Health 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: Page 1 of 2 106088 106088 08/22/2025 Clyde E Lassen State Veterans Nursing Home 4650 State Rd 16 Saint Augustine, FL 32092

F 0695 Level of Harm - Minimal harm or potential for actual harm Monitor oxygen saturation every shift; may apply as needed oxygen if less than 90%. Resident #91 will be maintained at their respiratory baseline with a patent airway and unlabored respirations through completion of treatment. Approach: Oxygen treatment as needed per medical doctor orders. If oxygen saturation drops below 88%, send to ER, If AMS, send to ER, if shortness of breath occurs, send to ER.Target Date: 10/10/25 (Short Term Goal). Residents Affected - Few A review of the August 2025 Medication Administration Record (MAR) revealed that nursing had signed off daily indicating that oxygen was provided as ordered by the physician. (Copy obtained) A Provider Care Note dated 8/5/25 by the Advanced Registered Nurse Practitioner (ARNP) revealed: Requires supplemental oxygen. Provider noted: Using supplemental oxygen as needed for dyspnea. On 8/20/25 at 4:00 PM, Licensed Practical Nurse (LPN) A confirmed that Resident #91's oxygen flow rate order was for 2L/minute and stated the oxygen settings should have been set to 2L/minute. All staff provided ongoing monitoring of the resident's oxygen therapy. We monitor every 2-3 hours to check the tank and also use the finger machine (pulse oximeter) to monitor oxygen levels. We check oxygen levels every two hours. Nursing is responsible for assuring that the resident is receiving the correct oxygen flow rate per the order. The doctor prescribes the order and nurses check levels. LPN A stated the correct oxygen settings were identified by checking the physician's order and looking for the number on the cylinder/concentrator gauge to verify the correct flow rate. Nursing staff on the night shift were responsible for changing the resident's oxygen tubing every 48 hours. Correct settings were communicated from one nurse to the next using nursing report sheets and reviewing the Medication Administration Record (MAR). LPN A stated Resident #91 did not refuse his oxygen therapy. On 8/20/25 at 4:35 PM, the Director of Nursing (DON) confirmed that the physician wrote the order and then the nurse checked the gauge on the oxygen tank or concentrator to verify flow rate accuracy. A review of the facility's policy and procedure titled Medication Administration (effective date: 12/31/2021) revealed: 1. Standard: The facility will ensure that medications are administered in a safe and timely manner, and as prescribed. Ll. Procedures: . Medications must be administered in accordance with the orders, including any required time frame. (Copy obtained) 106088 Page 2 of 2