Inspection·February 22, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen was administered consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory services, Resident #13 (Photographic evidence obtained). Residents Affected - Few Findings include: Review of Resident #13's admission record revealed the resident was admitted on [DATE] with the diagnoses that included acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and anemia. During an observation on 2/19/2024 at 9:40 AM, Resident #13 was in bed, receiving oxygen at 3 liters per minute via nasal cannula. During an observation on 2/20/2024 at 8:42 AM, Resident #13 was in bed, receiving oxygen at 3 liters per minute via nasal cannula. During an observation on 2/21/2024 at 8:11 AM, with Staff B, Licensed Practical Nurse (LPN), Resident #13 was receiving oxygen at 3.5 liters per minute via nasal cannula. During an interview on 2/21/2024 at 8:11 AM, Staff B, LPN, confirmed that Resident #13 was receiving oxygen at 3.5 liters per minute via nasal cannula. Review of Resident #13's physician order dated 1/25/2024 read, Oxygen at 2 LPM [liters per minute] via NC [nasal cannula] PRN [as needed] for SOB [shortness of breath]. Review of Resident #13's care plan dated 1/24/2024 read, Focus: Oxygen: The resident has oxygen therapy as needed r/t [related to] episodes of shortness of breath . Interventions/Tasks . Administer oxygen as ordered. During an interview on 2/21/2023 at 8:18 AM, Staff A, LPN, stated, Physician orders are written for oxygen at a rate of 2 liters via nasal cannula. I should have completed rounds with off going shift and checked for proper rate when I completed my resident assessment, but I did not. During an interview on 2/21/2023 at 8:20 AM, Staff B, LPN, stated, Physician orders are to be followed. I will check her oxygen saturation and call the doctor to verify the rate of oxygen delivery. During an interview on 2/21/2024 at 9:20 AM, the Director of Nursing stated, It is my expectation (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 3 Event ID: 105397 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 105397 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evergreen Woods 7045 Evergreen Woods Trl Spring Hill, FL 34608 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)