Health inspection·November 21, 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** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice by not dating the oxygen tubing for 1 of 3 residents reviewed for oxygen administration, Resident #184 (photographic evidence obtained). Residents Affected - Few Findings include: During an observation on 11/19/2023 at 10:50 AM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. During an observation on 11/19/2023 at 1:18 PM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. Review of Resident #184's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of, but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation. Review for Resident #184's physician order dated 11/16/2023 reads, Change oxygen and or nebulizer tubing, every week every night shift every Sun [Sunday] for preventative. During an interview on 11/20/2023 at 11:15 AM, the Director of Nursing stated, When a patient enters the facility, a date should be placed on the oxygen tubing, and then changed every Sunday night. Review of the facility policy and procedure titled Oxygen Administration reads, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration. Reporting 2. Report other information in accordance with facility policy and professional standards of practice. Page 1 of 2 106105 106105 11/21/2023 Skytop View Rehabilitation Center 2145 North Don Wickham Drive Clermont, FL 34711

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the clinical records was accurate for 1 of 3 sampled residents, Resident #82. Findings include: Review of Resident #82's admission record showed the resident was most recently admitted to the facility on [DATE]. Review of Resident #82's progress note dated 11/18/2023 showed the progress note reads, 97 y/o [year old] female arrived on 9/18/2023 . During an interview on 11/20/2023 beginning at 11:49 AM, the Director of Nursing confirmed Resident #82 was admitted on [DATE]. She confirmed the progress note entry related to Resident #82's admission date was inaccurate. Review of Resident #82's wandering risk assessment dated [DATE] showed the assessment reads Medications 1. Taking antipsychotics. Review of Resident #82's current, discontinued and completed physician orders with the Director of Nursing did not show any documentation indicating Resident #82 was or had been prescribed with an antipsychotic medication. During an interview on 11/20/2023 beginning at 11:49 AM, the Director of Nursing confirmed Resident #82's wandering risk assessment documented Resident #82 was taking an antipsychotic medication. She confirmed Resident #82 was not or had not been prescribed with an antipsychotic medication and stated that Resident #82's wandering risk assessment was inaccurate. 106105 Page 2 of 2