Inspection·July 30, 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 observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care received oxygen therapy as ordered for one (Resident #4) of 23 residents receiving oxygen therapy in a total survey sample of 26 residents. The findings include: On 7/28/2025, at 12:47 PM, Resident #4 was observed in her room in a chair beside her bed in a hospital gown. She was receiving oxygen via nasal cannula. She reported she received oxygen at a flow rate of two liters per minute (2 L/min). The oxygen concentrator was in her bathroom, not within arm's reach of the resident, and was set at 3 L/min. (Photographic evidence obtained) On 7/29/2025, at 12:13 PM, Resident #4 was observed in her room in a chair beside her bed in a hospital gown. She was receiving oxygen via nasal cannula. The oxygen concentrator was in her bathroom and was set at 3 L/min. (Photographic evidence obtained) A review of Resident #4's medical record revealed active physician's orders for oxygen therapy: Continuous oxygen via nasal cannula at 2L/min every shift for hypoxia (dated 3/7/2025). Oxygen bubbler and tubing need to be changed every week, write date and initials when changed, remove old bubbler and tubing (dated 3/9/2025), and oxygen in use card to be place by residents and door and checked - verified by nurse every shift for oxygen safety (dated 3/7/2025). Other orders included albuterol sulfate inhalation nebulization solution (2.5 mg/3ml - milligrams per milliliter) 0.083% (dated 3/7/2025) and morphine sulfate (concentrate) oral solution 20 mg/ml (morphine sulfate), give 0.25 ml by mouth every four hours as needed for shortness of breath/non-acute, moderate to severe pain SL (dated 7/9/2025). (Copy obtained) Further review of the medical record revealed that Resident #4 was readmitted to the facility on [DATE] with an initial admission date on 9/16/2023. Her primary diagnoses included: Acute respiratory failure with hypoxia, shortness of breath, chronic obstructive pulmonary disease (COPD), unspecified; and obstructive sleep apnea. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/25/2025, revealed the resident was receiving hospice care, required oxygen therapy, and had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 possible points, indicating moderate cognitive impairment. Resident #4 was independent with eating and required supervisory or touching assistance for toilet transfers. A review of the care plan, focus and goals related to oxygen therapy included altered respiratory status/difficulty breathing related to congestive heart failure (CHF), sleep apnea, and COPD. Interventions included oxygen settings: oxygen via nasal prongs (cannula) at 2L/min, administer medication/puffers as ordered, monitor for effectiveness and side effects, and set-up or clean-up assistance. A review of the resident's oxygen saturations from 7/1/2025 - 7/29/2025 revealed a range of 93-98% (oxygen via nasal canula), on 7/15/2025: 94% (room air), and on 7/22/2025: 98% (room air). The resident's Medication Administration Record (MAR) for July 2025 was initialed for continuous oxygen via nasal cannula at 2 L/min every shift for hypoxia and oxygen bubbler and tubing need to be changed every week, write date and initials when changed, remove old bubbler and tubing, as ordered by physician. (Copy obtained) On 7/29/2025 at 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 3 Event ID: 105630 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 105630 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vicar's Landing Nursing Home 1003 York Road Ponte Vedra Beach, FL 32082 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)