Inspection·July 21, 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 observations, medical record review, staff and resident interviews, and facility policy review, the facility failed to ensure that one (Resident #44) in a sample of 25 residents was provided respiratory care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #44 was administered oxygen at a flow rate which exceeded his physician's order. Residents Affected - Few The findings include: On 7/18/22 at 12:25 PM, Resident #44 was observed lying in bed with his oxygen (O2) concentrator set at 5 liters per minute (LPM). His nasal cannula was observed in his hands. The resident then placed the prongs of the nasal cannula in his mouth. On 7/18/22 at 3:00 PM, Resident #44 was observed lying in bed, awake, with no nasal cannula in place. His oxygen concentrator was running and the flow rate was set at 5 LPM. (Photographic evidence obtained) On 7/19/22 at 10:20 AM, Resident #44 was observed lying in bed, awake. His O2 concentrator flow rate was set at 5 LPM (Photographic evidence obtained) His nasal cannula tubing was in his mouth. He was asked if he knew what his oxygen flow rate was supposed to be set at. He stated, I think 2 or 3? He was asked if he ever changed the oxygen flow rate on the concentrator by his bed. He stated, No, I don't touch that. The nurses do that. On 7/19/22 at 2:40 PM, Resident #44 was observed lying in bed, awake. His O2 nasal cannula prongs were in his mouth. The O2 concentrator flow rate was set at 5 LPM. The resident was asked why his oxygen tubing was in his mouth. He stated, It annoys me. It hurts my nose. On 7/20/22 at 10:15 AM, Resident #44 was observed lying in bed, awake. His O2 nasal cannula prongs were in his mouth. His oxygen concentrator flow rate was set at 5 LPM. (Photographic evidence obtained) A review of the resident's medical record, revealed that he was diagnosed with Chronic Obstructive Pulmonary Disease (COPD). His physician' orders read: 9/22/20: Oxygen at 2 LPM per nasal cannula via O2 concentrator and/or tank PRN for SOB (shortness of breath) 9/22/20: O2 sats: pulse oximetry every shift and PRN. (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: 105651 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 105651 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center of Day 325 S Segrave Street Daytona Beach, FL 32114 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)