilepsy, tracheostomy status, ileostomy status and gastrostomy status. Review of the physician's orders for Resident #38 revealed he had an order dated 01/17/25 for a chest vest (used to help break the cycle of excess mucus, lung infections and lung damage) to be applied twice daily, every 12 hours, at 6:00 A.M. and 6:00 P.M. He also had an order for Albuterol Sulfate Inhalation Nebulization Solution 0.083% (medication that relaxes airway muscles and increases air flow to the lungs), 3 milliliters via trach every 12 hours for shortness of breath dated 01/17/25 to be done at 6:00 A.M. and 6:00 P.M. Review of the Respiratory Administration Record for January 2025 for Resident #38 revealed on 01/17/25 at 6:00 P.M. his chest vest and Albuterol Sulfate were not administered. Review of the nursing progress notes dated 01/17/25 at 8:58 P.M. revealed Respiratory Therapist (RT) #211 had not administered the chest vest because he was uncomfortable using the wrap over Resident a#38's tube sites as he was afraid it would dislodge them. RT #211 also did not administer the Albuterol as it was to be used in conjunction with the vest but he did not use the vest. On 01/18/25 at 5:57 A.M., RT #210 educated RT #211 on how to utilize the chest vest on Resident #38. There was no indication RT #211 updated the physician on not administering and performing the respiratory treatments on 01/17/25. Review of the facility investigation dated 01/18/25 revealed RT #211 was educated on 01/18/25 on the chest vest for Resident #38. It was noted Nurse Practitioner (NP) #212 was updated on 01/18/25 at 7:00 A.M. of the Albuterol and chest vest not being administered on 01/17/25 at 6:00 P.M. Interview on 02/20/25 at 10:31 A.M. with the Administrator verified Resident 38's chest vest and Albuterol were not administered and performed as ordered on 01/17/25 at 6:00 P.M. She also verified there was no indication the physician or nurse practitioner was updated until the following day. Review of the facility policy titled, Chest Vest, revised April 2023, revealed staff were to Page 1 of 2 366434 366434 02/20/2025 Hudson Springs Nursing and Rehab 5000 Sowul Boulevard Stow, OH 44224

F 0695 Level of Harm - Minimal harm or potential for actual harm document and communicate the date and time, how resident tolerated the procedure, who performed the procedure and to collaborate with the clinical team significant or changes in resident's normal tolerance or complications with the procedure. Residents Affected - Few 366434 Page 2 of 2