F 0693
Level of Harm - Minimal harm
or potential for actual harm
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on observations, interviews, and record review, the facility failed to follow physician orders for tube
feeding start time and formulary for 1 of 2 residents reviewed for tube feeding. (Resident #5)
Residents Affected - Few
The findings include:
During a tour of the facility conducted on 08/26/24 at 11:32 AM, Resident #5 was observed with a tube
feeding pump present in his room, but there was no tube feeding formulary hanging or infusing. An
additional observation was conducted on 08/26/24 at 12:08 PM, which revealed Resident #5 had Osmolite
1.5 tube feeding formulary infusing through the tube feeding pump at 65 milliliters per hour (mL/hr) with the
water flush running at 240 milliliters (mL) every 4 hours. (photographic evidence obtained)
An initial review of Resident #5's medical record revealed a physician order written on 06/07/24 for Enteral
Feed every shift for Nutritional Support Osmolite 1.5 at 55mL/hr x 22hrs. Down at 8:00 AM up at 10:00 AM.
water bolus 200mL every 4 hours.
During tours of the facility conducted on 08/27/24 at 10:30 AM and 12:06 PM, the surveyor observed
Resident #5's tube feeding was not infusing. An additional observation conducted on 08/27/24 at 1:36 PM
revealed Resident #5 had Osmolite 1.5 tube feeding formulary infusing through the tube feeding pump at
65mL/hr with the water flush running at 240 mL every 4 hours. (photographic evidence obtained)
An observation conducted on 08/27/24 at 4:45 PM revealed the staff had changed the tube feeding rate to
55mL/hr and the water flush rate to 200mL every 4 hours.
An interview was conducted with Staff A, Registered Nurse, on 08/27/24 at 4:48 PM. Staff A stated she had
realized the tube feeding was running at the incorrect rate earlier and had changed the rate to the match
the physician's order.
An interview was conducted with the Administrator and the Director of Nursing on 08/28/24 at 9:15 AM.
They stated they had conducted an audit on 08/27/24 of all residents receiving tube feeding and had
discovered Resident #5 was receiving his tube feeding and water flush at incorrect rates.
A review of the facility policy titled Enteral Feeding: Pump Method, dated 06/08, revealed the following,
Purpose: to administer enteral feeding per physician's orders; Procedure: verify physician's order; turn on
pump and set proper rate
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 2
Event ID:
105563
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
105563
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/29/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Centre Pointe Health and Rehab Center
2255 Centerville Road
Tallahassee, FL 32308
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to properly offer and document influenza, pneumococcal, and
COVID-19 vaccinations for 3 of 5 residents reviewed for vaccination status. (Resident #43, 100, and 326)
Residents Affected - Few
The findings include:
During a review of the resident's vaccination statuses on 08/28/24, the following areas of concern were
noted:
Resident #43 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. The medical
record revealed the only vaccination consent form present was dated 08/03/22 and included consents for
influenza, pneumococcal, and COVID-19 vaccinations. This consent form indicated Resident #43 refused
all the offered vaccinations. However, the signature on the form was from a nurse, not Resident #43's
designated representative.
Resident #100 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. The review
of Resident #100's medical record revealed the only vaccination consent form present was undated and
included consents for influenza, pneumococcal, and COVID-19 vaccinations. This consent form was signed
by Resident #100, but did not indicate if Resident #100 requested or refused the offered vaccinations.
Resident #326 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. The review
of Resident #326's medical record revealed the only vaccination consent form present was dated 08/14/24
and included consents for influenza, pneumococcal, and COVID-19 vaccinations. This consent form was
signed by Resident #326, but did not indicate if Resident #326 requested or refused the offered
vaccinations.
An interview was conducted on 08/28/24 at 3:38 PM with the facility's Infection Preventionist concerning
these oversights. For Resident #43, she stated there should have been a vaccination consent form signed
by the resident or their representative at the time of the most recent admission. For Resident #100, she
stated the vaccination consent form should have been dated and should have included whether Resident
#100 wanted to receive or refuse the vaccinations. For Resident #326, she stated the vaccination consent
form should have been dated and should have included whether Resident #326 wanted to receive or refuse
the vaccinations.
A review of the facility policy titled Pneumococcal, COVID-19, and Annual Influenza Vaccine Information
and Request, dated 04/21, revealed the following, Purpose: to document resident request or refusal of
these vaccines, When: upon admission, Instructions: ask the resident or legal representative to enter a
check mark indicating request or refusal of the vaccines and ask the resident or legal representative to sign
and date the form.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105563
If continuation sheet
Page 2 of 2
