Inspection·May 21, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident assessments accurately reflect the resident's status for 2 (Resident #1 and #5) of 3 residents reviewed for respiratory care. Residents Affected - Some Findings include: 1.) Review of the admission record documented Resident #1 was admitted to the facility on [DATE] with diagnoses that include COPD (Chronic Obstructive Pulmonary Disease and OSA (Obstructive Sleep Apnea). During an interview on 5/21/24 at 9:59 AM, Resident #1 confirmed it was her CPAP (Continuous Positive Airway Pressure) machine sitting on the nightstand. She stated that she is still using the machine; she just cannot clean it with her SoClean® [CPAP cleaner and sanitizer machine]. Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented Resident #1 is not using a CPAP machine. 2.) Review of the admission record documented Resident #5 was readmitted to the facility on [DATE] with diagnoses including CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease), and Pulmonary Edema. During an observation on 5/21/24 at 11:40 AM, Resident #5 was observed in his bedroom with a CPAP machine on the nightstand next to the bed. During an interview on 5/21/24 at 11:41 AM, Resident #5 stated, That is my CPAP machine on the table there, indicating the device on the nightstand next to the bed. Review of the care plan dated 7/25/22 for Resident #5's care plan dated 7/25/22 documented at risk for respiratory complications related to dx (diagnosis) of: CHF, COPD, Pulmonary Edema, with interventions that include Monitor use of Bi-Pap (Bilevel Positive Airway Pressure) machine use as ordered. Review of the MDS Quarterly assessment dated [DATE] documented Resident #5 as not using a CPAP machine. During an interview on 5/21/24 at 1:30 PM, the Minimum Data Set Coordinator confirmed Resident #1 and Resident #5's MDS assessments documented that they were not using CPAP machines. 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: 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 05/21/2024 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)