Inspection·April 1, 2021

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few March 17, 2021. It was signed off as given on March 18 and 19, 2021. It was signed off as held on March 20, 21, 22 and 23, 2021. The dose was discontinued on March 24, 2021. On 4/1/2021 at 10:21 AM, in an interview with the ADON, she was asked if she had any grievances or medication variances for Resident #58 related to her not having her aspirin 81 mg held for five days in March per the March 11, 2021 progress note mentioned above. She replied, Let me go see what I can find on that. I'm not familiar with Resident #58's occurrence. On 4/1/2021 at 11:10 AM, the ADON returned and stated, Okay, I just looked into this. Resident #58 was supposed to have her aspirin held for five days prior to a GI procedure on March 19th. It wasn't held, so it had to be rescheduled for March 24th, but on March 22nd she had some GI bleed symptoms and she was sent to the ER. The aspirin was on hold at that point for the March 24th procedure. I just called her niece to make sure she was aware that this happened, and she was. When asked whether a medication variance report was generated, she replied, Yes, I'll print you a copy. (Copy obtained) A review of the Medication Variance Report for Resident #58, dated 3/17/2021, read: Nursing description: Omission of order to hold aspirin for GI procedure. Resident description: Resident unable to give description. Immediate action taken: MD and family notified. GI procedure rescheduled for 3/24/2021. Though the facility documented on 3/17/2021 that the aspirin 81 mg had not been ordered or held per the 3/11/2021 progess note/order, and the appointment was rescheduled for 3/24/2021 with an order written to hold the aspirin 81 mg for five days prior to the 3/24/2021 surgery, on 3/19/2021, the fifth day before the surgery was scheduled, the medication was documented as having been given. The surgery appointment was delayed due to the facility's failure to hold medication as ordered, and the resident had to be sent to the hospital for care prior to her rescheduled surgery date as a result. (Copies obtained of all documentation noted above.) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105548 If continuation sheet Page 2 of 4 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 105548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moultrie Creek Nursing and Rehab Center 200 Mariner Health Way Saint Augustine, FL 32086 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #63) resident in a total sample of 34 residents. The findings include: A review of Resident #63's medical record, revealed and admission date of 10/29/2018, with a primary diagnosis of hemiplegia and hemiparesis following CVA (cerebrovascular accident - stroke). The secondary diagnoses included visual loss in the right eye, spondylosis and right hand contracture. The resident's cognition was impaired and she required extensive assistance with activities of daily living, including toileting and transfers. During a tour of the facility on 3/31/2021 at 2:58 PM, Resident #63 was overheard from the hallway yelling for help. Upon entering the room, the resident was observed yelling for help while sitting on the toilet in her bathroom. The room's call light was then triggered by the resident's roommate. On 3/31/2021 at 3:05 PM, two employees, identified as certified nursing assistants (CNA), were observed walking down the hallway and entering each room while giving verbal report. Resident #63 continued to yell for help and her call light was on outside of her room. The employees did not acknowledge the call light or the resident's verbal pleas for assistance. On 3/31/2021 at 3:08 PM, Employee G, CNA, was asked to check on the resident, as she had been yelling for assistance for approximately ten minutes. The employee explained that the resident was able to use the call cord in the rest room. She then entered the room. The CNA exited the room and exclaimed, That wasn't the resident I thought it was! That resident is actually blind and she can't pull the call cord. She is blind and has half a skull. She should never be left unattended! On 3/31/2021 at 3:10 PM, Employee H, CNA, entered Resident #63's room. She was the resident's assigned CNA. Upon exiting the room, Employee H stated, I could do it if we had more staff. Then we wouldn't have to run around like chickens with our heads cut off. A review of the resident's comprehensive care plan revealed a focus area for bowel and bladder incontinence. The care plan indicated the resident's incontinence placed her at risk for falls. An intervention on the care plan directed staff to remain with the patient during toileting to ensure safety. (Photographic evidence obtained) On 4/1/2021 at 2:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). She was asked to explain how staff accessed the care information specific to each resident. She explained that the facility's process was for direct-care staff to use the [NAME] for each resident, and that the staff were required to sign off on the care they provided each shift. The ADON confirmed that if a resident's care plan directed staff to remain with the patient during toileting, the resident should not be left alone while toileting. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105548 If continuation sheet Page 3 of 4 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 105548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moultrie Creek Nursing and Rehab Center 200 Mariner Health Way Saint Augustine, FL 32086 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interviews and record review, the facility failed to maintain complete, documented medical records for two (Residents #13 and #40) of 34 sampled residents , by failing to document apical pulses for Digoxin and blood pressures and heart rates for Lisinopril and Carvediolol. The findings include: 1. A record review was conducted for Resident #13, which noted an admission date of 7/17/2021 with diagnoses including congestive heart failure and hypertension. Physician's orders were reviewed, which noted an order for Lisinopril 2.5 mg (milligrams) daily, dated 7/19/2020, with parameters (hold if systolic blood pressure is below 110, diastolic below 60 and heart rate below 60), and Carvedilol 6.25 mg daily with parameters (hold for heart rate below 50 or systolic below 100), dated 3/22/2021. A review of the current Medication Administration Record (MAR) revealed that Lisinopril and Carvedilol were given daily with no blood pressures or heart rates documented. (Photographic evidence obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 3/31/2021 at 2:11 PM. She was asked to review the current MAR. The ADON reviewed the current MAR and confirmed the Lisinopril and Carvedilol had parameters which were not documented on the MAR. She confirmed the heart rates and blood pressures were missing. 2. A record review was conducted for Resident #40, which noted an admission date of 8/11/2011 and a re-entry date of 11/17/2020, with the following diagnosis: atrial fibrillation. A review of the current MAR, noted Digoxin 125 mcg (micrograms) daily, dated 8/24/2018, for heart disease, with no apical pulses documented. An interview was conducted with Employee D, Registered Nurse (RN), at 8:40 AM on 3/31/2021, while observing medication administration. The RN reported that when physician's orders were added to the electronic medical record, there was a place to add documentation for blood pressure or apical pulses, if needed, for medications. An interview was conducted with the ADON on 3/31/2021 at 2:03 PM. She reviewed the current MAR, and confirmed that apical pulses were not documented for the Digoxin. The ADON confirmed apical pulses should be taken and documented before administering Digoxin. The ADON corrected the MAR and added apical pulse to the Digoxin order. She also reported the resident required monthly vital signs. An interview was conducted with the ADON on 3/31/2021 at 4:30 PM. She reported that the resident had not had apical pulses documented since July 2020. (Photographic evidence obtained) A review of the policy and procedure for Medication Pass Guideline (Revised on 4/25/2017), noted the following under physician's orders: Medications are administered in accordance with written orders of the attending physician. Under Procedure 6:If applicable and or prescribed, take vital signs or tests prior to administration of dose (pulse with digitalis, blood pressure with anit-hypertensive) use. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105548 If continuation sheet Page 4 of 4