Health inspection·May 5, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility documentation review and policy review the facility failed to report one of one incident that resulted in serious bodily harm within the appropriate timeframe. Findings included: A review of Resident #1's medical record showed an admission date of 06/ 01/2020 with admitting diagnosis of Type II Diabetes Mellitus without Complications, History of Falling, Anemia, unspecified, Vascular Dementia with behavioral disturbance, Dizziness, and giddiness, Generalized edema, Acute kidney failure unspecified and other osteoporosis with current fracture to right humorous, subsequent encounter for fracture with routine healing. A physician order dated [DATE] showed Full Code meaning all resuscitation efforts would be utilized to keep the Resident alive. The comprehensive care plan showed a focus of Resident has an HCP [Healthcare Proxy] and incapacity and is a full code. With initiated date of [DATE]. A goal of Resident #1's designated representative will be educated regarding Advance Directive options through the target date of [DATE]. Intervention showed Full Code. Resident #1's facesheet showed full code. Review of a progress note, written by Staff A, Registered Nurse (RN), dated [DATE] at 10:03 AM showed, At 1045 [p.m. on [DATE]] I went, and the resident refused the medication, which is crush, she did not want to open her mouth to take to take it. I continued with my rounds and at 1258 the CNA [certified nursing assistant] came to tell me that the resident was not responding. I went to the room to see and confirm that she was not breathing active code [NAME] [blue] and I put the Cardiopulmonary Resuscitation (CPR) table[tablet] on the oxygen tank, and I started CPR when I went for the third cycle. The nurse and the supervisor tell me to stop not touching it, its Do Not Resuscitate (DNR), we stopped the CPR. I picked up the equipment when I come to the computer to make the report, I realized that was an error by the nurse and the supervisor because it is a full code, and I activated the blue code, and I ran to the room. I told the CNAs to activate the blue code by intercom and CPR continued until 911 arrived and relieved us. A review of Resident #1's medical record showed a Code Blue Form dated [DATE]. The Code Blue Form showed chain of events dates that included: Time of Respiratory/Cardiac Arrest: [DATE] at 12:58 a.m. Code Blue Called: [DATE] at 12:59 a.m. Code Status Verified: [DATE] at 1:05 a.m. Page 1 of 31 105140 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0609 911 Called: [DATE] at 12:59 a.m. Level of Harm - Minimal harm or potential for actual harm CPR Initiated: [DATE] at 12:59 a.m. EMS Arrived: [DATE] at 1:35 a.m. Residents Affected - Few Physician Notification: [DATE] at 2:00 a.m. Responsible Party Notified: [DATE] at 2:10 a.m. DON Notification: [DATE] at 1:45 a.m. Additional Comments: 10-45 [p.m.] the resident refused the acetaminophen and then the CNA at 1258 reported that the patient did not respond CPR was started and then they ordered to stop and not touch the patient because it was DNR when I returned to my computer to make the report I realized that is was an error full code and activate the blue and ran code for the room and we started CPR until the paramedics arrived. A review of the facility's documentation, Adverse Incident Tracker for the month [DATE] showed a [DATE] incident identifying Resident #1 with a type of description as CPR incident. A report date of [DATE] was noted. A review of the Federal Immediate Report Manager showed an immediate report was created on [DATE] at 10:22:58 PM by the Director of Nursing (DON). During an interview on [DATE] at 10:38 a.m., the Director of Nursing (DON) stated that she was notified of a Code Blue on [DATE] around 5:00 a.m. The DON stated she was told that the police were notified and already in the facility. DON remembered that around 8:00 a.m. on [DATE] Registered Nurse (RN) Staff B informed the DON that a code blue was called on Resident #1. DON stated that the morning of [DATE] a Certified Nursing Assistant (CNA) found Resident #1 and called for the Nurse (identified as RN Staff A). The DON stated that Staff A, RN called a Code Blue and started CPR. DON stated that Staff C, Licensed Practical Nurse (LPN) obtained the wrong chart to verify code status and RN Staff B then informed RN Staff A that Resident #1 was a DNR and not to touch Resident #1. The DON stated that upon investigation once RN Staff A quit CPR and went to the computer to document it was found that Resident #1 was a full code, so a code blue was called again, and CPR was resumed until EMS arrived. The DON stated that the incident was recorded as an adverse situation with neglect and reported within 24 hours of the incident. The DON stated that the incident occurred on [DATE] and the incident was reported on [DATE]. The DON stated that as of right now RN staff A and RN staff B were