Health inspection·June 20, 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 record review and interview, the facility failed to ensure assessments accurately reflect the resident's status for 1 (Resident #57) of 4 residents reviewed for discharge status. Residents Affected - Few Findings include: Review of the admission record documented Resident #57 was admitted on [DATE] with diagnoses including surgical aftercare, type 2 diabetes mellitus, chronic kidney disease and hypertension. Review of the social services progress note dated 5/14/24 for Resident #57 read, Discharge note: Per family/resident request, resident to discharge 05/15/2024. Resident to discharge home. Son will pick up and transport home . Review of the discharge summary progress note dated 5/15/24 for Resident #57 read, Resident, who is alert and oriented, transferred by son to Appointment then will go home . Review of Resident #57's Minimum Data Set (MDS) Discharge Return Not Anticipated assessment dated [DATE] read, discharge date , 05/15/2024. Discharge Status, Critical Access Hospital. During an interview on 6/18/24 at 10:15 AM the MDS Coordinator, Registered Nurse (RN), stated, [Resident #57's Name] discharge assessment documented him as going to the hospital and he actually discharged home. During an interview on 6/18/24 at 10:33 AM, the Social Services Director stated, Yes, that is an inaccurate assessment, it documents he [Resident #57] went to the hospital, and he [Resident #57] went home. Review of the Policy titled, Conducting an Accurate Resident Assessment, date reviewed 01/04/24, read, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Page 1 of 3 106009 106009 06/20/2024 Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). During an observation on 6/17/24 at 9:43 AM Resident #160 was sitting in bed, dressed in day clothes with a (Peripheral Inserted Central Catheter) PICC line dressing dated 6/7/24. Photographic evidence obtained. Residents Affected - Few Review of the admission record documented Resident #160 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, lumbar region. During an interview on 6/18/24 at 11:55 AM the DON (Director of Nursing) stated, My expectation is the nurses look at PICC line dressings when the resident is admitted and change it if it is more than 7 days and then every week unless soiled. Based on observation, interview, and record review, the facility failed to ensure the residents received medication as per physician orders for 2 (Resident #25, #211) of 4 residents reviewed for pain medication administration and for 1 (Resident #160) of 3 residents reviewed for the care and treatment related to Peripheral Inserted Central Catheter (PICC) line dressings. Findings include: 1). Review of Resident #211's physician's order dated 6/4/2024 read, Acetaminophen Tablet Give 650 mg (milligrams) by mouth every 6 hours as needed for Mild Pain Do Not Exceed 3gm (grams) in 24 hours, pain scale 1-3 Review of Resident #211's Medication Administration Record (MAR) for June 2024 documented the resident received Acetaminophen 650 mg on June 14 at 4:15 AM with a pain level of 6. Review of Resident #211's physician's order dated 6/4/2024 read, Oxycodone HCI Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for Pain related to chronic pain syndrome. Pain scale 4-10 Review of Resident #211's MAR for June 2024 documented the resident received Oxycodone HCI 5 MG on June 6 at 1233 [12:33 PM] for a pain level of 2 and at 2021 [8:21 PM] for a pain level of 1, June 7 at 0152 [1:52 AM] for a pain level of 1 and at 1242 [12:42 PM] for a pain level of 2, June 14 at 2115 [10:15 PM] for a pain level of 3, and on June 15 at 0244 [2:44 AM] for a pain level of 2. 2). Review of Resident #25's physician's order dated 5/30/2024 reads, Oxycodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for Pain pain scale 4-10 Review of Resident #25's MAR for June 2024 documented the resident received Oxycodone-Acetaminophen Tablet 5-325 MG on June 2 at 1549 [3:49 PM] for a pain level of 2, June 6 at 1244 [12:44 PM] for a pain level of 2 and at 2340 [11:40 PM] for a pain level of 2, June 14 at 2007 [8:07 PM] for a pain level of 3 and June 15 at 0422 [4:22 AM] for pain level of 2. Review of Resident #25's physician's order dated 5/30/2024 reads, Acetaminophen Tablet Give 650 mg by mouth every 6 hours as for Mild Pain Do Not Exceed 3gm every 24 hours pain scale 1-3. Review of Resident #25's MAR for June 2024 documented the resident received Acetaminophen Tablet 650mg on June 6 at 0656 [6:56 AM] for pain level of 6. 106009 Page 2 of 3 106009 06/20/2024 Cross City Nursing and Rehabilitation Center 583 NE 351 Hwy Cross City, FL 32628

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/19/2024 at 11:36 AM the Director of Nursing stated, The nursing staff should have not given [Resident #211's name] and [Resident #25's name] the medication if the pain level were out of the parameters ordered. Review of the facility policy and procedure titled Medication Administration date reviewed 01/04/24 read, Policy: Medication are administered by license 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. Policy Explanation and Compliance Guidelines: 9. Obtain pain level as indicated. Administer PRN (pro re nata or as needed) analgesics according to pain scale specifications. 106009 Page 3 of 3