Health inspection·January 13, 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 review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment and in accordance with physician's orders for five of 23 residents reviewed (Residents R4, R40, R75, R95 and R205). Residents Affected - Some Findings include: A facility policy entitled, Oxygen Concentrator (device that takes air from your surroundings, extracts oxygen and filters it into purified oxygen to breathe) dated 10/28/24, revealed to not run concentrator with a dusty filter. A facility policy entitled, Oxygen Therapy dated 10/28/24, revealed that humidification (process that adds moisture to oxygen therapy to prevent a dry, irritated respiratory tract) for patient comfort may be provided at any flow rate and whenever specifically ordered by the physician. A facility policy entitled, Oxygen Therapy via Nasal Cannula (thin, flexible tube that goes around your head with two prongs that go inside your nostrils that deliver the oxygen) dated 10/28/24, revealed to verify physician's order, attach the humidifying device, if liter flow is 4 or greater or upon resident request, and change the prefilled bottle humidifier when low or at least weekly. Resident R4's clinical record revealed an admission date of 10/24/17, with diagnoses that included Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), heart disease, heart failure, myopathy (disease that affects the muscles that control voluntary movement). Resident R4's clinical record lacked evidence of a physician's order/treatment to provide humidification to his/her supplemental oxygen and clean the concentrator filter. Observation on 1/11/25, at 2:25 p.m. revealed Resident R4's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance and the prefilled humidifier bottle attached to the oxygen tubing and secured to the external surface of the concentrator was empty. Observation on 1/12/25, at 11:53 a.m. revealed Resident R4's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface and a full prefilled humidifier bottle was sitting on the floor. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around, and Page 1 of 3 395404 395404 01/13/2025 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0695 that the humidification bottle should not have been resting on the floor. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/12/25, at 1:56 p.m. the Regional Director of Nursing confirmed Resident R4's clinical record lacked evidence of a physician's order to provide humidification and an order on the Treatment Administration Record (TAR) for cleaning the oxygen concentrator filter was not identified. Residents Affected - Some Resident R40's clinical record revealed an admission date of 5/09/24, with diagnoses that included blood clots in the legs, dependence on supplemental oxygen, stroke with paralysis, pleural effusion (condition where too much fluid builds up in the area between the lungs and chest wall). Resident R40's January 2025 TAR indicated that the oxygen concentrator was cleaned on 1/11/25, at 7:00 p.m. Observation on 1/11/25, at 2:00 p.m. revealed Resident R40's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:50 a.m. revealed Resident R40's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observtion on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R75's clinical record revealed an admission date of 4/06/22, with diagnoses that included respiratory failure, dependence on supplemental oxygen, blood clots in the legs, disorders of diaphragm (trauma, tumors, or other conditions that affect the diaphragm muscle and make it difficult to breathe). Resident R75's January 2025 TAR indicated that the oxygen concentrator was scheduled to be cleaned on 1/12/25, at 7:00 p.m. Observation on 1/11/25, at 3:10 p.m. revealed Resident R75's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:55 a.m. revealed Resident R75's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. Resident R95's clinical record revealed an admission date of 10/16/24, with diagnoses that included respiratory failure, dependence on supplemental oxygen, alcoholic cirrhosis of liver (severe form of liver disease that occurs when the liver is permanently scarred from excessive alcohol consumption), myopathy. Resident R95's January 2025 TAR indicated that the oxygen concentrator was cleaned on 1/11/25, at 7:00 p.m. Observation on 1/11/25, at 2:20 p.m. revealed Resident R95's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:53 a.m. revealed Resident R95's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal 395404 Page 2 of 3 395404 01/13/2025 Lecom at Presque Isle, Inc 4114 Schaper Avenue Erie, PA 16508

F 0695 surface of the filter was not clean and that it appeared that the filter had been turned around. Level of Harm - Minimal harm or potential for actual harm Resident R205's clinical record revealed an admission date of 1/06/25, with diagnoses that included respiratory failure, heart disease, chronic obstructive pulmonary disease (COPD- ongoing lung disease limits airflow into and out of the lungs). Resident R205's TAR lacked evidence of a treatment to clean the concentrator filter. Residents Affected - Some Observation on 1/11/25, at 2:30 p.m. revealed Resident R205's oxygen concentrator filter's external surface was covered with a white/grey fluffy substance. Observation on 1/12/25, at 11:58 a.m. revealed Resident R205's oxygen concentrator filter was clean on the external surface and covered with white/grey fluffy substance on the internal surface. At the time of the observation on 1/12/25, the Director of Nursing confirmed that the internal surface of the filter was not clean and that it appeared that the filter had been turned around. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f)(i)(viii) Medical records 395404 Page 3 of 3