Health inspection·January 25, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) was issued to 1 of 2 sampled residents reviewed for beneficiary notices. (Resident #136) Residents Affected - Few The findings include: A review of Resident #136's record revealed a Medicare Part A Skilled Services start date of 11/23/23, with the last covered day of Part A services listed as 12/13/23. The record did not contain the required SNF-ABN form. An interview was conducted with the Social Services Director on 1/24/24 at 12:01 PM. He stated the facility did not issue a SNF-ABN to Resident #136 because he was not aware of the requirement. A review of the facility policy SNF Advance Beneficiary Notification (ABN) & Notice of Medicare Provider Non-Coverage (BO-510 revised 5/1/18) revealed that the Care Center is responsible for delivering the Notice of Medicare Provider Non-Coverage and the SNF ABN to all beneficiaries not later than 2 days, before their covered services end and for delivering the Detailed Notice to the Quality Improvement Organization and the beneficiary by close of business of the day the beneficiary requests a review (if a review is requested). Page 1 of 4 105132 105132 01/25/2024 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Resident #70 Review of Resident #70's record revealed a consultant pharmacist recommendation dated 7/10/23, which indicated the resident had a diagnosis of diabetes, but a hemoglobin A1C (a blood test that measures the individuals average blood sugar levels over the past 3 months) was not available in the medical record in the past 6 months. The pharmacist recommended monitoring the hemoglobin A1C on the next convenient lab day and every 6 months if meeting treatment goals, or every 3 months if therapy has changed or goals are not being met. The pharmacist recommendation form contained a hand written telephone order by the Director of Nursing (DON) dated 7/20/23 stating, okay to do lab draw. A review of Resident #70's record revealed no hemoglobin A1C blood test on file. An interview was conducted with the DON on 1/24/24 at 11:48 AM. She stated the hemoglobin A1C was missed and not obtained. She and the Assistant DON were responsible for ensuring the pharmacy recommendations were acted upon. She may have been interrupted during the process. On 1/24/24, the survey team requested the pharmacy recommendations from December 2023. The review of the consultant pharmacist for Resident #70, dated 12/18/23, revealed a recommendation to consider adding an as needed parameter for the Glucagon injection as needed for hypoglycemia on when to administer the medication, for example blood sugar less than 60. A review of the record revealed the recommendation had not been acted upon by the facility. An interview was conducted with the DON on 1/24/24 at 3:15 PM. The DON stated the facility changed pharmacy consultants in December 2023 and the new pharmacist emailed some reports in December 2023. She did not realize she did not receive all of the reviews until the survey team requested specific pharmacy reviews for December 2023 and she did not have them. She stated the facility expects the reports on all residents to be provided in the same month of the review. Review of the facility policy for Monthly Drug Regimen Review (N-866 revised 10/10/18) revealed, During the drug regimen review, the consultant pharmacist is to identify drug regimen irregularities. Drug regimen irregularities are to be communicated to the attending physician, the Medical Director, and the DON/designee to complete follow up as indicated. Routine recommendations to be communicated to the DON/designee, attending physician, and Medical Director for response and resolution, after the completion of the Monthly Drug Regimen Review. Drug regimen irregularities identified by the consultant pharmacist that require urgent action are to be communicated to the DON/designee for resolution with the attending physician and/or Medical Director. Resident #60 On 01/25/2024 during a record review for Resident #60, the 12 month Pharmacy Review revealed that the December 2023 review had not been received by the facility or requested by the facility, and was only discovered by facility staff after the survey team requested the Pharmacy Review for Resident #60. The December 2023 pharmacist review recommended an antidepressant to be reviewed for a possible Gradual Dose Reduction in an effort to find the lowest effective dose, which had not been followed up. (Photographic evidence obtained) Resident #44 105132 Page 2 of 4 105132 01/25/2024 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0756 Level of Harm - Minimal harm or potential for actual harm On 01/25/2024, during record review for resident #44, the 12 month Pharmacy Review revealed the December 2023 review had not been received by the facility or requested by the facility, and was only discovered by facility staff after the survey team requested the Pharmacy Review for Resident #44. The pharmacist had recommended a dose reduction for an antihistamine prescribed for Resident #44, which had not been followed up. (Photographic evidence obtained) Residents Affected - Few Based on interview, record review, and policy review, the facility failed to obtain and/or act upon pharmacy recommendations in July and December 2023 for 4 of 5 sampled residents. (Residents #26, #46, #60, #70) The findings included: Resident #26 On 1/25/24, a review of a Consultant Pharmacist Medication Regimen Review to Psychiatry dated 12/18/23 for Resident #26 was conducted. The review stated, .the resident is due for a gradual dose reduction in an attempt to find the lowest effective dose. If the medication cannot be reduced at this time please check the appropriate rationale below related to the gradual dose reduction being clinically contraindicated at this time and make a brief clinical rational note that the benefits outweigh the risks. The form was not completed or signed by a medical practitioner or psychiatrist at the time of the survey. A review of the order summary report dated 1/24/24 for Resident #26 was conducted. Resident #26 had a diagnosis of Schizoaffective disorder and Alzheimer's Disease. The resident had an order dated 8/8/23 to take Seroquel (an antipsychotic medication) 50 mg 1 tablet by mouth twice daily. The last psychiatric assessment for Resident #26 was completed on 12/29/23. The assessment did not provide any information or statement regarding a gradual dose reduction for the Seroquel 50 mg twice daily for Resident #26. Resident #46 On 1/25/24 a review of two Consultant Pharmacist Medication Regimen Reviews dated 12/18/23 for Resident #46 was conducted. The first medication regimen review to the physician for Resident #46 was regarding guaifenesin oral tablet 400 mg give 1 tablet by mouth two times daily for seasonal allergies. This order was started on 10/10/23. The order stated that the medication may be used for an acute illness/symptoms for a defined duration and the stopped or may be of a chronic nature and that the medical staff should indicate if chronic or acute and discontinue if appropriate. The review will help reduce overmedication. The form was not completed or signed by a medical practitioner at the time of the survey. A review of the order summary report dated 1/24/24 for Resident #46 was conducted. Resident #46 had an order dated 10/10/23 to take guaifenesin oral tablet 400mg tablet by mouth two times daily for seasonal allergies. The second medication regimen review to the nurse for Resident #46 was regarding Midodrine HCL oral tablet 10 mg 1 tablet by mouth three times daily for Hypertension (HTN). The recommendation asked the nurse to please evaluate the indication of hypertension vs hypotension. At the time of the survey, the form was not signed or updated by a nurse or physician. A review of the order summary report dated 1/24/24 for Resident #46 was conducted. The summary noted that Resident #46 had a diagnosis of Essential Hypertension and had an order for Midodrine HCL 10 mg 1 tablet by mouth three times daily for Hypertension (HTN). 105132 Page 3 of 4 105132 01/25/2024 Aviata at Lakeside Oaks 1061 Virginia St Dunedin, FL 34698

F 0756 Level of Harm - Minimal harm or potential for actual harm On 1/25/23, a review of the Consultant Pharmacist Services Agreement effective 12/1/2023 was conducted. The agreement indicated that the consultant pharmacy would provide general supervision of clients pharmaceutical services including medication regimen reviews. These reports would be provided for each resident of the facility at least once each month. The consultant pharmacy agreement indicated that an electronic copy of the report would be sent within 3 business days to facility leadership. Residents Affected - Few 105132 Page 4 of 4