Health inspection·February 27, 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 observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care received such care (oxygen therapy) as ordered for two (Resident #31 and #86) of three residents reviewed for oxygen use, from a total of 23 residents receiving oxygen. Both residents were observed receiving oxygen at a flow rate of 1.5 Liters per minute over several days. Each resident was ordered oxygen at a flow rate of 2.0 Liters per minute. Residents Affected - Few The findings include: 1. On 02/24/25 at 12:28 PM, Resident #31 was observed in bed receiving oxygen via a nasal cannula. The oxygen concentrator, located next to the wall at the head of his bed and out of his reach, was set with a flow rate of 1.5 L/min. (Liters per minute). (Photographic evidence obtained) On 02/25/25 at 10:08 AM, Resident #31 was observed lying in bed. His nasal cannula was not in place. The oxygen flow rate setting on the concentrator was 1.5 L/min. (Photographic evidence obtained) Resident #31 stated he did not know where his call light was. It was attached to the sheet above the right side of his head. He was given his call light, and he pushed the button for staff assistance. Certified Nursing Assistant (CNA) F answered the call light and saw that the resident's nasal cannula was not in place. CNA F told the resident, You chewed it again. This is the second time today that [the resident] has chewed the cannula. He does that sometimes. CNA F took the nasal cannula from the bed and removed it from the concentrator, stating it would be replaced. On 02/25/25 at 10:27 AM, Resident #31 was observed receiving oxygen via a nasal cannula with his oxygen concentrator flow rate set at 1.5 L/min. (Photographic evidence obtained) A review of Resident #31's active physician's orders revealed: Oxygen at 2 liters/min via nasal cannula. Humidification: yes (9/12/2024) A review of Resident #31's medical record revealed an admission date of 08/20/24. The resident's diagnoses included acute and chronic respiratory failure with hypoxia. A review of the resident's Quarterly MDS (minimum data set) assessment, dated 02/13/25, revealed that the resident was receiving hospice care, required oxygen therapy, and had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 possible points, indicating severe cognitive impairment. A review of the resident's care plan revealed a focus area for oxygen therapy related to signs/symptoms of poor oxygen absorption. Interventions included administration of medications as ordered by (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: 105586 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 105586 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073 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)