Health inspection·November 15, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, interviews and record review, the facility failed to ensure accurate documentation for dispensing and administration of controlled substances for two residents (Resident#15 and #16) of two residents sampled for pain medication administration. Findings included: 1) A review of Resident #16's Clinical Face Sheet revealed an admission date of 09/19/2023. The Medical Diagnoses list included: Multiple Sclerosis and chronic pain syndrome. A review of Resident #16's Medication Administration Record (MAR) for 10/2023, revealed a physician order as follows: Oxycodone HCI (hydrochloride) Oral Tablet 20 MG (milligrams) give 1 tablet by mouth every 4 hours as needed for non-acute pain 6-10, start date of 09/22/2023. A review of Resident #16's Grievance form, dated 10/30/2023, revealed the following: (Resident #16) stated that the two nurses did not fill his order and he was mad that his pain pills almost ran out. The form revealed the grievance had been investigated and the summary of the investigation was, They (sic) was no lapse in medication and (Resident #16) never ran out of medication. The allegation of the complaint was not confirmed, with no corrective actions listed. An interview was conducted on 11/15/2023 at 2:38 p.m. with the Social Service Director (SSD), and the Nursing Home Administrator. The SSD stated the grievance for Resident #16 had been investigated and signed off by the resident. A review of the Controlled Medication Utilization Record for Resident #16 revealed the following discrepancies when compared to the MAR: 10/04/2023, medication was signed for on the control sheet at 2130 (9:30 p.m.), but not reflected as administered. 10/05/2023, medication was signed for on the control sheet at 12:32 p.m., but not reflected as administered. 10/06/2023, the MAR reflected administration at 6:01 a. m., but the time on the controlled sheet was blank. 10/06/2023, medication was signed for on the control sheet at 10:00 a.m., but not reflected as Page 1 of 4 105045 105045 11/15/2023 Braden River Rehabilitation Center LLC 2010 Manatee Ave E Bradenton, FL 34208

F 0755 administered. Level of Harm - Minimal harm or potential for actual harm 10/08/2023, medication was signed for on the control sheet at 6:15 a.m., 10:15 a.m., 1521 (3:21 p.m.), but not reflected as administered. Residents Affected - Few 10/09/2023, medication was signed for on the control sheet at 12:12 p.m., but not reflected as administered. 10/11/2023, medication was signed for on the control sheet at 1500 (3:00 p.m.), but not reflected as administered. 10/12/2023, medication was signed for on the control sheet at 1545 (3:45 p.m.) and 2245 (10:45 p.m.), but not reflected as administered. 10/13/2023, medication was signed for on the control sheet at 6:30 a.m., but not reflected as administered. 10/15/2023, medication was signed for on the control sheet at 0000 (12:00 a.m.) and 6:00 a.m., but not reflected as administered. No control sheet was provided by the facility for 10/17/2023. The MAR reflected administration for 2:35 a.m., 6:30 a.m., 10:29 a.m.; 1429 (2:29 p.m.); 1830 (6:30 p.m.); 2230 (10:30 p.m.). 10/18/2023, medication was signed for on the control sheet at 1500 (3:00 p.m.), but not reflected as administered. 10/19/2023, medication was signed for on the control sheet at 1:00 a.m., 5:00 a.m., and an unreadable time, but not reflected as administered. 10/21/2023, medication was signed for on the control sheet at 9:12 a.m., 1707 (5:07 p.m.), and 2100 (9:00 p.m.), but not reflected as administered. 10/22/2023, medication was signed for on the control sheet at 9:00 a.m., 1300 (1:00 p.m.), 1700 (5:00 p.m.), and 2100 (9:00 p.m.), but not reflected as administered. 10/23/2023, medication was signed for on the control sheet at 5:00 a.m., 9:00 a.m., and 1600 (4:00 p.m.), but not reflected as administered. 10/24/2023, medication was signed for on the control sheet at 1:45 a.m., 6:25 a.m. and 1410 (2:10 p.m.), but not reflected as administered. The MAR for 10/24/2023, documented administration at 1750 (5:50 p.m.) and 2150 (9:50 p.m.), versus the control sheet time of 1400 (2:00 p.m.) and 12:50 p.m. The MAR for 10/25/2023, documented administration at 1:56 a.m., 9:55 a.m., 1407 (2:07 p.m.), and 1807 (6:07 p.m.), versus the facility provided no control sheet for 10/25/2023. 10/26/2023, medication was signed for on the control sheet at 1800 (6:00pm.), but not reflected as administered. 10/27/2023, medication was signed for on the control sheet at 10:00 a.m., 1400 (2:00 105045 Page 2 of 4 105045 11/15/2023 Braden River Rehabilitation Center LLC 2010 Manatee Ave E Bradenton, FL 34208

