Inspection·September 1, 2022

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #75) of 10 residents receiving respiratory treatment, from a total of 13 residents in the sample. Residents Affected - Few The findings include: On 8/29/2022 at 10:16 a.m., Resident #75 was observed asleep in bed. Her nasal cannula was lying across her chest and an oxygen concentrator was observed at bedside. The concentrator was set to administer oxygen at a rate of 4 liters per minute (LPM). During a follow-up attempt to interview the resident at 1:11 p.m. the same day, she was again observed sleeping. The oxygen concentrator flow rate remained set at 4 LPM. On 8/30/2022 at 10:53 a.m., the resident was observed sitting up in bed with her nasal cannula in place. Her oxygen concentrator was still set to administer oxygen at 4 LPM. (Photographic evidence obtained) During another visit to the resident's room on 8/31/2022 at 11:07 a.m., her nasal cannula was in place. The oxygen concentrator remained set to administer oxygen at 4 LPM. On 8/31/2022 at 1:54 p.m., Resident #75 was observed resting in bed with her nasal cannula in place and her oxygen concentrator set to administer oxygen at 4 LPM. During an interview with Registered Nurse (RN) A on 8/31/2022 at 11:18 a.m., she confirmed the resident's oxygen was ordered at a flow rate of 2 LPM. She stated the certified nursing assistants (CNAs) were responsible for taking the residents' vital signs, and the nurses were responsible for adjusting the oxygen flow rates as needed. During the interview, RN A was asked to observe the oxygen for Resident #75. She went to the resident's room and confirmed that the resident's nasal cannula was in place. She further stated the concentrator was set to administer oxygen at 4 LPM. When she was asked about the flow rate, she stated it was titrated up to keep the resident's oxygen saturation (sats) above 92%. She was asked if there was an order for the titration to which she replied, At this point it's to keep her comfortable. RN A was unable to provide supporting physician's orders as requested. During an interview with CNA B on 8/31/2022 at 2:05 p.m., she stated she had been employed at this facility for nine years and Resident #75 was a total assist. She further stated the CNAs were responsible for ensuring that the residents' oxygen concentrators were set at the ordered flow rate. She stated the CNAs could consult the nurses or the residents' care plans for the oxygen orders. She (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: 106077 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 106077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moosehaven 1701 Park Avenue 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)