Inspection·March 10, 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 oxygen was administered consistent with professional standards of practice for 1 of 3 residents, Resident #30, in a total sample of 34 residents. Residents Affected - Few Findings: During an observation on 03/08/2022 at 10:52 AM of Resident #30 it showed the resident was being administered oxygen at 2 liters per minute (2L/min) via nasal cannula. During an observation on 03/09/2022 at 10:03 AM of Resident #30 it showed the resident was being administered oxygen at 3.25 L/min (liters per minute) via nasal cannula. During an observation on 03/09/2022 at 12:23 PM of Resident #30 it showed the resident was being administered oxygen at 3.25 L/min via nasal cannula. Review of the physician's order dated 2/28/2022 read: Continuous oxygen at 4 liters/min via nasal canula each shift. During an interview conducted on 03/09/2022 at 2:00 PM Staff A, Licensed Practical Nurse (LPN) stated, Looks like it's [oxygen setting] is between 3 to 3 1/2 liters per minute. The Certified Nursing Assistants never adjust the oxygen, only the LPNs adjust the oxygen; even the respiratory therapist will ask the LPNs, before they adjust it. I'd be surprised if he could get out of bed alone and change it. Review of the physician's order for Resident #30 was conducted with Staff A, LPN. Staff A verified the physician's order as written is for oxygen at 4L/min. Review of Resident #30's care plan initiated on 01/21/2022 read: Resident #30 has a potential for complications of respiratory distress r/t (related to) dx (diagnosis) of: SOB (shortness of breath), PNA (pneumonia) HX (history), hypoxia HX, COPD (chronic obstructive pulmonary disease), and CHF (congestive heart failure). Goal: Resident will remain free from cardiovascular complications thru the next review dated. Interventions: O2 sats [saturation] as ordered. Administer O2 [oxygen] as ordered. Observe for signs and symptoms of respiratory distress; update physician if noted. Vital signs as ordered and as needed. Elevate HOB [head of bed]>30 degrees to minimize SOB as needed. 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: 105621 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 105621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Campus Rehabilitation and Nursing Center 700 N Palmetto St Leesburg, FL 34748 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)