Inspection·February 11, 2021

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** 2. Resident #23 was admitted to the facility 12/01/20 with diagnoses that included viral pneumonia, and end stage renal disease. A review of the resident's physician's orders dated 12/01/20 read, Oxygen 2 liters per minute (LPM) as needed for shortness of breath or oxygen saturation less than 94% on room air. An observation of the resident's oxygen concentrator was made with the DON on 2/10/21 at 11:47 AM. The concentrator filter was covered with dust. The DON acknowledged the filter was not clean and was covered with dust. Residents Affected - Few 3. Resident #25 was admitted to the facility on hospice services on 12/21/20. Her diagnoses included kidney disease and multiple myeloma. Physician orders dated 12/21/20 included Oxygen at 2 LPM when sleeping for comfort. On 2/08/21 at 2:37 PM, and 2/09/21 at 12:31 PM, resident #25 was received oxygen via nasal cannula. The concentrator filter was noted to be covered with dust. 4. Resident #43 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease. His admission physician orders included O2 at 2 LPM via nasal cannula. On 2/09/21 at 11:29 AM, resident #43 was in bed with oxygen being administered via nasal cannula at 2 LPM. The left side of the concentrator filter was noted to be dusty. On 2/10/21 from 11:47 and 12:03 PM, the O2 concentrators for residents #23, #25 and #43 were observed with the Director of Nursing (DON). The DON acknowledged the filters were covered in gray dust. She said the RT was responsible for changing the O2 tubing weekly and cleaning the filters when needed. The Operator's Manual for the oxygen concentrators section 6- Maintenance. The concentrators were designed to minimize routine preventative maintenance. At a minimum, clean the concentrator cabinet filters weekly. Remove the filters and clean at least weekly dependent upon environmental conditions. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. Dry the filters thoroughly before reinstallation. Review of the electronic maintenance log showed the oxygen concentrators were maintained monthly, not weekly. They were last noted to be cleaned on 1/09/2021 by the Director of Maintenance. The Cleaning and Disinfection of Oxygen Concentrators Policy Statement revised on 1/12/2021 noted: Resident-care equipment, such as oxygen concentrators will be cleaned and disinfected according to facility cleaning procedure. There was no staff personnel specifically assigned to complete the task. On 2/10/21 At 1:30 PM, the Administrator, DON and the Director of Maintenance explained that (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: 105701 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 105701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solaris Healthcare Merritt Island 500 Crockett Blvd Merritt Island, FL 32954 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)