Inspection·November 4, 2021

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record reviews, the facility failed to promote and facilitate resident self-determination through support of resident choice, by not allowing the resident to make choices about aspects of his/her life in the facility that were significant to the resident for one (Resident #21) out of a total sample of 24 residents. The findings include: A tour of House 5, including the lunch meal observation, was on conducted at 12:00 p.m. on 11/1/2021. Resident #21 was observed rejecting his lunch tray. Certified Nursing Assistant (CNA) H delivered the facility-provided meal the to resident. When the resident saw what was offered, he declined the meal. CNA H set the food to the side and stated, I guess you are not eating today. and left the room. CNA H was interviewed at the time of the observation, but stated he didn;t know much about Resident #21 because he didn't normally work in House 5. The resident was also interviewed at the time of the observation, and during the interview, the resident stated he did not want a pureed meal, he wanted food. Licensed Practical Nurse (LPN) G entered the room at 12:16 p.m. and asked the resident what he would like to eat. The resident stated he wanted a quarter-[NAME] with cheese. LPN G explained that she couldn't get him a quarter-[NAME] with cheese, but she would request a cheeseburger. She told the resident the cheeseburger would be pureed. During an interview with LPN G on 11/1/2021 at 12:19 p.m., she stated the resident was on hospice. The family signed a waiver for comfort foods/regular texture but the resident choked on it. When asked about whether a mechanical-soft textured diet had been considered, LPN G stated she was unsure why the resident was not prescribed a mechanical soft diet. LPN G was interviewed again on 11/3/2021 at 2:00 p.m. During the interview she stated she spoke with the Dietician and Certified Dietary Manager (CDM) on 11/2/2021. She said all agreed to upgrade the resident's diet from a pureed consistency to mechanical soft. She stated the resident ate his lunch meal today without resistance and drank a Dr. Pepper instead of the thickened liquid he always spit out. A follow-up observation/interview was conducted with Resident #21 on 11/3/2021 at 2:15 p.m. When he was asked about his lunch meal, he replied It was good. An interview with the CDM was conducted on 11/4/2021 at 10:15 a.m. The CDM stated the resident was still on a regular diet with a pureed texture. When asked about the resident having received a mechanical soft meal for lunch on 11/3/2021, the CDM was not aware of the meal having been provided to the resident. The CDM acknowledged that the resident was able to receive comfort foods and could get items he requested. The CDM stated the kitchen staff sent out a pureed meal based on the meal ticket, (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 7 Event ID: 106088 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 106088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde E Lassen State Veterans Nursing Home 4650 State Rd 16 Saint Augustine, FL 32092 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)