Health inspection·December 18, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and interviews, the facility failed to obtain written consent prior to starting psychotropic medications for 2 of 5 residents reviewed. (Resident #3 and #54)The findings include:On 12/16/25 at 2:09 pm a record review was conducted for Resident #3 who was initially admitted to facility on 8/3/23, then discharged and re-admitted on [DATE] with diagnoses that include Parkinsonism, Chronic Kidney disease, Cellulitis, Type 2 Diabetes, Major Depressive disorder, and Unspecified Dementia. Amongst the current medications, orders for Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 ms by mouth two times a day for depression/anxiety and Cimetidine Oral Tablet 200 MG tablet by mouth in the morning for off label use for sexually inappropriate behavior. An additional record review was conducted for Resident #54, who was admitted on [DATE] with diagnoses including Psychophysiologic Insomnia and Major Depressive Disorder. Current medications include Sertraline HCl Oral Tablet 100 MG one time a day for depression and Trazadone 100 mg at bedtime for mood disorder initiated on 10/23/25 increased to 150 mg on 11/21/25. Upon further review, no psychotropic medication consent forms for Resident #3 or Resident #54 informing of the risk and benefits for psychotropic medication use prior to initiating treatment was present. An interview was conducted with the Unit Manager on 12/18/25 at 10:00 am, who stated that the consent forms are usually scanned into the computer system for each individual. When this was not found, she acknowledged she could not find that any of these forms had been completed. At 12:20 pm an interview was conducted with the Director of Nursing (DON), stating that the facility has an ongoing performance improvement plan (PIP) for antipsychotic and psychotropic monitoring. The PIP was initiated in February 2025 for psychotropic medications, ensuring orders have the correct diagnosis, behavior monitoring, gradual dose reductions, and side effects being documented in the medical record with the target date of June 2025. Per the DON she states, this PIP does not address the psychotropic medication informed consent forms. Residents Affected - Few 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 5 Event ID: 105924 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 105924 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blountstown Health and Rehabilitation Center 16690 SW Chipola Rd Blountstown, FL 32424 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)