Health inspection·March 5, 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 observation, clinical record review, hospital record review, and resident and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and follow the physician's orders for two of the two residents reviewed (Resident CL1 and Resident 1). Residents Affected - Few Findings include: A review of Resident CL1's hospital records dated February 2, 2025, revealed that the resident was sent to the hospital on January 26, 2025, for shortness of breath and was admitted with a diagnosis of Acute Respiratory Failure. The same report revealed that the Resident was using a BIPAP (a non-invasive ventilator technique that provides pressurized air to assist with breathing) in the hospital. A review of the hospital record BIPAP order dated February 10, 2025, revealed Auto Bipap Max-18 Min-5 PS-5 for associated diagnosis of Acute Respiratory Failure and Obstructive Sleep Apnea (A potentially serious sleep disorder in which breathing repeatedly stops and starts). A review of the hospital discharge summary order dated February 11, 2025, revealed DME (Durable medical equipment) SUPPTY-RT-CPAP/BiPAP A review of Resdient CL1's clinical records revealed the resident was admitted to the facility on [DATE]. Further review of resident CL1's clinical record revealed there was no physician order for Bipap or that the physician was notified of Resident CL1's Bipap order from the hospital. An interview with the supply staff, Employee E3 conducted on March 5, 2025, at 11:00 a.m., revealed that the facility liaison sent her/him Resident CL1's Bipap order supplies and settings from the hospital so she/he could order it and have it ready for the resident's admission to the facility. Employee E3 reported that the order was made from [name of the DME company] and got a confirmation email that the machine and supplies would be delivered on February 11, 2025. A phone interview with the DME representative conducted on March 5, 2025, at 11:30 a.m., confirmed that Resident CL1's Bipap (with supplies) was delivered to the facility on February 11, 2025. An interview with the Director of Nursing conducted March 5, 2025, at 1:00 p.m., revealed that hospital reports are reviewed by the facility's liaison and communicated to the facility to determine the Resident's device and treatment needs for admission. The DON was unable to provide an explanation as to why Resident CL1 did not have a Bipap order despite it being on the Resdient CL1's hospital orders when discharged from the hospital on February 10, 2025. Page 1 of 2 395400 395400 03/05/2025 Susquehanna Health and Wellness Center 745 Old Chickies Hill Road Columbia, PA 17512

F 0695 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's hospital record revealed resident was hospitalized from [DATE]-10, 2025, for a diagnosis of Acute Respiratory Failure with Hypoxemia (A life-threatening condition where the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in low oxygen level). Further review revealed resident was ordered Bipap with the setting of: Total Inspiratory pressure-14, and expiratory pressure-6 while in the hospital. Residents Affected - Few A review of Resident 1's Hospital Discharge Summary report dated February 10, 2025, revealed: Should use Noninvasive ventilator with all naps and during bedtime. A review of the physician's order dated February 19, 2025, revealed an order for a BIPAP every night shift. A review of the nursing progress notes dated February 11, 2025, at 10:51 p.m., revealed resident had been taking off his/her BIPAP throughout the night as he/she felt as though he/she could not breathe. An interview conducted with Resident 1 on March 5, 2025, at 10:30 a.m., revealed that he/she felt that the machine (BIPAP) was not properly working because the pressure was too much causing his/her mouth and throat to be severely dry. The resident reported that someone checked the machine, but he/she was told that it was properly working. An observation of Resident 1's Bipap machine in the presence of the Director of Nursing on March 5, 2025, at 11:00 a.m., revealed that the machine had a setting of IP-18, and EP-5. Instead of the ordered of setting of IP-14, EP-6 from the hospital. An interview with the DON on March 5, 2025, at 11:10 a.m., revealed that the Bipap machine was already set up to the setting ordered from the hospital when it was delivered to the facility by the DME company. A phone interview with the DME representative conducted on March 5, 2025, at 11:30 a.m., confirmed that Resident 1's Bipap machine had a setting order of IP-14, EP-6. The machine with a serial number [B ----------] was delivered to the facility. The DME representative also reported that A Bipap for Resident CL1 with a setting order of IP-18, EP5 with a serial number of [B----------] was delivered to the facility on February 11, 2025. An observation of Resident 1's Bipap machine conducted on March 5, 2025, at noon., in the presence of the DON revealed that Resident 1 had Resident CL1's machine based on the serial number reported by the DME representative. An interview with the DON on March 5, 2025, at 1:00 p.m., was conducted. The DON was unable to explain why Resident 1 was using Resident Cl1's Bipap machine instead of his/her machine with physician ordered setting. The facility failed to ensure physician orders for Residents CL1 and 1 for Bipap were followed when admitted to the facility following hospitalization. 28 Pa. Code 211.5(f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services 395400 Page 2 of 2