F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure foods were properly labeled
and stored.
Residents Affected - Few
Findings include:
During an observation on 3/24/2025 at 9:20 AM while conducting the initial tour of the kitchen with the
Certified Dietary Manager (CDM), there were thirteen bags of frozen variety of meats, without an identifying
label, and one bag that was left open exposing chicken with ice particle buildup and the appearance of
freezer burn in the reach-in freezer.
During an interview on 3/24/2025 at 9:25 AM, the CDM confirmed that there were thirteen bags of a variety
of meats without an identifying label and one bag of chicken that was completely open exposing the
product to the elements and freezer burn.
Review of the facility policy and procedure titled Date Marking for Food Safety dated 11/2020 and revised
on 1/2025 showed it read, Policy Explanation and Compliance Guidelines for Staffing . 4. The marking
system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be
consumed or discarded.
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
03/27/2025
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 performed hand
hygiene and followed infection control standard of practice during medication administration for 1 of 4
residents observed for medication administration, Resident #7, to prevent the possible spread of infection
and communicable diseases.
Residents Affected - Few
Findings include:
During an observation on 3/26/2025 at approximately 9:10 AM, Staff A, Licensed Practical Nurse (LPN),
prepared medications for administration to Resident #7, which included Baby Shampoo on a wet
washcloth. Staff A donned a gown and gloves and proceeded to clean Resident #7's eyelids with the
washcloth containing Baby Shampoo and placed the soiled washcloth on a piece of aluminum foil. Staff A
did not remove her gloves or did not perform hand hygiene and proceeded to administer medications to
Resident #7 through her gastrostomy tube (G-tube: a thin, flexible tube inserted through the abdominal wall
and into the stomach. It is used to provide nutrition and medication to individuals who cannot eat or drink
adequately by mouth.) While holding a medicine cup containing a crushed pill of Amlodipine (a medicine for
treating high blood pressure) mixed with a small amount of water, Staff A used her gloved finger to stir the
mixture before she administered it through Resident #7's G-tube.
Review of Resident #7's physician order dated 3/18/2025 showed it read, Enhanced Barrier for tube
feeding.
During an interview on 3/26/2025 at approximately 9:30 AM, Staff A, LPN, stated, I should have washed my
hands and changed my gloves after I washed her eyes, before I gave her meds. I shouldn't have mixed the
medicine with my finger.
During an interview on 3/26/2025 at 10:50 AM, the Director of Nursing (DON) stated, For a resident who
was on Enhanced Barrier Precautions who had a procedure requiring cleaning on her eyes, the nurse
should wash her hands and change her gloves before administering any medications through the gastric
tube. The nurse should only use a spoon to mix the crushed medication suspended in water in a medication
cup.
Review of the facility's policy and procedures titled Medication Administration last reviewed on 1/19/2025
showed it read, Policy: Medications are administered by licensed nurses, or other staff who are legally
authorized to do so in this state, as ordered by the physician and in accordance with professional standards
of practice, in a manner to prevent contamination or infection.
Review of the facility's policy and procedures titled Infection Prevention and Control Program last reviewed
on 1/19/2025 showed it read, Policy: This facility has established and maintains an infection prevention and
control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the
development and transmission of communicable diseases and infection as per accepted national standards
and guidelines . Policy Explanation and Compliance Guidelines . 4. Standard Precautions . b. Hand hygiene
shall be performed in accordance with our facility's established hand hygiene procedures.
Review of the facility's policy and procedures titled Hand Hygiene last reviewed on 1/19/2025, showed it
read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other
personnel, residents, and visitors. This applies to all staff working in all
(continued on next page)
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
03/27/2025
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
locations within the facility . Policy Explanation and Compliance Guidelines: 1. Staff will perform hand
hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand
hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached
hand hygiene table . Hand Hygiene Table - Condition . Before preparing or handling medications . After
handling items potentially contaminated with blood, body fluids, secretions, or excretions . When, during
resident care, moving from a contaminated body site to a clean body site.
Event ID:
Facility ID:
105825
If continuation sheet
Page 3 of 3
