Health inspection·March 24, 2022

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 respiratory services were provided in accordance with professional standards for 2 of 5 residents, Residents #89 and #76 reviewed for respiratory care in a total sample of 36 residents. Residents Affected - Few Findings: 1) During an observation on 03/21/2022 at 10:17 AM, Resident #89 was observed in her room lying in bed. Oxygen was being administered to the resident at 2.5 liters via nasal cannula. Review of Resident #89's physician's order summary report, the active medication orders as of 03/23/2022, did not document a physician's order for oxygen. During an interview on 3/23/2022 at beginning 8:06 AM, Staff A, RN (Registered Nurse) stated she could not find a current physician's order for Resident #89 to be administered oxygen. Resident #89 had an order for oxygen a long time ago, that order had been discontinued. 2) During an observation of Resident #76 on 3/21/2022 at 9:45 AM the resident was resting in bed with oxygen being administered at 3.5 liters per minute via nasal cannula. During an observation of Resident #76 on 3/24/2022 at 10:00 AM, the resident was resting in bed with oxygen infusing at 3.5 liters per minute via nasal cannula. (Photographic evidence obtained) Review of the physician's order dated 11/02/2021 for Resident #76 read, Oxygen at 2 liters per minute via nasal cannula continuous every shift for shortness of breath. During an interview with Staff B, RN on 3/24/2022 at 10:10 AM she verified Resident #76 has a physician order for oxygen therapy to infuse at 2 liters per minute via nasal cannula. She stated, The oxygen concentrator should be set at 2 liters per minute and is currently running at 3.5 liters per minute. During an interview with Staff C, Licensed Practical Nurse (LPN) on 3/24/2022 at 10:15 AM she verified Resident #76's oxygen concentrator was set at 3.5 liters per minute. During an interview with the Director of Nursing (DON) on 3/24/2022 at 10:30 AM she stated it is her expectation that the nurses on the floor would follow the physicians' orders related to oxygen therapy. Review of the policy and procedure titled Administering Medications Last Reviewed: 03/10/2022 read: (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: 105437 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 105437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Cove Care Center 700 SE Dr Martin Luther Jr Ave Crystal River, FL 34429 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)