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 record review and interview, the facility failed to ensure pain medications were administered as
ordered for 1 of 3 residents reviewed for accuracy of medication administration, Resident #2.
Residents Affected - Few
Findings include:
Review of Resident #2's physician order dated 10/30/2024 read, Oxycodone HCl Oral Tablet 5 MG
[milligrams] (Oxycodone HCl) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for pain.
Review of Resident #2's physician order dated 11/12/2024 read, Oxycodone HCl Oral Tablet 10 MG
(Oxycodone HCl) *Controlled Drug* Give 10 mg by mouth every 4 hours as needed for Non Acute Pain.
Review of Resident #2's progress note dated 11/12/2024 at 3:03 PM read, Spoke with family regarding
Residents [Sic.] POC [Plan of Care]. Requesting [Local hospice's name] Consult. Email sent to Social
Services. Family requesting pain med [medication] increase. Notified NP [Nurse Practitioner] with new
orders initiated. No further questions or concerns at this time.
Review of Resident #2's progress note dated 11/12/2024 at 4:51 PM read, Resident told 7-3 CNA [Certified
Nursing Assistant] that resident needed pain medication. CNA told writer (nurse) resident was requesting
pain meds. Writer told CNA she would assess resident as soon as possible. Writer went to assess resident,
writer asked resident if he needed pain meds, resident stated yes. Writer administered pain meds at
approximately 0922 [9:22 AM]. Writer went in resident's room at 1530 [3:30 PM], and asked resident if he
was in pain, resident stated yes, writer asked resident what his pain level on a scale of 0-10, resident said a
2. [APRN's name], NP write a new prescription for a higher dose of pain medication, code was rejected
from pyxis at 1540 [3:40 PM], writer then administered the lower dose of medication.
Review of Resident #2's Medication Administration Record for November 2024 showed Oxycodone 5 mg
was discontinued on 11/12/2024 at 2:47 PM and Oxycodone 10 mg order stated on 11/12/2024 at 3:00 PM.
During an interview on 12/4/2024 at 9:10 AM, the Director of Nursing (DON) stated, The nurse had difficulty
remembering who the resident was. I reviewed the record and call the nurse in question. It was the last
dose on the med cart. If the medication dosage is not available, the nurse should notify the supervisor,
pharmacy and escalate to the NP. That would be my expectation the staff to follow the physician orders.
During an interview on 12/4/2024 at 9:11 AM, the Regional Nurse Consultant stated, The staff know that
anything out of their control they should let their supervisor know. The nurse stated it was a
(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:
105613
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
105613
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Live Oak Healthcare and Rehabilitation Center
1620 Helvenston St SE
Live Oak, FL 32064
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
new patient, and she was making sure she was managing his pain. The medication was not available and
just had that medication left.
During an interview on 12/4/2024 at 9:14 AM, Staff A, Licensed Practical Nurse (LPN), stated, The order
the APRN [Advanced Practice Registered Nurse] gave was to increase Oxycodone to 10 mg and
oxycodone 5 mg would have had to be discontinued. We get a run early in the morning before day shift or
right at shift change and a run late at night during the night shift. Two runs a day. My expectation would be
for staff to notify the NP and get the order to administer two 5 mg to equal the 10 mg and make sure the
one-time order is put in the system. Staff should call pharmacy and NP at that point and notify they need
the medication.
During an interview on 12/4/2024 at 1:34 PM, the APRN stated, I assume the staff give what I order. I write
an order, and I would expect the staff to call me or call pharmacy that is what the nurse should do if the
medication is not available or having trouble getting the medication form the pyxis. The staff should contact
somebody if the medication is not available.
Review of the facility policy and procedure titled Administering Medication with a revised date of 6/18/2024
read, Policy: Medications shall be administered safety and timely, as prescribed. Protocol . 3. Medications
must be administered in accordance with orders, including any required time frame.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105613
If continuation sheet
Page 2 of 2
