Health inspection·August 11, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to ensure that one (Resident #33) of 45 residents receiving respiratory care, from a total of 27 sampled residents, had a care plan in place for oxygen as ordered. The findings include: During a tour of the facility on 08/08/22 at 2:03 pm, Resident #33's oxygen concentrator was observed in her room at bedside. A closer observation revealed the concentrator was set to administer oxygen at 1.5 liters per minute (L/min). Resident #33 was observed wearing the nasal cannula and receiving oxygen at 1.5 L/min (Photographic evidence obtained of concentrator setting) On 08/09/22 at 11:21am, another observation of Resident #33's oxygen concentrator, revealed it was set to administer oxygen at 1.5 L/min. (Photographic evidence obtained) A review of Resident #33's medical record revealed an admission date of 05/24/22 and diagnoses including acute respiratory failure with hypoxia, major depressive disorder, anxiety disorder, and pneumonia. Physician's orders revealed that on 05/24/22, she was ordered oxygen at 3 L/min via nasal cannula continuously every shift, morning and night and change oxygen tubing every Sunday and as needed. On 05/25/22, an order was written to document shortness of breath (SOB) when lying flat, SOB at rest, and SOB with exertion. Head of Bed (HOB) was to be elevated every shift, starting in the morning at 7:00 am. (Photographic evidence obtained) Resident #33's July 2022 and August 2022 Medication Administration Records (MARs) revealed that oxygen was to be set with a flow rate of 3 L/min via nasal cannula continuously. Nursing initials indicated the oxygen had been provided per the order. (Photographic evidence obtained) Resident #33's vital signs for July 2022 revealed that her oxygen saturation was between 92 and 98 percent. Her vital signs for August 2022 revealed her oxygen saturation ran between 96 and 98 percent. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/31/2022, revealed the resident had a brief interview for mental status (BIMS) score of 99, indicating the resident was unable to complete the interview. She required extensive assistance for bed mobility and she was totally dependent for eating. Resident #33 was documented as receiving oxygen therapy. A review of her active care plan revealed no care plan addressing her oxygen therapy. Further review of the resident's medical record revealed a Progress Note dated 07/07/22 at 6:47am, which read, Respirations even and unlabored, no SOB, oxygen saturation at 93 percent on 3 L/min of oxygen. Further review revealed a Nursing Note on 07/10/2022 at 11:11am, revealing, The resident continues oxygen at 3 L/min for diagnosis of acute respiratory failure, HOB elevated to facilitate breathing, and becomes shortness of breath with exertion-rest periods provided. Orders in place for weekly change of oxygen tubing. (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 4 Event ID: 105423 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 105423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257 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)