Inspection·November 21, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to administered physician ordered medications in accordance with professional standards for 2 of 6 residents, Residents #10 and #18, reviewed for medication administration. Residents Affected - Few Findings include: Review of Resident #10's Medication Administration Record (MAR) for November of 2024, the physician's order read, Insulin Glargine Subcutaneous Solution: 100 UNIT/ML (Insulin Glargine) Inject 12 unit subcutaneously at bedtime for diabetes mellites (DM). Start Date 09/19/2024 9:00 PM (2100). Review of Resident #10's physician orders did not provide parameters to hold the Glargine long-acting insulin. Review of the Resident #10's MAR for November 2024 documented the physician ordered Glargine Insulin was held on 11/15/2024 and 11/17/2024 and documented 4: Vitals outside of parameters for administration. Review of Resident #10's Care Plan documented Focus Area - [Resident #10's name] has a physician's order for insulin or hypoglycemic r/t [related to] DM. Goal - Resident will be free of adverse drug reactions from insulin administration through the next review date. Interventions - administer insulin as ordered. Monitor/document for side effects and effectiveness. Monitor and report blood glucose levels per physician's order. Date Initiated: 09/19/2024. Review of Resident #10's Progress Notes did not provide documentation on 11/15/2024 or 11/17/2024 of the blood sugar values at bedtime, notification to the physician when not administering the physician ordered Glargine long-acting insulin, and the reason for not administering the insulin. During an interview on 11/20/2024 at 2:15 PM, the Director of Nursing (DON) stated, For medications that do not have parameters, such as long-acting insulin, the expectation is that if they hold the medication, they notify the doctor. During an interview on 11/21/2024 at 8:40 AM, Physician A stated, I don't recall getting any calls about [Resident #10's name] or giving any orders to hold the long-acting insulin. Usually, we don't hold the long-acting insulin. It's the short-acting [insulin] that's usually the culprit [for dropping blood sugar levels]. If it was just a couple of days, there wouldn't be any significant harm. During an interview on 11/21/2024 at 8:50 AM, Physician B stated, I haven't gotten any calls about [Resident #10's name] insulin, and I did not give any orders to hold her long-acting insulin. If it (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: 105437 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 105437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Cove Care Center 700 SE Dr Martin Luther Jr Ave Crystal River, FL 34429 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)