Inspection·August 22, 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 a review of the facility's policies and procedures, the facility failed to ensure that residents who required respiratory care, received such care, consistent with professional standards of practice for one (Resident #91) of seven residents receiving respiratory care from a total survey sample of 26 residents. The findings include: Residents Affected - Few On 8/18/25 at 1:05 PM, Resident #91 was observed dressed and sitting in his electric wheelchair outside of his doorway. He was wearing a nasal cannula connected to a green, portable oxygen tank on the back of his wheelchair. The oxygen flow rate setting was for one Liter per minute (L/min). (Photographic evidence obtained) On 8/19/25 at 11:27 AM, Resident #91 was observed in bed. He was receiving oxygen via nasal cannula from a bedside concentrator with an oxygen flow rate set at 2.5 L/min. (Photographic evidence obtained) On 8/20/25 at 10:20 AM, Resident # 91 was observed in bed. He was receiving oxygen via nasal cannula from a bedside concentrator with an oxygen flow rate set at 2.5 L/min. (Photographic evidence obtained) A review of the resident's active oxygen orders revealed: Oxygen at 2 liters per min via nasal cannula as needed to maintain an oxygen saturation greater than 90% (1/8/2025) Monitor oxygen saturation every shift, may apply as needed oxygen if less than 90% (1/8/2025) A review of the resident's medical record revealed that Resident #91 was admitted to the facility on [DATE]. Pertinent diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (bodily tissues do not receive enough oxygen), and obesity. A review of the minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/8/25 revealed that during the facility's interview with the resident, conducted on 7/8/25, it was identified that Resident #91 wore oxygen continuously throughout the day. A recommendation was made for oxygen to be changed from as needed to routine per the resident's preference. As of 8/20/25, this recommendation had not been carried out. A review of the Care Plan focuses and goals, dated 7/10/25, revealed: (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: 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 08/22/2025 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)