Inspection·December 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 record review and interview, the facility failed to ensure residents received medications in accordance with standard of practice for 1 of 7 residents reviewed, Resident #4. Residents Affected - Few Findings include: Review of Resident #4's Medication Administration Record revealed Amlodipine Besylate was administered on 12/5/2023 with a pulse of 53 and on 12/6/2023 with a pulse of 55. Review of Resident #4's physician order dated 11/14/2023 reads, Amlodipine Besylate oral tablet 10 mg (Amlodipine Besylate) Give 1 tablet by mouth in the morning for hypertension related to essential (primary) hypertension (110) Administer 1 tablet by mouth in the morning. If pulse is below 60 hold and recheck BP [Blood Pressure] and pulse in two hours. Administer if within parameters. During an interview on 12/12/2023 at 1:27 PM, the Medical Director stated, The staff should let me know if parameters are not being met. The order should be followed. During an interview on 12/13/2023 at 7:27AM, Staff A, Licensed Practical Nurse (LPN), stated, It depends on the resident if it is close to the parameter, I will ask the resident. I prefer not to give it since I have worked in a hospital setting and here you do not have all the things you do in a hospital. During an interview on 12/13/2023 at 10:58 AM, the Director of Nursing stated, It all depends on the resident. If the staff wants to give medication out of parameters, they should contact the doctor and get clarification. I spoke to the doctor, and he said that the parameters should have been 50. Medication should never be given out of parameters. Review of the facility policy and procedures titled Medication Administration with the last review date of 1/4/2023 reads, Policy Explanation and Compliance Guidelines . 8. Obtain and record vital signs, when applicable or per physician orders. when applicable, hold medication for those vital signs outside the physician's prescribed parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105825 If continuation sheet Page 2 of 6 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 12/13/2023 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post the nurse staffing information on a daily basis. Residents Affected - Many Findings include: During an observation on 12/10/2023 at 9:15 AM, the facility's staffing information posted on the bulletin board adjacent to the A Hall Nursing Station was dated 9/7/2023. During an interview on 12/10/2023 at 9:40 AM, the Director of Nursing (DON) confirmed that the staffing information was dated 9/7/2023 and stated it was supposed to be updated daily and the facility did not have the records from 9/8/2023 until current. Review of the facility policy and procedures titled Nurse Staffing Posting Information with the last review date of 1/4/2023 reads, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing sheet will be posted on a daily basis and will contain the following information: a. Facility name, b. The current date, c. Facility's current resident census, d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses, ii. Licensed Practical Nurses/ Licensed Vocational Nurses, iii. Certified Nurse Aides. 2. The facility will post the Nurse Staffing sheet at the beginning of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105825 If continuation sheet Page 3 of 6 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 12/13/2023 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 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. 2. Review of Resident #57's Progress Notes dated 12/1/2023 at 9:10 PM reads, Insulin Glargine-yfgn 100 Unit/ML [milliliter] Solution pen-injector, Inject 50 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications (E11.9), Resident refused 50 units per order, she stated, I only want 25 units. Review of Resident #57's Medication Administration Record (MAR) showed staff initials indicating administration of 50 units of Insulin Glargine-yfgn on 12/1/2023. Review of Resident #57's Progress Notes dated 11/27/2023 at 9:29 PM reads, Insulin Glargine-yfgn 100 Unit/ML Solution pen-injector, Inject 50 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications (E11.9), Resident refused to be administered the 50 units, she only wanted 25 units at this time. Review of Resident #57's MAR showed staff initials indicating administration of 50 units of Insulin Glargine-yfgn on 11/27/2023. Review of Resident #57's Progress Notes dated for 11/26/2023 at 8:52 PM reads, Glargine-yfgn 100 Unit/ML Solution pen-injector, Inject 50 unit subcutaneously at bedtime related to type 2 diabetes mellitus without complications (E11.9), Resident stated she feels 50 units at night is too much for her because she stated she is dropping at night, resident agreed to 25 units tonight and would like the dosage revaluated. Review of Resident #57's MAR showed staff initials indicating administration of 50 units of Insulin Glargine-yfgn on 11/26/2023. During an interview on 12/10/2023 at 2:30 PM, the DON stated, When staff is not giving the prescribed dosage, they are supposed to document in a progress note and refer to it on the MAR with the number 9. I see that they didn't do that. We will have to re-educate them. Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 of 3 residents reviewed for nutrition, Resident #4, and for 1 of 2 residents reviewed for insulin administration, Resident #57. Findings include: 1. During an observation on 12/11/2023 at 8:10 AM, Resident #4 was eating independently in his room. The meal tray contained eggs, grits, ground sausage, orange juice, and coffee. Review of Resident #4's physician order dated 11/14/2023 reads, Regular diet regular texture. Review of Resident #4's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 11/13/2023 reads, Q. Nutrition/Hydration: Regular soft/thin liquids. Review of Resident #4's Dietary Profile dated 11/14/2023 reads, A. Diet. 1. Current diet order: Regular Mech [Mechanical] Soft Diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105825 If continuation sheet Page 4 of 6 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 12/13/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/12/2023 at 11:08 AM, the Registered Dietician (RD) stated, Usually the registered nurse from the facility or the director of nursing will put in the diet orders. Usually, first orders are what the hospital sends and the facility match the orders. His orders were regular soft/thin liquids that would be equivalent to mechanical soft. We follow the 3008 form. During an interview on 12/12/2023 at 11:22 AM, the Director of Nursing (DON) stated, We were following his home diet. It was a preference. The resident did not need that kind of meal. I do not know. Maybe the CDM [Certified Dietary Manager] made a documentation error. During an interview on 12/13/2023 at 9:12 PM, the CDM stated, [Resident #4's name] has no teeth and wanted his food really soft because he could not chew. After I do the dietary preference, the DON or the RD put the diet orders in place. Mechanical Soft diet is ground meats. Review of the facility policy and procedures titled Documentation in Medical Record with the last review date of 1/4/2023 reads, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Policy Explanation and Compliance Guidelines . 3. Principles of Documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105825 If continuation sheet Page 5 of 6 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 12/13/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards of practice while administering medications. Residents Affected - Few Findings include: During an observation on 12/12/2023 at 8:59 AM, Staff B, Licensed Practical Nurse (LPN), removed 4 tablets for Resident #41 from the pill blister pack and medication bottle by grabbing the medication with her hands without wearing gloves. Staff B placed the medications in the medication cup, which contained other medications. Staff B entered Resident #41's room and administered medications. Staff B exited the room and used hand sanitizer stored in the medication cart to sanitize her hands. During an interview on 12/12/2023 at 9:10 AM, Staff B, LPN, stated, I did not realize I was touching the medication with my hands. Normally, I pop them straight into the medication cup. During an interview on 12/12/2023 at 9:40 AM, the Director of Nursing stated, Staff should not be touching medication with their hands while preparing medication. Review of the facility policy and procedures titled Medication Administration with the last review date of 1/4/2023 reads, Policy Explanation and Compliance Guidelines . 13. Remove medication from source, taking care not to touch medication with bare hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105825 If continuation sheet Page 6 of 6