Inspection·February 15, 2024

F 0684 resident) and using standardized assessment tools can help the interdisciplinary team evaluate the resident's pain and responses to interventions and determine whether the care plan should be revised. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106149 If continuation sheet Page 2 of 5 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 106149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Ridge Health and Rehabilitation Center 6517 NW 39th Avenue Gainesville, FL 32606 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and policy and procedure review the facility failed to ensure medications were locked to permit only authorized personnel to have access. Findings include: During an observation on 02/14/2024 at 9:22 AM it showed there was a medication cart that was facing toward a resident's room on the 600 hall. The staff member in the room was not facing the medication cart, looked up, saw this writer, and then entered the bathroom. There were no other staff present in the area. The Administrator was walking by and when asked if there was a concern related to the medication cart, the Administrator walked around the cart, and verified the lock was not engaged and there was no staff member present. Staff A, Licensed Practical Nurse (LPN), the staff member in the room, returned to the cart at 9:24 AM. During an interview on 02/14/2024 at 9:23 AM the Administrator stated, The medication carts should be locked. During an interview on 02/14/2024 at 9:24 AM Staff A, LPN, in front of the Administrator, stated, I wasn't aware I had left the cart unlocked. According to the P & P [policy and procedure] the medication cart is to be locked at all times when I'm not at it. During an observation on 02/14/2024 at 9:28 AM a staff member was observed at the treatment cart in front of the nurses' station located on the 500 hallway. The employee removed a plastic bag that was labeled with a resident's name and medication. The employee walked away from the cart and started up the hallway. The treatment cart was observed unlocked and unattended. During an interview on 02/14/2024 at 9:28 AM the Registered Nurse/Case Manager (RNCM) stated, There are medications kept in the treatment cart. I don't know if it is supposed to be locked. I'm a nurse and all medications should be locked so the cart should be locked. I don't know how to lock it. I thought I would need to have a key to lock it. I was getting something for a CNA [Certified Nursing Assistant]. It was some nystatin powder; she was going to take it to [Staff A, LPN's name] for a resident. When asked when the employee unlocked the cart to get the medication did she have to use a key, the RNCM stated, I didn't unlock it, it was unlocked when I went to get the medication. I don't know who unlocked it or how long it had been unlocked. It should have been locked. Since it was not locked anyone could have access to the medications. Review of the policy and procedure titled, Medication Storage and Labeling read, Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: Secured (locked) locations, accessible only to designated staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106149 If continuation sheet Page 3 of 5 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 106149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Ridge Health and Rehabilitation Center 6517 NW 39th Avenue Gainesville, FL 32606 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 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interviews, and record reviews, the facility failed to ensure that resident records were complete and accurate for 1(Resident #3) of 3 residents reviewed. Residents Affected - Few Findings include: 1. During an observation on 2/15/2024 at 1:50 PM, Resident #3 requested pain medication from Staff C, License Practical Nurse (LPN). Staff C, LPN did not discuss with Resident #3 pain characteristic, location, or request Resident #3 to rate his pain on a scale of 1 - 10. Staff C, LPN left the room and returned at 1:56 PM and administered Hydrocodone Acetaminophen Tablet 5-325 mg (milligrams) to Resident #3. Staff C, LPN did not discuss pain location, characteristic of the pain or request Resident #3 to rate his pain on a pain scale of 1-10. Staff C, LPN was observed documenting on the electronic medication record medication given and did not document pain scale rating. During an interview on 2/15/2024 at 1:52 PM, Resident #3 stated I'm always in pain and right now my pain is a 11 on scale of 1 -10. During an interview on 2/15/2024 at 1:57 PM, Staff C, LPN stated, I've taken care of [Resident #3's name] for years and he always tells me that his pain in a 7 on a scale of 1-10 so I don't ask him anymore and do not document a pain rating. I should ask him and will in the future and document it. Review of Resident #3's physician's order dated 1/20/2024 read, Hydrocodone-Acetaminophen Tablet 5-325mg Give 1 tablet by mouth every 4 hours as needed for chronic pain 6-10. Review of Resident #3's physician's order dated 1/19/2023 read, Document for verbal/non verbal pain level then code which # intervention used below (must have 1 non pharmacological code) 1)1:1 2)massage 3)activities 4)food/drink 5)redirection/reassurance 6)deep breathing/relaxation 7)quiet area/rest period 8)therapy 9)heat/ice if ordered 10)PRN(as needed)/routine medication 11)none 12)other see note. every shift for Pain observation. Review of the daily shift pain level monitoring documentation on the Medication Administration Record (MAR) for February 2024 documented no pain rating for Resident #3 except for 2/6/2024 on the evening shift. Review of the MAR for Resident #3 for February 2024 read, Hydrocodone-Acetaminophen Tablet 5-325mg Give 1 tablet by mouth every 4 hours as needed for chronic pain 6-10. There was no documentation of a pain rating on prior to administering Hydrocodone-Acetaminophen on 2/1/2024, 2/5/2024, 2/7/2024 times 3, 2/8/2024 times 2, 2/11/2024, 2/13/2024, 2/14/2024, and 2/15/2024. Review of Resident #3's care plan dated 6/27/2022 read, The resident has potential for pain related to neuropathy, lower back pain, liver cirrhosis and phantom pain right with interventions including administer analgesia per physician order and evaluate the effectiveness of pain interventions. During an interview on 2/15/2024 at 3:22 PM the Director of Nursing confirmed that the physician's orders for [Resident #3's name] dated 1/20/2024 for Hydrocodone-Acetaminophen Tablet 5-325mg ( milligram) for 1 tablet by mouth every 4 hours as needed for chronic pain 6-10 was not followed as ordered. There was no nursing assessment of pain monitored or rate of pain on a scale of 1 - 10 as ordered. There was no documentation related to pain rating noted in the chart. Nurses are to complete a pain assessment on the resident when the resident complains of pain, document the pain on a scale of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106149 If continuation sheet Page 4 of 5 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 106149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Ridge Health and Rehabilitation Center 6517 NW 39th Avenue Gainesville, FL 32606 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 1-10 and then follow up and reassess the pain on the pain scale of 1-10 within 1 hour after administering the medication and document assessments in the electronic medication administration record (EMAR). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106149 If continuation sheet Page 5 of 5