F 0755 p.m.), and 2200 (10:00 p.m.), but not reflected as administered. Level of Harm - Minimal harm or potential for actual harm 10/28/2023, medication was signed for on the control sheet at 6:00 a.m., but not reflected as administered. Residents Affected - Few The control sheet for 10/28/2023 documented two pills were withdrawn at 1400 (2:00 p.m.), with no reason associated with the 2nd withdrawal. 10/29/2023, medication was signed for on the control sheet at 6:25 a.m., but not reflected as administered. 10/30/2023, medication was signed for on the control sheet at 2:37 a.m. and 6:37 a.m., but not reflected as administered. The control sheet for 10/30/2023 documented two pills were withdrawn at 1415 (2:15 p.m.), with no reason associated with the 2nd withdrawal. 10/31/2023, medication was signed for on the control sheet at 10:30 a.m., but not reflected as administered. The control sheet for 10/31/2023 documented two pills were withdrawn at 1430 (2:30 p.m.), with no reason associated with the 2nd withdrawal. An interview was conducted on 11/15/2023 at 4:05 p.m. with the Director of Nursing (DON). She stated the MAR should match the control sheet. The DON was re-interviewed at 4:28 p.m. after the review of Resident #16's MAR and control sheets for the Oxycodone. She confirmed the discrepancies after reviewing the documents. 2) A review of Resident #15's Face Sheet revealed an admission date of 01/2023, and a readmission of 07/19/2023. The medical diagnoses list included: idiopathic peripheral autonomic neuropathy and chronic pain syndrome. A review of Resident #15's Care Plan revealed a focus area for Diabetic neuropathy, disease process, initiated 10/12/2023. Interventions included, Analgesics as ordered, initiated 01/14/2023. An interview was conducted on 11/15/2023 with Resident #15. He was observed in bed, he agreed to an interview. He was alert and oriented, able to answer questions. Resident #15 stated, For myself there has been concerns. I take two different pain medications. There has been three times in the last 60 days when they ran out of the medication. Not at the same time. One is a film that is placed inside my cheek, Belbuca. The other is Oxycodone. A review of the 11/2023 MAR listed the following physician order: Oxycodone-Acetaminophen Tablet 10-325 MG, give 1 tablet by mouth every 12 hours as needed for severe pain, start date 11/02/2023. A review of the Controlled Medication Utilization Record for Resident #15 revealed the following 105045 Page 3 of 4 105045 11/15/2023 Braden River Rehabilitation Center LLC 2010 Manatee Ave E Bradenton, FL 34208

F 0755 discrepancies compared to the MAR: Level of Harm - Minimal harm or potential for actual harm 11/04/2023, medication was signed out on the control sheet at 2230 (10:30 p.m.), but not reflected as administered. Residents Affected - Few 11/06/2023, medication was signed for on the control sheet at 9:10 a.m., but not reflected as administered. 11/10/2023, medication was signed for on the control sheet at 2000 (8:00 p.m.), but not reflected as administered. A review of the facility policy titled Medication Pass Guidelines, revised 04/25/2017, revealed the following: Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systematically distribute medications to residents in accordance with state and federal guidelines. Fundamental information: Physician's Orders-Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive to be unrelated to the resident's current diagnosis or condition, contact the physician of clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. Procedures: .10-Record the results of medications administered as necessary. Documentation: Record the name, dose, route, and time of medication on the Medication Administration Record. Initial the record after the mediation is administered to the resident. Record the reason for not administering if not administered 105045 Page 4 of 4