Health inspection·January 27, 2022

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. During an observation on 1/24/2022 at 11:10 AM, Resident #362's oxygen delivery tubing was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). Residents Affected - Some Review of Resident #362's admission records revealed the resident was admitted on [DATE] with the diagnosis to include pneumonia. Review of Resident #362's Minimum Data Set (MDS) dated [DATE] read, Section O. Special Treatments, Procedures, and Programs: C. Oxygen 1. While Not a Resident: Yes, 2) While a Resident: Yes. Review of the physician orders for Resident #362 read, Order Summary: Nebulizer: tubing change weekly Sunday 7p-7a every night shift every Sun [Sunday] for PNA [Pneumonia]. Order Date: 01/06/2022. Order Summary: Oxygen: Change oxygen tubing every week as needed for O2 [oxygen] therapy. Order Date: 01/06/2022. Order Summary: Oxygen: Change oxygen tubing every week every night shift every Sun for O2 therapy. every night shift every Sun for O2 (oxygen) therapy. During an observation on 1/25/2022 at 1:44 PM, Resident #362's oxygen delivery tubing attached to the oxygen tank was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). During an observation on 1/25/2022 at 2:53 PM, Resident #362's oxygen delivery tubing attached to the oxygen tank was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). During an interview on 1/25/2022 at 2:53 PM, Staff D, LPN, Unit Manager, confirmed that the Resident #362's nebulizer tubing was dated 1/9/2022 and oxygen tubing was dated 1/16/2022. She stated, It is the facility expectation that oxygen tubing and nebulizer tubing is changed weekly on Sundays. Nebulizer tubing was due to be changed on 1/16/2022 and oxygen tubing was due to be changed on 1/23/2022. Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #44 and #362, in a total sample of 30 residents. Findings: 1. Review of the physician orders for Resident #44 read, Order Date: 1/30/2020. Order Summary: Page 1 of 2 105796 105796 01/27/2022 Edgewater at Waterman Village 300 Brookfield Ave Mount Dora, FL 32757

F 0695 Oxygen: 2 liters via N/C [Nasal Canula] PRN [as needed] every shift and as needed. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/24/2022 at 10:27 AM, Resident #44 way lying in her bed receiving oxygen via nasal cannula. Resident #44's oxygen concentrator gauge showed she was receiving oxygen at 3 liters via nasal cannula. Residents Affected - Some During an observation on 1/25/2022 at 8:47 AM, Resident #44 was lying in her bed receiving oxygen via nasal cannula. Resident #44's oxygen concentrator gauge showed she was receiving oxygen at 2.5 liters via nasal cannula. During an interview on 1/25/2022 at 8:47 AM, Resident #44 stated, I did not adjust the gauge on my oxygen concentrator. I let them do it. During an interview on 1/26/2022 at 7:54 AM, Staff A, Licensed Practical Nurse (LPN)/ Unit Manager, confirmed Resident #44's physician order was for oxygen to be administered at 2 liters via nasal cannula. During an observation on 1/26/2022 at 7:56 AM with Staff A, LPN, Unit Manager, Resident #44's oxygen concentrator gauge was adjusted between 2.5 and 3 liters. During an interview on 1/26/2022 at 7:56 AM, Staff A, LPN, Unit Manager, confirmed Resident #44's oxygen concentrator gauge showed a higher rate than the prescribed 2 liters via nasal cannula. 105796 Page 2 of 2