Inspection·March 23, 2023

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** Residents Affected - Few Based on observations, interviews, medical record review, and a review of the facility's policies and procedures, the facility failed to ensure residents who required respiratory care received care consistent with professional standards of practice and their comprehensive care plans, for two (Residents #87 and #76) of three residents reviewed for respiratory care, from a total of 36 residents in the sample. The findings include: 1. An observation of Resident #87 was made on 03/20/23 at 11:59 AM in her room. An oxygen concentrator was in the room and the flow rate (gauge) was set between the 1 and 2 measurement, indicating oxygen was flowing at a rate of 1.5 liters per minute (lpm). (Photographic evidence obtained) Resident #87's nasal cannula was lying on the bed. The resident stated she took it off for a few minutes, becasue it hurt her nose. She stated her oxygen flow rate should be set at 2 lpm. On 03/22/23 at 10:00 AM, Resident #87 was observed in her bed. Her oxygen concentrator was on and her nasal cannula was in place. She was observed with labored breathing as evidenced by the deep rise and fall of her chest. She stated she did not feel well, however denied difficulty breathing. Her oxygen concentrator was set at 1.5 lpm. (Photographic evidence obtained) Resident #87 again reported that her oxygen flow rate should be set at 2 lpm. On 03/22/23 at 1:46 PM and again at 2:28 PM, Resident # 87 was observed with her oxygen in use. Both observations found that the oxygen concentrator was set at 1.5 lpm. (Photographic evidence obtained) A review of Resident #87's medical record found that she was admitted to the facility on [DATE]. She had an annual Minimum Data Set (MDS) assessment, dated 02/05/23, that noted she had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating she was cognitively intact. She required limited assistance with activities of daily living. Her diagnoses included, but were not limited to, coronary artery disease, hypertension, asthma/COPD (chronic obstructive pulmonary disease), interstitial pulmonary disease unspecified (a group of disorders that cause lung scarring and affect breathing) and bronchiectasis (a condition in which the lung's airways become damaged). Resident #87 was documented as receiving oxygen while a resident of the facility. Resident #87 was care planned on 02/11/22 for her diagnosis of COPD with a goal to be free from signs and symptoms of respiratory infections through the next review date. Interventions included, but were not limited to, Oxygen (O2) settings: O2 via (nasal cannula) at 2 liters (continuous), (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: 105928 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 105928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Orange Park 2145 Kingsley Ave Orange Park, FL 32073 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)