Health inspection·February 16, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, record review the facility failed to implement the care plan of 1 of 27 sampled residents. (Resident #89) Residents Affected - Few The findings include: Observations: On 02/12/2024 at 07:15 PM, an observation was made of Resident #89 lying in bed on his back with the head of his bed elevated at a 30-degree angle. On 02/13/2024 at 09:00 AM, Resident #89 was observed lying on his back with his head turned to right side. No wedge or extra pillow was observed to be on the bed. On 02/13/2024 at 11:30 AM, an observation was made of Resident #89 lying in bed on his back with his head straight. On 02/13/2024 at 03:12 PM, an observation of Resident #89 was made lying on his back with the head of the bed elevated. This was an indication that the resident had been pulled up in bed. He was still lying on his back. On 2/14/2024 at 10:10 AM, an observation of Resident #89 revealed him lying in bed on his back. On 02/14/2024 at 11:24 AM, Resident #89 was observed lying on his back with no pillow or wedge on the bed. On 02/15/24 at 09:36 AM, Resident #89 was observed lying on his back in bed with the head of bed elevated. Record review: On approximately 02/14/2024, a record review was conducted for Resident #89. Resident #89 had a care plan initiated for bed mobility on 05/24/2023 indicating that Resident #89 required assistance by 2 staff to turn and reposition in bed every 2 hours and as needed due to a diagnosis of Hemiplegia and Hemiparesis Cerebral Infarction affecting left non dominant side that had impaired his mobility. Interviews: Page 1 of 3 105543 105543 02/16/2024 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/14/2024 at 02:49 PM, an interview was conducted with Certified Nurse Assistant (CNA) F. She explained she tries to do frequent checks on Resident #89 since he can't reposition himself, and he is often soiled. She indicated that she had not turned Resident #89 at all today. On 02/15/2024 at approximately 09:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) E. LPN E explained she asked the CNA about Resident #89 being turned yesterday. She indicated that the CNA's place a pillow under the resident. On 02/25/2024 at 10:15 AM, the Director of Nursing was interviewed. She stated that documentation should be in the Electronic Health Record indicating where staff are turning residents and that staff should be using a wedge or pillow every 2 hours. She acknowledged that Resident #89 had not been positioned as ordered. She did state that Certified Nurse Assistants are trained on care plans and positioning upon hire. 105543 Page 2 of 3 105543 02/16/2024 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on resident interview, record reviews, staff interviews, and facility policy review, the facility failed to ensure complete and accurate medical records for 1 of 1 residents sampled for pain management. Residents Affected - Few The findings include: On 2/12/24 at 7:38 PM, an interview was conducted with Resident #21. During the interview, the resident was grimacing and indicated that she had constant paint of a level of 8-9 out of 10 (on a scale of 0 being no pain and 10 being the worst pain). She further stated the last time she received pain medication was 4:00 PM that day. A review of Resident #21's medical record was conducted. A physician's order stated to receive oxycodone (a controlled pain medication) 7.5 mg 1 tablet every 4 hours as needed for acute pain. A review of the resident's Medication Administration Record (MAR) revealed the resident received 14 doses of 1 tablet oxycodone. A review of the resident's narcotic controlled record sheet revealed oxycodone had been documented as pulled 17 times, totaling 17 tablets. There was 1 pill left inside the bottle of a total of 18. On 2/14/24 at 9:14 AM, an interview was conducted with Staff B, a Licensed Practical Nurse (LPN). She reviewed Resident #21's MAR and compared this with the narcotic sheet for oxycodone and verified the amount of pills recorded on the narcotic record sheet and the amount of pills recorded on the MAR did not match. She stated the facility's protocol was to notify the unit manager when a discrepancy occurs. On 2/14/24 at 11:38 AM, an interview was conducted with Director of Nursing (DON). The DON reviewed Resident # 21's narcotic sheet for oxycodone as well as Resident # 21's MAR and stated she was not aware of that discrepancy until this moment. A review of the facility's policy titled Medication Administration (revised 10/23) was conducted. The policy stated, Sign MAR after administration, If medication is a controlled substance, sign narcotic book , and correct any discrepancies and report to nurse manager. 105543 Page 3 of 3