Inspection·December 27, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, and staff interviews, the facility failed to provide a safe, clean and orderly environment for 8 of 22 rooms sampled. (Rooms 111, 114, 118, 201, 203, 205, 213 and 223) The findings include: On 12/27/23 at 11:05 AM, an observation of room [ROOM NUMBER]-2 revealed a fall mat with several rips and exposed padding. room [ROOM NUMBER]-2 was occupied by Resident #3 at the time of the survey. (Photographic evidence was obtained.) On 12/27/23 at 11:08 AM, an observation of room [ROOM NUMBER] -2 was conducted. The room was occupied by Resident #6 at the time of the survey. The trim on the wall by the head of the bed was detached from wall and fallen. Per resident interview, the trim had been detached for over 2 weeks. (Photographic evidence was obtained.) On 12/27/23 at 11:10 AM, an observation of room [ROOM NUMBER]-1 revealed a fall mat with several rips and exposed padding. room [ROOM NUMBER]-1 was occupied by Resident #4. (Photographic evidence was obtained.) On 12/27/23 at 11:18 AM, an observation of room [ROOM NUMBER] was conducted. room [ROOM NUMBER] was occupied by Resident #5 at the time of the survey. The air conditioner (AC) unit by the window had a blanket underneath. Per Resident #5, the blanket had been there since she was admitted weeks ago. The room also had exposed telephone wires and the overbed table was missing the outer border and had exposed particle board. (Photographic evidence was obtained.) On 12/27/23 at 11:19 AM, an observation of room [ROOM NUMBER] revealed a blanket underneath the AC unit. (Photographic evidence was obtained.) On 12/27/23 at 11:21 AM, an observation of room [ROOM NUMBER] revealed a blanket underneath the AC unit. (Photographic evidence was obtained.) On 12/27/23 at 11:27 AM, an observation of occupied room [ROOM NUMBER] was conducted. There were exposed wires underneath the AC unit. (Photographic evidence was obtained.) On 12/27/23 at 11:31 AM an observation of occupied room [ROOM NUMBER] revealed a blanket underneath the AC unit. (Photographic evidence was obtained.) (continued on next page) 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: 106043 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 12/27/2023 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)