Inspection·August 12, 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 observation, interview, and record review, the facility failed to administer Oxygen (O2) therapy as ordered by the physician for 2 of 4 residents reviewed for respiratory care, of a total sample of 4 residents, (#3 and #4).1. Resident #3 was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).Review of resident #3's medical record revealed a care plan revised on 8/07/25 which indicated the resident's oxygen to be applied, as ordered by physician, for respiratory complications related to CHF, COPD, and pneumonia.Supplemental oxygen therapy helps people with COPD, COVID-19, emphysema, sleep apnea and other breathing problems get enough oxygen to function and stay well. Low blood oxygen levels (hypoxemia) can damage organs and be life-threatening, (retrieved on 8/15/25 from www.myclevelandclinic.org).Resident #3's Order Summary Report showed an active physician's order dated 8/4/25 for oxygen at 1 liter per minute (LPM) via NC (nasal cannula) and an order for nurses to check the oxygen delivery rate every shift.On 8/12/25 at 9:35 AM, resident #3 was observed sitting up in bed with O2 delivered through a NC. The O2 tubing was connected to a concentrator set to deliver 3.5 LPM of oxygen. Resident #3 was alert and oriented to person, place and time, and denied adjusting her O2 concentrator settings herself. Later that day on 8/12/25 at 12:45 PM, resident #3 was in her room with O2 administered through the nasal cannula. The oxygen tubing was connected to an O2 concentrator still set at 3.5 LPM. On 8/12/25 at 12:50 PM, Registered Nurse (RN) A checked resident #3's medical record physician order and verified the oxygen was ordered by the physician for 1 LPM. The nurse confirmed she did not check the resident's oxygen settings today and said she should check every time she went in the room to ensure the resident was getting rate that was ordered by the physician. On 8/12/25 at 12:53 PM, the Assistant Director of Nursing (ADON) observed and acknowledged resident #3 was not getting her oxygen as ordered by the physician. The ADON confirmed the oxygen flow rate was ordered by the physician for 1 LPM. 2. Resident #4 was readmitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia (paralysis on side of the body), CHF, adult failure to thrive and quadriplegia (paralysis that affects all a person's limbs and body from the neck down). Review of resident #4's medical record revealed a care plan revised on 5/02/24 which indicated a resident focus for Respiratory Complications related to CHF and history of pneumonia which included an intervention to apply oxygen therapy as ordered with the goal that she would not have symptoms of respiratory distress. Resident #4's current active physician order dated 5/01/24 was for oxygen at 2 LPM continuously via nasal cannula. On 8/12/25 at 9:45 AM, resident #4 was lying in bed asleep with O2 administered through a NC. The O2 tubing was connected to an oxygen concentrator set at 1.5 LPM. Later that day on 8/12/25 at 1:00 PM, resident #4 was lying in bed asleep with oxygen administered through a nasal cannula. The oxygen tubing was connected to an O2 concentrator set at 1.5 LPM. On 8/12/25 at 1:05 PM, Licensed Practical Nurse (LPN) B explained she was assigned to resident #4 and verified the physician Residents Affected - Few (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: 105879 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 105879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Winter Park 1111 S Lakemont Ave Winter Park, FL 32792 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)