Inspection·November 21, 2024

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, facility document review, and the facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, for one (Resident #95) of four residents reviewed for respiratory care, in a total survey sample of 28 residents. Resident #95 did not receive oxygen at the flow rate ordered by his physician. Residents Affected - Few The findings include: On 11/18/24 at 1:10 PM, Resident #95 was observed fully dressed, sitting in his wheelchair inside his doorway communicating with Maintenance Director A in Spanish. His room was approached and the resident's nasal cannula was observed on the floor next to his wheelchair. Maintenance Director A advised Licensed Practical Nurse (LPN) B that Resident #95's nasal cannula was on the floor. The Director of Nursing (DON) also advised LPN B that Resident #95 needed an oxygen tank for his wheelchair. The oxygen flow rate on the concentrator was set between 1.5 and 2.0 Liters per minute (L/min). (Photographic evidence obtained) On 11/19/24 at 8:34 AM, Resident #95 was not wearing his nasal cannula and the oxygen flow rate on his wheelchair oxygen tank was set at 2 L/min. (Photographic evidence obtained) A review of the resident's active Physician's Orders revealed the following: Oxygen at 3 L/min via nasal cannula, continuously every morning and at bedtime for oxygen management. (Dated 10/1/24) Change oxygen tubing weekly. Label each component with date and initials every night shift every Sunday for infection control. Change humidifier and label. (Dated 11/17/24). (Copy obtained) A review of the resident's medical record revealed an admission date of 10/1/24 with a previous admission on [DATE]. Resident #95's diagnoses included acute respiratory failure with hypoxia; shortness of breath, other pneumonia, unspecified organism, a need for assistance with personal care; adjustment disorder with anxiety; and anxiety disorder. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 10/4/24, revealed that the resident was independent with eating and required oxygen therapy. A review of the resident's active care plan revealed that focuses and goals included altered or potential for altered respiratory status related to shortness of breath. Interventions included to (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: 105692 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 105692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Orange Park 570 Wells Rd 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)