Health inspection·March 2, 2023

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and facility policy review, the facility failed to provide appropriate treatment to prevent further decrease in range of motion for 1 of 2 residents reviewed for limited range of motion. (Resident #69) The findings include: An observation of Resident #69 was conducted on 2/27/23 at 12:46 PM. The resident was in bed and contractures were observed to the upper and lower extremities. A review of the quarterly minimum data set, with an assessment reference date of 12/23/22, revealed the resident had functional limitation in range of motion to upper and lower extremities on both sides. The occupational therapy Discharge summary, dated [DATE], revealed the resident had contractures to bilateral upper extremities. Review of the resident's electronic medical record revealed a current plan of care dated 11/10/22 for a passive range of motion restorative nursing program. The interventions included passive range of motion with stretching at the end of the range on shoulder flexion, elbow extension as tolerated, to be completed every day 4 days per week. Review of the documentation of passive range of motion (PROM) for the time period of 1/31/23-2/28/23 revealed the PROM had been completed a total of 7 times on the following dates: 2/5/23, 2/6/23, 2/9/23, 2/13/23, 2/20/23, 2/26/23, and 2/27/23. An interview was conducted with Employee C (Restorative Licensed Practical Nurse) on 3/1/23 at 10:06 AM. Employee C stated she has trouble with restorative therapy getting completed because the staff are pulled to the floor. She stated, It has been a constant battle since I took over the position, and, if the restorative aid is pulled to the floor, I try to complete the range of motion or restorative ordered. She confirmed that any zeros entered on the documentation meant the task was not completed. She stated the resident does not usually tolerate the range of motion well and her contractures have worsened in the last few months. She states that Resident #69 had been referred back to therapy for an evaluation on 2/3/23. An interview was conducted with the Rehabilitation Director on 3/1/23 at 10:30 AM. She stated the resident declined and contracted really fast. She was last discharged from therapy on 12/9/22. She did not recall the resident being referred backed to therapy by restorative staff in the last 30 days. An interview was conducted with the Director of Nursing (DON) on 3/1/23 at 10:55 AM. The DON stated she was aware that staff get pulled to the floor from restorative, but she was not aware restorative tasks were not being completed. Review of the facility policy for Restorative Nursing Program (SHCRC 3006.01) revealed it is the policy of the center to assist each Resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance to State and Federal Regulations. The center's restorative program will include, but not be limited to, hygiene, mobility, elimination, dining-eating, and communication. The programs will be documented on the center's designated restorative care forms/tools in the resident's electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105190 If continuation sheet Page 2 of 3 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 105190 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crestview Rehabilitation Center, LLC 1849 First Avenue East Crestview, FL 32539 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interviews, and record reviews, the facility failed to provide medications in a timely manner for 2 of 5 residents sampled for medication administration. (Residents #85 and #30) Residents Affected - Few The findings include: On 3/1/23 at approximately 9:30 AM, an observation was made of Resident #85's medication administration by Nurse F, a Licensed Practical Nurse (LPN). Nurse F was scheduled to administer a Vitamin B-12 injection, 1000 micrograms subcutaneously, but could not as it was not available from pharmacy. Nurse F stated she would notify the Nurse Practitioner and the pharmacy to have this medication delivered from the back-up pharmacy. On 3/1/23 at approximately 2:00 PM, an observation was made of Nurse D, a Registered Nurse. Nurse D was scheduled to administer the medication Urecholine 10 milligrams to Resident #30 but could not as it was not available from the pharmacy. The nurse stated she would notify the physician or Nurse Practitioner and the pharmacy and have the medication delivered. On 3/1/23 at approximately 2:10 PM an interview was conducted with Nurse B, a Registered Nurse and Unit Manager. Nurse B stated that the medications should be re-ordered when the current supply was down to one week's supply to ensure medications are received in a timely manner. Nurse B was observed to re-order the missing medications while the surveyor observed. Nurse B confirmed that the empty medication card had not been pulled to be faxed to the pharmacy for a refill. On 3/1/23 at approximately 5:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that it was her expectation that all medications should be reordered from pharmacy when the medication is down to one week's supply in order to receive the refill medications from the pharmacy in a timely manner. The DON stated that the Vitamin B-12 injection for Resident #85 was incorrectly listed as on hand in the medication record, which is why it was not delivered from the pharmacy. The DON confirmed that Resident #30's Urecholine had not been re-ordered electronically until today at 2:00 PM. On 3/2/23, a review was conducted of the Policy titled,4.5 Reordering, changing, and Discontinuing Orders (last revised January 1, 2022). Under procedure number 2, it states Reorder/Refill Orders: Facilities are encouraged to re-order medications electronically or by fax whenever possible. On 3/2/23 at approximately 12:41 PM, a follow up interview was conducted with the DON and the Corporate Nurse concerning the time frame for re-ordering medications. The DON confirmed that the policy 4.5 did not state what time frame to re-order medications, but stated that the nurses are trained during orientation on when to re-order medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105190 If continuation sheet Page 3 of 3