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** Based on
interview and record review, the facility failed to ensure treatment and care was provided to all facility
residents for physician prescribed medications for 2 of 4 residents, Resident #1 and #4, reviewed for
medication administration.Findings include:Review of Resident #1's admission data revealed the resident
was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections and chronic
kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double strength] oral
tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14
days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645 [6:45
AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700
Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was
blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 - Other/See Nurse
Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note
dated 12/18/2025 and 12/19/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG
(Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting
delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1
tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/19/2025 at 1700
[5:00 PM]; D/C date 12/22/2025 at 1104 [11:04 AM].Review of the MAR documented dated 12/19/2025 at
1700 Bactrim was administered as ordered by the physician. Dated 12/20/2025, 12/21/2025, and
12/22/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes
documented an eMAR (electronic) Medication Administration Note dated 12/20/2025 and 12/21/2025 that
read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2
times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented,
Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 days. Start Date:
12/22/2025 at 1700; D/C date 12/23/2025 at 1654 [4:54 PM].Review of the MAR documented dated
12/22/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/23/2025 at 0600 was
documented with a 9.Review of the Progress Notes dated 12/23/2025 did not provide for documentation for
the 0600 note of 9.Review of Resident #1's physician orders read, Bactrim DS oral tablet 800-160 mg. Give
1 tablet by mouth two times a day for UTI for 14 Days, Start Date 12/23/2025 at 2100 (9:00 PM).Review of
a Progress Note dated 12/24/2025 read, Nurse spoke with pharmacy in regards to Bactrim, pharmacy to
stat out. Facility to use [name of medication dispensing system] supply until delivered. MD [Medical Doctor]
and family notified.During an interview on 2/18/2026 at 1:35 PM the DON (Director of Nursing) said the
nurses should be documenting on the MAR if they are unable to administer a medication, such as if it was
not available from the pharmacy, and they should notify the provider. Bactrim was also available in the
[name of the automated medication dispensing system] machine.Review of Resident #4's admission data
documented the resident was admitted on [DATE] with medical diagnoses
Residents Affected - Few
(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 4
Event ID:
106145
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
106145
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/18/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Hill Health & Rehabilitation
7371 Cortez Oaks Blvd
Brooksville, FL 34613
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
to include primary generalized osteo arthritis; cerebellar ataxia in diseases classified elsewhere;
pneumonia, unspecified organism; muscle weakness (generalized).Review of Resident #4's MDS
(Minimum Data Set) assessment, an admission assessment dated [DATE], documented a BIMS score of
15 out of 15 = cognitively intact.Review of Resident #4's physician orders documented Cyanocobalamin
[Vitamin B-12] Injection Kit 1000 mcg/ml [micrograms per milliliter] (Cyanocobalamin) Inject 1000 mcg
intramuscularly [into the muscle] one time a day for neuropathy [damage to the nerves outside the brain
and spinal cord] for 7 days. Start Date 02/11/2026 0900 [9:00 AM].Review of Resident #4's MAR for
Cyanocobalamin administration documented on 02/12/2026 and 02/13/2026 at 0900 12 = Not Applicable.
Dated 02/17/2026 at 0900 was documented with a 9 = Other/See Nurse Note.Review of Resident #4's
Progress Notes did not contain documentation for 02/12/2026 and 02/13/2026 for the code of 12, or for
02/17/2026 for a code of 9.During an interview on 2/18/2026 at 4:20 PM Resident #4 said she was
participating in therapy but some days it really wore her out. She didn't have as much energy as she usually
did and thought it might be because she had not received all of the B-12 injections she was supposed to
get. The facility was having some problems getting the shots. During an interview on 2/18/2026 at
approximately 5:50 PM the DON said the pharmacy had sent Resident #4's B-12 injections in a kit and not
all of the doses had arrived. The nurses should have contacted Resident #4's physician when the
medication wasn't available and they should have checked with the pharmacy. Review of the policy and
procedure titled, Medication Monitoring, read, Policy: this facility takes a collaborative, systematic approach
to medication management, including the monitoring of medications for efficacy and adverse
consequences. Policy Explanation and Compliance Guidelines: 5. Licensed nurses, with periodic oversight
by nurse managers, shall: Report refusals of medications, frequent holding of medications, or signs of
adverse consequences of medications to the physician.Review of the policy and procedure titled,
Medication Administration, read, Policy: medications are administered by licensed nurses, 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: 22. Report and document any adverse side effects or refusals. 23. Correct any
discrepancies and report to nurse manager.
