F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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 observation, interview, and record review, the facility failed to prevent possible complications of
enteral feeding including but not limited to aspiration pneumonia, diarrhea, and vomiting for 1 of 3 residents,
Resident #34.
Findings include:
During an observation on 6/14/22 at 7:58 AM, Resident #34 was observed to have tube feeding being
administered. The head of the resident's bed was flat.
During an interview on 6/14/22 at 8:00 AM, Staff A, Registered Nurse (RN), confirmed the head of the bed
was not elevated and stated it should be elevated to at least 30 degrees.
During an interview on 6/14/22 at 8:05 AM, Staff D, Certified Nursing Assistant (CNA), stated that the head
of the bed should be elevated.
During an interview on 6/14/22 at 8:10 AM, the Director of Nursing (DON) stated her expectations were for
the staff to make sure to elevate the bed 30-45 degrees while tube feeding was running and for any staff
rendering care to ensure they raised the bed back after finishing the task.
Review of Resident #34's care plan reads, Problem/Need - Requires G-tube [gastrostomy tube] feedings for
adequate nutritional intake due to resident's inability to swallow nutrients without chocking aspiration (CVA
with dysphagia). Goal: Will remain adequately nourished & hydrated and without s/s [signs/symptoms] of
aspiration/infection. Gtube will remain viable daily. Approaches: HOB [head of bed] elevated 30 degress
[sic] @ [at] all times when in bed. Monitor for s/s aspiration, infection, dehydration.
Review of the policy and procedure titled, Enteral Feedings--Safety Precautions reads, Preventing
Aspiration: 3. Elevate the head of the bed (HOB) at least 30 degrees during tube feeding and at least 1 hour
after feeding.
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:
105825
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
105825
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/16/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Suwannee Valley Nursing Center
427 15th Avenue Northwest
Jasper, FL 32052
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview, the facility failed to ensure residents receiving respiratory care were
provided such care consistent with professional standards of practice for 1 of 3 residents, Resident #48.
Residents Affected - Few
Findings include:
During an observation of Resident #48's room on 6/13/22 at 11:36 AM, his oxygen and nebulizer tubing
were uncovered and laying on the floor. His nebulizer mask was uncovered and sitting on a chair in the
room, and the nebulizer machine was sitting on the floor. The oxygen and nebulizer tubing did not have a
date to show when the oxygen and nebulizer tubing were changed.
During an observation of Resident #48's room on 6/13/22 at 2:26 PM, the oxygen and nebulizer tubing
were on the floor, undated and uncovered. His nebulizer mask was uncovered and sitting on a chair in the
room, and the nebulizer machine was on the floor.
During an interview on 6/14/22 at 3:55 PM, the Director of Nursing (DON) stated, The day nurse or unit
managers are supposed to change and date the tubing changes weekly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105825
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
105825
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/16/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Suwannee Valley Nursing Center
427 15th Avenue Northwest
Jasper, FL 32052
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals
used in the facility were labeled in accordance with currently accepted professional principles and failed to
separate expired medications from active use medications in 2 of 2 medication storage rooms and 1 of 2
medication carts.
Findings include:
During an observation of the drug/medication storage room on Unit A on 6/13/22 at 10:03 AM, there were
four (4) 12.5 mg (milligram) Promethazine suppositories stored in the medication refrigerator with active
use medications that showed an expiration date of 5/2022.
During an interview on 6/13/22 at 10:05 AM, the Director of Nursing (DON) confirmed the Promethazine
was expired. The DON stated, The medication nurse is supposed to check the drug room refrigerator every
night.
During an observation of the B-Hall medication storage room on 6/13/22 at 10:18 AM, there was one (1)
sterile culture swab II diagnostic tube that showed an expiration date of 4/20/2022.
During an interview on 6/13/22 at 10:20 AM, the DON confirmed the sterile culture swab diagnostic tube
was expired.
During an observation of the medication cart with Staff A, Registered Nurse (RN), on 6/13/22 at 10:27 AM,
there were one (1) opened bottle of Lidocaine 20 ml (milliliters) with an expiration date of 3/2022 and no
label showing resident name or an open date; two (2) bottles of Levemir insulin injection with no label
showing open date and a label from the pharmacy that reads, Medication expires 42 days after open.
During an interview on 6/13/22 at 12:13 PM, Staff A, RN, stated, The Lidocaine is used to mix Rocephin
with Lidocaine for intramuscular injections for Resident #8. Staff B, licensed Practical Nurse (LPN), stated,
Every nurse is responsible for checking each medication cart.
Review of the policy and procedure titled, Labeling of Medication Containers with a revision date of
December 2021 reads, All medications maintained in the facility shall be properly labeled in accordance
with current state and federal regulations. Policy Interpretation and Implementation: 1. Medication labels
must be legible at all times. 2. Any medication packaging or containers that are inadequately or improperly
labeled shall be returned to the issuing pharmacy. 3. Labels for individual drug containers shall include all
necessary information, such as: a) The residents' name. b) The prescribing physicians name. d) The name,
strength, and quantity of the drug. f) The date that the medication was dispensed and i) Direction for use.
Review of the document titled Expiration Dates For The Following Medications After Opening provided by
the facility reads, Levemir Insulin vial expires in 42 days. All other multi-dose vials 28 days unless
manufacturer states a shorter or longer date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105825
If continuation sheet
Page 3 of 3
