Health 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 Page 1 of 2 105381 105381 06/29/2023 Orange Park Rehabilitation and Nursing Center 2029 Professional Center Dr Orange Park, FL 32073

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oxygen wasn't running at the accurate flow rate per the physician's order, they would make the adjustment accordingly. (Photographic evidence obtained) A review of the facility's policy and procedure for Administration of Drugs (dated April 2022), revealed under policy implementation: Drugs must be administered in accordance with the written orders of the attending physician. (Photographic evidence obtained) . 105381 Page 2 of 2