Inspection·February 25, 2025

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 (O2) therapy was administered as per physician orders for 1 resident reviewed for oxygen, of a total sample of 7 residents, (#5). Residents Affected - Few Findings: Resident #5, a 75- year-old female was admitted to the facility on [DATE]. Her diagnoses included sequelae of cerebral infarction (stroke complications), major depressive disorder, and chronic diastolic (congestive) heart failure. Review of the resident's quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. The assessment also revealed resident #5 received oxygen. The resident's care plan for oxygen therapy initiated on 3/01/21, indicated interventions which directed staff to, give medications as ordered by the physician, and, oxygen as ordered. Observations on 2/24/25 at 10:17 AM, at 12:31 PM, and at 12:45 PM, showed the resident sitting up in bed awake, alert, and oriented. She had an O2 nasal cannula (NC) connected to an oxygen concentrator set at 4.5 liters per minute (LPM). The resident could not say how many LPM the flow rate for her O2 should be set at. Clinical record review of the resident's physician orders revealed an order dated 10/01/24 for Oxygen 2 LPM via NC as needed for congested heart failure (CHF). On 2/24/25 at 12:33 PM, Licensed Practical Nurse (LPN) A stated O2 therapy should be checked every shift, unless there was a change in the resident's status. The LPN stated that when care was provided care, and medications given, the nurse was supposed to check the resident's O2 therapy, to ensure the O2 was flowing at the ordered rate. LPN A confirmed resident #5 had physician's orders for O2 at 2 LPM as needed. On 2/24/25 at 12:45 PM, observation of the flow rate of the resident's O2 therapy was conducted with LPN A. She acknowledged that the O2 was infusing at 4.5 LPM, and said the rate should be at 2 LPM. On 2/24/25 at 12:48 PM, the [NAME] Wing Unit Manager (UM) stated O2 therapy should be checked by nurses when giving medications, and throughout the day to ensure that O2 was going at the right flow rate. The resident's physician orders were reviewed by the UM, and she confirmed that the O2 order (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: 105564 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 105564 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Nursing and Rehabilitation Center 7950 Lake Underhill Road Orlando, FL 32822 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)