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: (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: 105796 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 105796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater at Waterman Village 300 Brookfield Ave Mount Dora, FL 32757 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)