Health inspection·October 3, 2024

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 resident record review, observations, interviews with the resident and staff, and a review of the facility's policy and procedure, the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for one (Resident #17) of two residents reviewed for accident hazards, from a total survey sample of 33 residents. The findings include: An observation was made of Resident #17 on 9/30/2024 at 1:55 PM in his room. He was awake and lying in bed under the covers watching television. During the observation of the resident's room, one shaving razor was observed inside of a plastic container on the bedside table located over the resident's bed. No facility staff were present. (Photographic evidence obtained) On 10/1/2024 at 9:39 AM, Resident #17 was observed again, lying in bed under his covers and watching television. During observations of the surrounding area, one shaving razor (same razor observed the previous day), was still inside of a plastic container on the bedside table next to the resident's bed. No facility staff were present. (Photographic evidence obtained) A return visit and interview on 10/2/2024 at 9:40 AM found that Resident #17 was in his room lying in bed under his covers and watching television. During the observation of the surrounding area of the bed, one shaving razor (same razor observed on previous days) was observed inside of a plastic container on the bedside table next to the resident's bed, and one shaving razor (second shaving razor found) was observed on top of the nightstand behind the resident's oxygen concentrator equipment, next to the bed. (Photographic evidence obtained) When asked if the facility allowed residents to store shaving razors inside their rooms, Resident #17 stated the certified nursing assistants (CNAs) were supposed to remove the razors from the rooms after shaving the residents. No facility staff were present. A review of Resident #17's medical record found that he was admitted to the facility on [DATE] with a previous admission on [DATE]. He had diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting his left non-dominant side, anemia, chronic respiratory failure, diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, chronic kidney disease - stage 2, anxiety disorder, cervical disc disorder with myelopathy, and fusion of the spine - cervical region. There was no indication in the record that the resident could safely shave himself. There were no physician's orders permitting Resident #17 to independently engage in personal hygiene tasks such as shaving. (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 4 Event ID: 105548 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 10/03/2024 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)