F 0742
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental
disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress
disorder.
Based on observations, interviews, and record review, the facility failed to implement appropriate behavioral
interventions for 1 of 5 residents sampled. (Resident #2)
The findings include:
On 8/2/23 at 9:51 AM, Resident #2 was observed wearing a wanderguard device (an elopement prevention
system consisting of an anklet/bracelet wore by a resident that contains a sensor that monitors doors and
sends safety alerts when a resident approaches a monitored door).
A review of the resident's medical record indicated the resident exited the building on 6/10/23. Interventions
in the care plan after this included a wanderguard device. However, a review of the resident's Electronical
Medical Record (EMR) revealed no orders for a wanderguard.
On 8/3/23 at 9:42 AM, an interview with Staff A, a Licensed Practical Nurse and unit manager, was
conducted. Staff A reviewed the resident's EMR and stated there should have been an order placed onto
the Resident #2's medical record to ensure staff was monitoring placement and functionality of the
wanderguard anklet.
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 3
Event ID:
105810
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
105810
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Miracle Hill Nursing & Rehabilitation Center, Inc
1329 Abraham Street
Tallahassee, FL 32304
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observations, interviews, and record review, the facility failed to follow to consistently document
the administration of physician ordered medications for 1 of 5 residents sampled. (Resident #1)
Residents Affected - Few
The findings include:
On 8/1/23 at 4:55 PM, an interview was conducted with Resident #1 via telephone. During the interview,
Resident #1 stated she did not receive her hypotensive medication for 3 days.
A review of Resident #1's clinical record revealed a physician's order for Midrodine 10 mg, three times a
day, for hypotension. The Medication Administration Record (MAR) revealed Midrodine was scheduled to be
given at 8:00 am, 2:00 pm and 10:00 pm daily. The MAR was not documented on the following dates:
7/7/23 at 10:00 pm, 7/8/23 at 10:00 pm, 7/9/23 at 8:00 am, 2:00 pm, and 10:00 pm, and 7/10/23 at 8:00 am
and 2:00pm. In addition, the most recent blood pressure reading was recorded on 5/8/23.
On 8/3/23 at 3:15 PM, an interview was conducted with the Director of Nursing (DON). The DON reviewed
the resident's MAR and stated she was unaware that Resident #1 missed 3 days of hypotensive
medications. The DON further stated she should have been notified and nursing should have properly
documented the reason for the missing doses.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105810
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
105810
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Miracle Hill Nursing & Rehabilitation Center, Inc
1329 Abraham Street
Tallahassee, FL 32304
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 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record review, the facility failed to provide or facilitate the provision
of required therapy services for 1 of 5 residents sampled. (Resident #3)
Residents Affected - Few
The findings include:
A review of an incident reports submitted to the Agency was conducted. According to one report involving
Resident #3 dated 6/4/23, Resident #3 sustained an unwitnessed fall that led to a laceration on the right
forehead and transfer to an Emergency Department for treatment and evaluation. In this report, there was a
reference that the facility would monitor Resident #3 and refer them to therapy upon return. A review of the
resident's clinical record showed there were no documentation indicating Resident #3 received therapy
services after the incident. The resident's plan of care was reviewed and indicated that the resident was at
risk for a fall and had an incident of falling dated 4/26/23.
On 8/3/23 at 1:58 PM, an interview was conducted with the facility's Administrator. He stated that the
resident had COVID-19 during the time of the accident and the facility could not offer the resident Physical
Therapy (PT) at that moment because the facility did not have Physical Therapist on site. The administrator
acknowledged that the resident did not get evaluated by therapy because it fell through the cracks.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105810
If continuation sheet
Page 3 of 3
