Health inspection·December 18, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure there were no discrepancies between the narcotic records and the residents' medical records for three (Residents #3, #4, #5) of three residents who had physician's orders for and received narcotics to relieve their pain. Findings included: 1. Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction and Pressure Ulcers to her sacral region. A review of Physician Orders revealed an order for tramadol HCl 50 mg, one tablet by mouth every 6 hours as needed for pain, with a start date of 11/30/2023. On 12/18/2023 a short interview was conducted with the resident beginning at 10:15 a.m. The resident was observed sitting in her wheelchair with both legs bent at the knees and drawn up to her chest. She was leaning toward her left side. She was agreeable to an interview and while answering questions, it was noted that she was moaning and fidgeting in her chair. When asked if she was in pain, she agreed and said she wanted to ask her nurse for her pain pill. At that same time, the resident's aide walked into the room and she confirmed she had told the nurse the resident was ready for a pain pill. The surveyor left the room and spoke with the resident's nurse who confirmed she was aware the resident was asking for her pain pill. She reported the resident preferred to ask for the pain pill, and usually was very specific about the time that she wanted it. A review was conducted of the Medication Administration Sheets (the MAR) , the Nurse's notes, and the Controlled Drug Declining Inventory Sheet (the Narc Count Sheet) to ensure all entries matched and the administration of the tramadol was accounted for and documented. Several discrepancies were noted. On 12/07/2023 at 9:00 a.m. the Narc Count Sheet listed one tramadol was administered, but the administration was not documented on the MAR or in the Nurse's notes. On 12/08/2023 at 12:00 p.m. the Narc Count Sheet listed one tramadol was administered, but it was not documented on the MAR or in the Nurse's notes. On 12/18/2023 the Narc Count Sheet did not list a second dose as administered but the MAR and the Nurse's notes documented a dose was administered at 12:07 p.m 2. Resident # 4 was admitted to the facility on [DATE] after having sustained a fractured lower end of the right radius and a displaced fracture of the right ulna after a fall. A review of Physician Orders revealed an order at admission for Percocet Oral Tablet 5-325 mg, give one tablet by mouth every 6 hours as needed for acute pain. This order was in place until 12/11/2023 when the order (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: 105393 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 105393 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667 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)