Inspection·June 29, 2023

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, record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for one (Resident #2) of 11 sampled residents who were receiving oxygen therapy, from a total sample of 28 residents. Resident #2's oxygen flow rate was set higher than the physician ordered. Residents Affected - Few The findings include: On 06/26/2023 at 12:02 PM, Resident #2 was observed lying in bed at an elevated position wearing a nasal cannula (device used to provide supplemental oxygen). Resident #2 reported her oxygen should have been set to run at 2 liters per minute (L/min). Resident #2's oxygen concentrator was observed to be set on 3 L/min. (Photographic evidence obtained) A review of Resident #2's physician's order dated 05/20/2023, revealed that she should have been receiving oxygen at 2 L/min via nasal cannula as needed. (Photographic evidence obtained) On 06/27/2023 at 11:12 AM, another observation was made of Resident #2, who was sleeping in bed with her nasal cannula on and her oxygen concentrator set at 2.5 L/min. (Photographic evidence obtained) A medical record review for Resident #2 revealed that she was admitted to the facility from an acute care hospital on 5/19/2023. Her admitting diagnoses included Chronic Obstructive Pulmonary Disease (COPD), unspecified dementia, liver transplant, paraplegia, and major depressive disorder. The Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/25/2023, revealed that the resident scored 09 out of 15 possible points on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. She required extensive staff assistance to complete Activities of Daily Living (ADL) and she was receiving oxygen therapy. A review of the resident's comprehensive care plan, dated 06/01/2023, revealed she had a focus area for Emphysema/COPD with the goal to display optimal breathing patterns daily through the next review date. Interventions included oxygen settings per the physician's orders. (Photographic evidence obtained) During a 06/28/2023 interview with Registered Nurse (RN) A (assigned to Resident #2) at 12:20 PM, she confirmed the correct oxygen settings through the physician's orders. She stated the resident's oxygen flow rate setting should be 2 L/min as needed. RN A went to the resident's room and was asked to read the resident's current oxygen flow rate setting. RN A confirmed that the current setting was 2.5 - 3 L/min. She further stated the nursing staff checked oxygen settings every shift, and if the (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: 105381 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 105381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073 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)