Health inspection·December 28, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to follow physician's orders related to oxygen equipment for one of two residents reviewed for oxygen usage (Resident R56). Residents Affected - Few Findings include: Review of a facility policy entitled, Disposable Supply Changes dated 12/5/23, indicated that Guideline for when disposable supplies for medical equipment need changed for infection control purposes. Disposable supplies need to be dated when changed And Oxygen Cannulas [a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen], Oxygen Supply Lines [tubing that connects from the oxygen source to the nasal cannula], and Oxygen Humidifier Bottles [plastic bottles filled with distilled water used to humidify oxygen] should be changed weekly or prn [as needed]. Resident R56's clinical record revealed an admission date of 8/30/22, with diagnoses that included Chronic Obstructive Pulmonary Disease, (COPD - a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), Heart Failure (A progressive heart disease that affects pumping action of the heart muscles, causing fatigue and shortness of breath), and Diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar). Review of Resident R56's clinical record revealed a physician's order dated 11/5/23, indicating to Change O2 [oxygen] tubing and supply bag weekly . Change water jug weekly. Observations on 12/26/23, at 12:20 p.m. and 12/28/23, at 11:47 a.m. revealed that Resident R56's oxygen tubing was dated for 11/14/23, and his/her water jug was not dated. Review of Resident R56's treatment records for November 2023 and December 2023 revealed that Resident R56's oxygen tubing and water jug were not changed as ordered on November 19, 2023, and November 26, 2023, or on December 3, 2023, December 10, 2023, or December 17, 2023. During an interview on 12/28/23, at 11:49 a.m. the Interim Director of Nursing confirmed that the oxygen tubing was dated for 11/14/23, and was not changed per physician's orders and the water jug was not dated at all. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 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: 395489 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 395489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Corry Manor 640 Worth Street Corry, PA 16407 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)