Inspection·June 13, 2023

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 observations, interviews, record review, and a review of the facility's policy and procedure, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to administer scheduled medications within the required timeframes per the ordered times and the facility's policy, allowing for administration one hour before to one hour after the scheduled time for two (Residents #4 and #1) of eight sampled residents. Failure to administer medications timely could result in changes to therapeutic drug levels, ineffective pain management, development of antibiotic resistance, unregulated blood pressures, unregulated blood sugar levels and more. Residents Affected - Few The findings include: On 6/13/23 at 10:31 a.m., Licensed Practical Nurse (LPN) A was observed during morning medication administration. She was preparing medication for Resident #4. An observation of the resident's electronic Medication Administration Record (MAR), revealed that the text color was red. When LPN A was asked what the red type indicated, she replied, The MAR is set up to show red if the medication is an hour past the administration time. When she was asked if there was a process for obtaining help when medication administration was running late, she replied that she was not sure. On 6/13/23 at 10:47 AM, an interview was conducted with LPN B, who was in the process of dispensing medications for Resident #1. The electronic MAR text was red. When she was asked what the significance of the red text was, she replied, It means we are outside the one-hour window. With thirty residents and not knowing them, it's impossible to get all the meds out on time. When she was asked if anyone was available to help ensure the medications were administered timely, she replied that she did not know. She stated she did a quick review of the residents' medications to determine which medications/residents were a priority. She administered those medications and then finished medication administration for the rest of her assigned residents. On 6/13/23 at 12:25 PM, an interview was conducted with Registered Nurse (RN) C, former Director of Nursing (DON) for this facility, now at a sister facility, but brought in to assist with this survey. RN C confirmed that the medication administration window was one hour before to one hour after the scheduled administration time. If the medication was not administered within this window of time, the resident's physician was to be notified to change the dispensing time if not contraindicated. When he was asked if there was a protocol for nurses to ask for help with medication administration when they were falling behind, he replied that they should be letting someone know so we can try to find them help. When he was asked how often medications were not given at the scheduled time, he replied that he was not sure. On 6/13/23 at 12:50 PM, an interview was conducted with the Regional Nurse Consultant (RNC). When (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 2 Event ID: 105589 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 105589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Coquina Center 170 N Center Street Ormond Beach, FL 32174 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)