Health inspection·January 30, 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 observation, interview, record review, and facility policy review, the facility failed to post oxygen in use signs per acceptable standards of nursing practice for Residents #10, #21, #22, #34, #47, #48 and #64. This affected seven residents (#10, #21, #22, #34, #47, #48 and #64) of 27 residents reviewed for respiratory care. The census was 67. Residents Affected - Some Findings include: 1. Record review revealed Resident #10 was admitted on [DATE]. Diagnoses included pneumonia due to methicillin resistant staphylococcus aureus (MRSA), acute respiratory failure with hypoxia, and chronic bronchitis. The physician order dated 01/27/24 indicated oxygen continuous at 2 LPM (liters per minute) via nasal cannula. 2. Record review revealed Resident #21 was admitted on [DATE]. Diagnoses included unspecified bacterial pneumonia, pulmonary hypertension, acute respiratory failure with hypoxia, chronic atrial fibrillation, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). The physician order dated 01/30/24 indicated oxygen at 2 LPM as needed to maintain oxygen saturation above 92 percent every shift. 3. Record review revealed Resident #22 was admitted on [DATE]. Diagnoses included pneumonia, sleep apnea and asthma. The physician order dated 01/28/24 indicated oxygen at 2 LPM via nasal cannula every shift. 4. Record review revealed Resident #34 was admitted on [DATE]. Diagnoses included pneumonia due to MRSA, acute and chronic respiratory failure with hypercapnia and hypoxia, shortness of breath, and COPD. The physician order dated 01/16/24 indicated oxygen at 3 LPM via nasal cannula continuous every shift. 5. Record review revealed Resident #47 was admitted on [DATE]. Diagnoses included atrial fibrillation, chronic bronchitis, CHF, and COPD. The physician order dated 01/27/24 indicated oxygen at 3 LPM every shift. 6. Record review revealed Resident #48 was admitted on [DATE]. Diagnoses included bronchitis, CHF, acute pulmonary edema, and acute respiratory failure with hypoxia. The physician order dated 10/23/24 indicated oxygen at 2 LPM via nasal cannula as needed. 7. Record review revealed Resident #64 was admitted on [DATE]. Diagnoses included pneumonia, acute and chronic respiratory failure, heart failure, COPD, and obstructive sleep apnea. The physician (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: 366447 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 366447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Village Skilled Nursing & Rehabilitation 10955 Capital Parkway Concord, OH 44077 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)