Health inspection·February 1, 2024

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 policy, record review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 21 residents reviewed (Resident 86). Residents Affected - Few Findings include: Review of facility policy, titled Procedure: Infection Control: BiPAP [bi-level positive airway pressure which is a type of ventilator used to treat sleep apnea] & CPAP [Continuous Positive Airway Pressure - a machine that uses mild air pressure to keep breathing airways open while one sleeps] Devices, dated May 14, 2013, with a last review date of January 25, 2024, revealed the following, in part: E. The following must be done weekly: 4. Change Ziploc bag weekly that holds mask date and initial (3-11); V. SPECIAL CONSIDERATIONS: A. When the mask is not in use store in clear Ziploc bag (bags to be replaced weekly); and B. Date and initial on bag when changed. Review of Resident 86's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and Parkinson's disease (a long term degenerative disorder of the central nervous system that mainly affects the motor system). Review of Resident 86's physician orders revealed an order for CPAP mask-wash daily with soap and water, air dry, dated July 13, 2023. Observations of Resident 86's room on January 29, 2024, at 10:20 AM and 12:39 PM, revealed their CPAP mask was attached to tubing, which was attached to the machine, laying directly on the nightstand and not bagged. Observation of Resident 86's room on January 30, 2024, at 11:09 AM, revealed their CPAP mask was attached to tubing, which was attached to the machine, bagged in a black bag dated 8/[?] The actual day date was noted be illegible as it had been written over. During an interview with Employee 2 on January 30, 2024, at 11:28 AM, the aforementioned observation was shown. Employee 2 confirmed that the actual date was illegible on the bag in which the CPAP mask was being stored. Employee 2 further indicated that they were not sure of the policy as to when the bag should be changed, but they would look into it. Further review of Resident 86's physician orders revealed no order for the CPAP storage bag to be changed on a weekly basis prior to January 30, 2024. Page 1 of 2 395677 395677 02/01/2024 Sarah A Todd Memorial Home 1000 West South Street Carlisle, PA 17013

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of Resident 86's January Medication, Treatment, and Task Administration Record Report or documentation of the CPAP storage bag being changed on a weekly basis prior to January 30, 2024. Observation of Resident 86's room on January 30, 2024, at 11:28 AM, revealed that their CPAP mask was stored in a clear Ziploc bag dated January 30, 2024. Residents Affected - Few During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on January 31, 2024, at 10:51 AM, all the aforementioned observations were shared. The ADON indicated that Resident 86 had an order for their mask to be rinsed and air dried daily. It was further discussed that the observations on January 29, 2024, revealed that their CPAP mask was still attached to the tubing and to the machine. In addition, it was again shared that the mask was laying directly on the nightstand with no barrier between the mask and the surface of the nightstand. During a follow-up interview with the NHA and DON on January 31, 2024, at 2:25 PM, the DON confirmed that the CPAP mask should not have been laying directly on the nightstand without a barrier if it was being air dried, and that the storage bag should have been changed weekly. 28 Pa code 211.12(d)(1)(2) Nursing Services 395677 Page 2 of 2