Inspection·September 28, 2023

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Lovenox and documented the site opposite from the last nurse's documentation. She reports calling the Advanced Practice Registered Nurse (APRN), but when he didn't answer the phone, she hung up without leaving a message. At approximately 09:59 AM, an interview was conducted with Nurse F, another LPN. She explained that when she worked on Friday 09/22/2023 on the 7:00 AM-7:00 PM shift that she administered the Lovenox to Resident #418 and that there were 2 or 3 doses left in the cart. At approximately 10:10 AM, an interview was conducted with Nurse H, another LPN. She explained that, on Monday 09/25/2023 during day shift, she didn't give the Lovenox medication because it wasn't available to give, but that she had already documented administering the Lovenox to Resident #418 prior to retrieving the medication. She reports faxing a written request over to the pharmacy to reorder it and notifying the resident that it was out and waiting for the pharmacy to bring it. She explained that she did not notify the doctor or anyone else at that time and that she forgot to go back and change her documentation. At approximately 10:25 AM, an interview was conducted with Nurse E, another LPN. She explained that she worked on the cart for Resident #418 on Friday 09/22/23, Saturday 09/23/23, Sunday 09/24/23 and Tuesday 09/26/23. She reports giving the resident her Lovenox injection on Thursday and noticed that it was running low, so she reordered it. On Saturday she reports there were three doses before she gave the prescribed morning dose and then there were 2 doses left after. She then administered the Lovenox on Sunday 09/24/2023 around 9:00 AM and noted there were no doses left in the cart. She called the pharmacy, and was told it was on back order, and they would send it as soon as it came in. She notified the APRN that the Lovenox was out and he verbalized to place the Lovenox on hold until it arrives from the pharmacy and resume it when it comes in. She reports calling the unit manager and notifying her of the medication Lovenox being out and speaking with Resident #418 to let her know it was on back order. She explained that when the APRN was in the facility on Tuesday 09/26/2023 that she advised him that Resident #418 was still out of Lovenox. At approximately 10:40 AM an interview was conducted with Nurse G, another LPN. She explained that on Saturday 09/23/23 during the night shift she administered the Lovenox injection to Resident #418 and there were two doses prior to her administering it. At approximately 11:03 AM an interview was conducted with Nurse M, the unit manager of the south wing. She explained that she received a call from Nurse E on Sunday 09/23/2023 stating that she talked to the APRN and called the pharmacy to notify of Resident #418 being out of Lovenox. The unit manager then spoke with the APRN on Tuesday 09/26/2023 when he came into the facility and told him that Resident #418 needed something because they still hadn't received the lovenox from the pharmacy. She explained that the APRN gave the order to discontinue the Lovenox and start on Eliquis. At approximately 11:22 AM, a telephone interview was conducted with the APRN. He explained that he received a call from Nurse E on Sunday 09/23/2023 regarding the Lovenox being out and that he gave her orders to hold the Lovenox until it came in. On Tuesday 09/26/2023, he reports that the unit manager notified him when he came into the facility that the Lovenox had still not come in, so he gave the order to discontinue it and start Resident #418 on Eliquis twice a day. A review of the facility policy for medication administration dated 11/2020 was conducted. The policy directed nurses to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106043 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 106043 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverchase Health and Rehabilitation Center 1017 Strong Rd Quincy, FL 32351 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 0760 #10. Review MAR to identify medication to be administered. Level of Harm - Minimal harm or potential for actual harm 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Residents Affected - Few c. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.). 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 20. Correct any discrepancies and report to nurse manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106043 If continuation sheet Page 3 of 3