Event ID:
Facility ID:
106145
If continuation sheet
Page 2 of 4
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
106145
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/18/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Hill Health & Rehabilitation
7371 Cortez Oaks Blvd
Brooksville, FL 34613
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to document unavailable medications and notification to
physicians of missed doses of ordered medications for 2 (Resident #1 and Resident #4) of 4 residents
reviewed for medication administration.Findings include:Review of Resident #1's admission data revealed
the resident was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections
and chronic kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double
strength] oral tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract
infection] for 14 days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645
[6:45 AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700
Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was
blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 - Other/See Nurse
Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note
dated 12/18/2025 and 12/19/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG
(Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting
delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1
tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/19/2025 at 1700
[5:00 PM]; D/C date 12/22/2025 at 1104 [11:04 AM].Review of the MAR documented dated 12/19/2025 at
1700 Bactrim was administered as ordered by the physician. Dated 12/20/2025, 12/21/2025, and
12/22/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes
documented an eMAR (electronic) Medication Administration Note dated 12/20/2025 and 12/21/2025 that
read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2
times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented,
Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 days. Start Date:
12/22/2025 at 1700; D/C date 12/23/2025 at 1654 [4:54 PM].Review of the MAR documented dated
12/22/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/23/2025 at 0600 was
documented with a 9.Review of the Progress Notes dated 12/23/2025 did not provide for documentation for
the 0600 note of 9.Review of Resident #1's physician orders read, Bactrim DS oral tablet 800-160 mg. Give
1 tablet by mouth two times a day for UTI for 14 Days, Start Date 12/23/2025 at 2100 (9:00 PM).Review of
a Progress Note dated 12/24/2025 read, Nurse spoke with pharmacy in regards to Bactrim, pharmacy to
stat out. Facility to use [name of medication dispensing system] supply until delivered. MD [Medical Doctor]
and family notified.During an interview on 2/18/2026 at 1:35 PM the DON (Director of Nursing) said the
nurses should be documenting on the MAR if they are unable to administer a medication, such as if it was
not available from the pharmacy, and they should notify the provider. Bactrim was also available in the
[name of the automated medication dispensing system] machine.Review of Resident #1's medical record
for the period of 12/17/2025 through 12/31/2025 did not contain documentation the physician was notified
when the Bactrim DS was not administered as order.Review of Resident #4's admission data documented
the resident was admitted on [DATE] with medical diagnoses to include primary generalized osteo arthritis;
cerebellar ataxia in diseases classified elsewhere; pneumonia, unspecified organism; muscle weakness
(generalized).Review of Resident #4's MDS (Minimum Data Set) assessment, an admission assessment
dated [DATE], documented a BIMS score of 15 out of 15 = cognitively intact.Review of Resident #4's
physician orders documented Cyanocobalamin [Vitamin B-12] Injection Kit 1000 mcg/ml [micrograms per
milliliter] (Cyanocobalamin) Inject 1000 mcg intramuscularly [into the muscle] one time a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106145
If continuation sheet
Page 3 of 4
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
106145
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/18/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Hill Health & Rehabilitation
7371 Cortez Oaks Blvd
Brooksville, FL 34613
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
day for neuropathy [damage to the nerves outside the brain and spinal cord] for 7 days. Start Date
02/11/2026 0900 [9:00 AM].Review of Resident #4's MAR for Cyanocobalamin administration documented
on 02/12/2026 and 02/13/2026 at 0900 12 = Not Applicable. Dated 02/17/2026 at 0900 was documented
with a 9 = Other/See Nurse Note.Review of Resident #4's Progress Notes did not contain documentation
for 02/12/2026 and 02/13/2026 for the code of 12, or for 02/17/2026 for a code of 9.During an interview on
2/18/2026 at 4:20 PM Resident #4 said she was participating in therapy but some days it really wore her
out. She didn't have as much energy as she usually did and thought it might be because she had not
received all of the B-12 injections she was supposed to get. The facility was having some problems getting
the shots. During an interview on 2/18/2026 at approximately 5:50 PM the DON said the pharmacy had
sent Resident #4's B-12 injections in a kit and not all of the doses had arrived. The nurses should have
contacted Resident #4's physician when the medication wasn't available and they should have checked with
the pharmacy. Review of Resident #4's medical record for the period of 02/11/2026 through 02/18/2026 did
not contain documentation the physician was notified the medication was not administered as
ordered.Review of the policy and procedure titled, Medication Monitoring, read, Policy: this facility takes a
collaborative, systematic approach to medication management, including the monitoring of medications for
efficacy and adverse consequences. Policy Explanation and Compliance Guidelines: 5. Licensed nurses,
with periodic oversight by nurse managers, shall: Report refusals of medications, frequent holding of
medications, or signs of adverse consequences of medications to the physician.Review of the policy and
procedure titled, Medication Administration, read, Policy: medications are administered by licensed nurses,
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: 22. Report and document any adverse side effects or refusals. 23.
Correct any discrepancies and report to nurse manager.
Event ID:
Facility ID:
106145
If continuation sheet
Page 4 of 4