Health inspection·March 10, 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** 3. On 03/08/22 at 9:43 AM, Resident #39 was observed lying in his bed. The oxygen concentrator was running, and he was wearing his n/c. The concentrator was set at 4 LPM. He stated, he thought it should be at 2.5 LPM. (Photographic evidence obtained). Residents Affected - Some A review of the medical record for Resident #39 revealed an admission date of 10/03/21 and re-admission date of 03/01/22. His diagnoses included A-Fib, pulmonary hypertension, personal history of COVID-19, chronic diastolic heart failure, end stage renal disease, dependence on renal dialysis, dependence on supplemental oxygen, personal history of malignant neoplasm of bronchus and lung, and neoplasm of left kidney. A review of the physician's order revealed, Oxygen at 2 LPM via n/c with humidification used every shift with start date: 03/02/22. (Photographic evidence obtained) A review of the MDS assessment dated [DATE] revealed the resident was assessed as receiving oxygen therapy and respiratory therapy 3 days out of the assessment period. He reported no shortness of breath, none observed. He reported shortness of breath or trouble breathing when lying flat. His Brief Interview for Mental Status (BIMS) score was 11 out of a possible 15, indicating mild cognitive impairment. A review of the care plan dated 12/31/21 revealed the resident has altered respiratory status/difficulty breathing related to acute respiratory failure with hypoxia, Congestive heart failure and end stage renal disease. On 03/09/22 at 8:51 AM, Resident #39 was observed seated in his wheelchair in the dining area on the 300 hallway. He stated he was waiting to go to his dialysis appointment. He did not have a n/c on, or an oxygen tank strapped to the back of his wheelchair. He stated he is supposed to always have oxygen but, They don't send it with me to dialysis very often. The dialysis clinic does not apply oxygen when he gets there either. He stated he does not know why. Employee F, RN was informed that Resident #39 did not have his oxygen running and was about to leave for his dialysis appointment. She stated, she was unaware of the fact that he did not have it. She immediately went and got him a tank and cannula and applied it. On 03/10/22 at 1:30 PM, during an interview and observation of Resident #39. He was lying in bed attempting to feed himself. His nasal cannula was on. The oxygen concentrator was set at 2.5 LPM. On 03/10/22 at 2:29 PM, an interview was conducted with Employee F, RN who was assigned to care for Resident #39. She was asked what the oxygen liter flow order was for Resident #39. After reviewing the oxygen order, she stated, he was supposed to receive 2 LPM. She was informed that the concentrator was set at 2.5 LPM. She stated, she was unaware of that and would change it right away. (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 8 Event ID: 106061 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 106061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgecrest Healthcare and Rehabilitation Center 1200 North Stone Street Deland, FL 32720 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)