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 observation, interview, and record review, the facility failed to ensure that one (Resident #109) of
two residents receiving oxygen therapy, from a total of 47 residents in the sample, was administered
oxygen at the flow rate ordered by the physician.
Residents Affected - Few
The findings include:
On 8/22/2022 at 11:02 am, Resident #109 was observed lying in bed with his covers pulled to his chest and
was receiving oxygen via nasal cannula. He complained that he was not receiving enough oxygen. The
resident stated he should receive 3 liters per minute (L/min). The oxygen concentrator located at bedside
was observed to be set at 1.5 L/min. (Photographic evidence obtained)
A review of Resident #109's physician's order, dated 4/07/2022, revealed he was to receive oxygen at 2
L/min continuously every shift.
On 8/23/2022 at 11:58 am, another observation of Resident #109's oxygen concentrator revealed it was set
at 1.5 L/min. (Photographic evidence obtained)
A medical record review revealed the resident was admitted into the facility on 4/06/2022. His diagnoses
included chronic respiratory failure, unspecified whether with hypoxia or hypercapnia; other specified
disorders of kidney and ureter; and heart failure, unspecified.
A review of the August 2022 Medication Administration Record (MAR) revealed an order for oxygen at 2
L/min via nasal cannula continuously, with nursing initials indicating the oxygen had been provided per the
order. (Photographic evidence obtained) Resident #109's vital signs revealed oxygen saturations for August
2022 ranging between 96 to 98 percent for both room air and oxygen via nasal cannula.
A review of the quarterly minimum data set (MDS) assessment, dated 7/11/2022, revealed Resident #109
had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 points, indicating moderately
impaired cognition. The assessment also documented that he was receiving oxygen therapy.
A review of the active care plan, dated 4/11/2022, revealed he was at risk for respiratory complications
related to obesity, history of respiratory issues, and continuous oxygen via nasal cannula. Interventions
included: check oxygen saturation levels as needed, and oxygen as ordered via nasal canula at 2 L/min.
A review of Resident #109's vital signs for August 2022, revealed oxygen saturations ranging between 96 to
98 percent for both room air and oxygen via nasal cannula.
(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:
105052
Printed: 05/28/2026
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
105052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/25/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Seaside Health and Rehabilitation Center
324 Wilder Blvd
Daytona Beach, FL 32114
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A review of the medication administration note dated 8/6/2022 at 1:41am, revealed oxygen 2 L/min
continuously every shift. Resident using oxygen only when he wants.
On 08/25/2022 at 10:00 am, accompanied by Licensed Practical Nurse (LPN) A, observed the oxygen
concentrator for Resident #109 set to administer oxygen at 1.5 L/min (Photographic evidence obtained).
LPN A confirmed that Resident #109's physician's order was for oxygen at a flow rate of 2 L/min. She
stated the resident's oxygen saturation was between 96 to 97 percent and he had no distress. Changes in
Resident #109's condition regarding his respiratory care was communicated to the Director of Nursing
(DON) and his physician. Correct oxygen settings were communicated from one staff person to another by
reviewing the medication administration record and through shift reports.
On 08/25/2022 at 11:38 am, the DON confirmed that the correct oxygen settings were identified in the MAR
and reviewed on the shift-to-shift report. She stated, We have some residents that play with them. Staff
respond by educating the residents on their oxygen therapy. It is the nurse's responsibility to ensure that
oxygen therapy is provided as ordered.
A review of the facility's policy and procedure for Oxygen Administration (undated), revealed procedures for
preparation included: Verify that there is a physician's order for this procedure. Review the physician's
orders or facility protocol for oxygen administration.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105052
If continuation sheet
Page 2 of 2
