Health inspection·July 20, 2023

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 record review and interview, the facility failed to ensure resident records were accurate for 1 of 7 residents reviewed for advanced directives, Resident #67, and 1 of 2 residents reviewed for nutrition, Resident #19. Finding include: 1. Review of Resident #67's records revealed Resident #175's DNR (Do not Resuscitate) form uploaded into the electronic medical record. Review of Resident #67's care plan initiated on 4/25/2023 reads, [Resident #67] has advanced directives: Full Code, HCS. Review of the physician order dated 4/22/2023 for Resident #67 reads, Full Code. During an interview on 7/17/2023 at 1:18 PM, Resident #67 stated, I want to be resuscitated. During an interview on 7/17/2023 at 1:28 PM, the Director of Nursing stated, Mr. [Resident #67's name] is a full code, and that DNR was incorrectly uploaded into his medical record. 2. Review of Resident #19's Weights and Vitals Summary read, 06/14/2023, 160.8 Lbs [pounds] (Wheelchair) . 05/17/2023, 161.8 Lbs (Standing) . 04/2/2023, 169.6 Lbs (Wheelchair) . 02/15/2023, 170.2 Lbs (Wheelchair). Review of Registered Dietician's noted dated 6/29/2023 at 11:14 AM for Resident #19 reads, Rt's [Resident's] appetite and intake is fair is fair but fluid intake is poor around 500 ml [milliliters] per day. Weighs 161.8 lbs on 5/17/23 and lost about 8.4 lbs (5%) in 3 months. Wt [weight] loss may be due to lasix use and fair appetite. Being on remeron may also help improve her appetite and weight. Continues on NAS [No Salt Added], NCS [No Concentrated Sweets] diet with 90 ml SF medpass tid [three times a day] to help improve weight, total proteins and maintain albumin levels. On MVM [multivitamin/mineral] supplement to help with anemia. Plan: Continue on current diet and medpass and MVM supplements. Recommend to have TSH [Thyroid Stimulating Hormone] levels done due to being on Synthroid. Continue to monitor weights and labs and adjust diet and supplements accordingly. Review of Registered Dietician's note dated 6/29/2023 at 11:48 AM for Resident #19 reads, Rt's wt is at 131.6 lbs. on 6/8/223. lost about 14.6 lbs (10%) in 3 months. Appetite and intake is fairly good and ate 100% at lunch today. Continues on 90 ml medpass tid and 30 ml liquid protein qd [once a day] to help maintain weight and albumin levels. Labs indicate anemia, low albumin, and high glucose & BUN [Blood Urea Nitrogen]. Plan: Continue on current diet and supplements. Encourage fluids for hydration. Monitor weights and adjust diet as needed. During an interview on 7/19/2023 at 1:55 PM, the Registered Dietician stated, I was working in the facility and the internet was not great. I was copying and pasting quickly and in a hurry to lock in the notes before it would delete. The correct one is the 161.8 pounds. The other one was for another resident whom also was on the weight lost list. During an interview on 7/19/2023 at 2:15 PM, the Administrator stated, I expect documentation to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 2 of 3 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 105770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tri-County Nursing Home 7280 SW State Rd 26 Trenton, FL 32693 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 accurate and staff revise their work. Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedures titled Charting Errors and/or Omissions last reviewed on 7/14/2023 reads, Policy Statement: Accurate medical records shall be maintained by this facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105770 If continuation sheet Page 3 of 3