Health inspection·October 2, 2025

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, record review, staff interviews, and a review of facility policies and procedures, the facility failed to ensure that one (Resident #73) of 15 residents who required respiratory care, received supplemental oxygen at a flow rate of 2 liters per minute (L/min) as prescribed by the physician.The findings include: Residents Affected - Few On 9/29/2025 at 10:55 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. She was receiving supplemental oxygen via nasal cannula that was connected to an oxygen concentrator located behind her wheelchair. The oxygen flow rate setting on the concentrator was set to 4 L/min, and the oxygen humidifier bottle attached to the concentrator was dated 7/26/2025. (Photographic evidence obtained) On 9/30/2025 at 9:55 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. She was receiving supplemental oxygen via nasal cannula from an oxygen concentrator located beside her chair. The oxygen flow rate was observed to be set at 4 L/min. (Photographic evidence obtained) On 10/01/2025 at 9:55 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. Her oxygen concentrator flow rate setting was verified to be set at 4L/min. (Photographic evidence obtained) The oxygen humidifier bottle was still unchanged and remained dated 7/26/2025 (Photographic evidence obtained) On 10/02/2025 at 9:00 AM, Resident #73 was observed in her room, dressed and sitting in her wheelchair. On 10/2/2025 at 9:05 AM, Nurse A was asked what Resident #73's oxygen flow rate should be. Nurse A replied that the resident was receiving oxygen at 2 L/min. The nurse was accompanied to the resident's room at 9:10 AM, and she checked the oxygen flow rate on Resident #73's oxygen concentrator. She stated it was currently set at a flow rate of 4 L/min. She lowered the setting to 2 L/min. A review of the resident's active physician's orders revealed: 8/5/2025 - Check distilled water level in oxygen humidifier. If less than half full, then refill. Check every shift to ensure oxygen tubing is in Ziplock bag when not in use. 3/25/2025 - Change oxygen humidifier bottle and date monthly. 3/2/2025 - Change O2 (oxygen) tubing and clean O2 concentrator filter once weekly on Sunday. Page 1 of 3 105821 105821 10/02/2025 Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217

F 0695 Level of Harm - Minimal harm or potential for actual harm 2/25/2025 - O2 at 2L/min NC (via nasal cannula) every night at bedtime (QHS) for chronic obstructive pulmonary disease (COPD). 2/24/2025 - O2 at 2L/min via nasal cannula as needed to maintain O2 saturation % >92%. Check O2 saturation % every shift to keep O2 saturation levels > 92%. Residents Affected - Few Further review of Resident #73's medical record revealed that she was admitted to the facility on [DATE] with an admitting diagnosis of acute on chronic diastolic (congestive) heart failure. Additional diagnoses included, but were not limited to, atherosclerotic heart disease, atrial fibrillation, anxiety disorder and non-rheumatic aortic (valve) stenosis. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 8/29/2025, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. She was documented as receiving hospice care and had a DNR (Do Not Resuscitate) status. 9/2/2025, and a completed date of 9/26/2025. The resident was noted as at risk for breathing problems related to her diagnosis of COPD and was at risk for respiratory complications. Goals and interventions included but were not limited to: Maintain respiratory baseline as evidenced by no occurrence of dyspnea or SOB (shortness of breath) through the review period. Administer medications as ordered by the physician. Administer oxygen at night as ordered. Encourage to clear secretions. Head of bed with 2-3 pillows while in bed/chair as tolerated per patient. Monitor O2 saturation as ordered. Observe and report signs and symptoms of respiratory infections and report to MD. Observe and report signs of dyspnea and SOB. Observe respiratory status for rate, depth and ease, essence of tachypnea, dyspnea in relation to disease process or decreased energy level. Assess for shortness of breath and cyanosis as needed. Monitor vital signs as ordered. Notify MD (physician) of significant abnormalities. COPD/SOB - Continue Long-Acting Beta-Antagonist (a type of bronchodilator medication) every 12 hours, as needed O2, and nocturnal O2. Patient has orders for O2 as needed and she does okay with this during the day but reports she needs O2 all throughout the night - order nocturnal O2 via Nasal Cannula @ 2L. Patient assessed and well compensated on Room Air, lungs diminished but clear; 9/9/25 patient seen and assessed, she is alert and doing well - patient wearing O2 today and sats 95%, continue O2 throughout day PRN (as needed) and continuous QHS as well as pulmonary toilet - lungs clear – monitor. On 10/02/2025 at 12:08 PM, Nurse A stated she had worked at the facility for about two years. She further stated she reviewed doctors' orders in the electronic medical record to verify the oxygen flow rate a resident should be receiving. She stated she checked the oxygen concentrator and oxygen delivery tubing about once per shift but would check more often if the resident seemed to be experiencing distress. She checked the oxygen saturation levels per the physicians' orders using the monitor that was kept in the nursing cart. She stated the facility conducted different in-service training throughout the year and had staff sign an attendance log when training was provided. When asked what Resident #73's oxygen flow rate should be, Nurse A stated 2 L/min. Earlier on this date at 9:10 AM, Resident #73's O2 flow rate was adjusted from 4 L/min to 2 L/min by Nurse A after she was asked what the resident's flow rate should be. 105821 Page 2 of 3 105821 10/02/2025 Vivo Healthcare Taylor 6535 Chester Avenue Jacksonville, FL 32217

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/02/2025 at 1:00 PM, Nurse B/Unit Manager stated she had worked at the facility for 20 years. She stated she would review the orders in the EMR to verify at what flow rate Resident #73's oxygen should be set. She stated residents' oxygen saturation levels were obtained by using the pulse oximeter kept in the nursing cart. Oxygen delivery tubing was usually ordered to be changed weekly, and oxygen humidifier bottles were changed monthly. She further stated if a resident was receiving oxygen, they should be checked on a regular basis, like, every nurse should check every shift. When she was asked to check the oxygen flow rate order in Resident #73's EMR, she did and replied that the resident should be receiving 2 L/min. A review of the facility's policy titled Oxygen Administration Level III (revised October 2010), revealed: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the preparation section, the policy directed the reader to verify that there was a physician's order for this procedure and to review the physician's orders or facility protocol for oxygen administration. The policy listed a humidifier bottle under equipment and supplies. The policy stated the humidifying jar was to be checked to be sure it was in good working order, securely fastened, and that the water level was high enough that the water bubbled as oxygen flowed through. (Photographic evidence obtained) 105821 Page 3 of 3