suspended but LPN Staff C was back to work already. The DON stated that LPN Staff C was cleared on the CPR incident already because the only involvement LPN Staff C had was pulling a Resident hard copy chart and giving the chart to the supervisor. The DON was asked when reporting an adverse situation or a case of neglect what was the timeframe for reporting? The DON stated that the facility only reports cases of abuse, neglect or exploitation in two hours, everything else is 24 hours. The DON stated that the incident would have been reported on [DATE] within two hours of the incident however, the state survey team came into the facility to survey, and this caused a delay because she was busy getting all the information needed for the survey team. The DON stated that she could not report the adverse situation until after the state survey team left the first day of survey until after 7:00 p.m. on [DATE]. 105140 Page 2 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy, Abuse Prevention Program revised date [DATE] showed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegation of abuse within timeframes as required by federal requirements. A facility policy titled Abuse Investigating and reporting revised [DATE], was reviewed. The policy stated the following: Policy Statement, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be properly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 105140 Page 3 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for one (Resident #8) of three discharge records reviewed. Residents Affected - Few Findings included: A review of Resident #8's medical record showed Resident #8 was admitted to the facility on [DATE] with diagnoses of Acute and Chronic Respiratory Failure,Chronic Obstructive Pulmonary Disease (COPD), and Unspecified Acute and Chronic heart failure. A progress note dated 02/17/23 at 12:30 a.m. showed, Resident was admitted to room [ROOM NUMBER]-A and left [against medical advice] AMA at 12:30 AM. Resident requested to be 911 to the VA. A discharge without physician's approval form was obtained. And [Medical Doctor] MD was notified. Review of the Entry minimal data set (MDS) showed an admitted date of 02/16/23. A second MDS Discharge return not anticipated dated 02/17/23 was marked in section A as discharged to the community. During an interview on 04/27/23 at 10:30 a.m., Staff V, Registered Nurse (RN) stated that resident information used to code the discharge return not anticipated MDS was retrieved from hospital clinicals, on the floor interviews, therapy evaluations, physician orders and progress notes. RN Staff V reviewed the 02/17/23 progress note that stated Resident was admitted to room [ROOM NUMBER]-A and left [against medical advice] AMA at 12:30 AM. Resident requested to be 911 to the VA. A discharge without physician's approval form was obtained. And [Medical Doctor] MD was notified. RN Staff V stated based on the progress note dated 02/17/23 at 12:30 a.m. the Resident should have been coded on the Discharge Return not Anticipated MDS dated [DATE] with a discharge to an acute hospital not the community. RN Staff V stated that usually when a Resident leaves AMA they go to the community so that may have been why the MDS was marked in error. 105140 Page 4 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility documentation review and policy review the facility failed to accurately identify a resident, follow facility policy, and accurately identify a code status of one resident (#1) out of six residents reviewed for advance directives. Resident #1, had physician orders and care plan showing her wishes were for a Full Code (meaning all resuscitation procedures will be provided to keep her alive if found without a pulse and/or respirations). On [DATE] when Resident #1 was found to be unresponsive without pulse and respirations, resuscitation efforts were begun, and then stopped due to a mistake in identifying the correct medical record. Resuscitation efforts were started again after Resident #1's actual medical record was found and a nurse realized the error. The resident was not successfully revived and was pronounced dead by Emergency Medical Service (EMS) staff. This failure created a situation that resulted the likelihood for serious injury and or death and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D. Findings included: A review of Resident #1's medical record showed an admission date of [DATE] with admitting diagnoses of Type II Diabetes Mellitus without Complications, History of Falling, Anemia, unspecified, Vascular Dementia with behavioral disturbance, Dizziness, and giddiness, Generalized edema, Acute kidney failure unspecified and other osteoporosis with current fracture to right humorous, subsequent encounter for fracture with routine healing. A physician order dated [DATE] showed Full Code. The comprehensive care plan showed a focus of Resident has an HCP [Healthcare Proxy] and incapacity and is a full code. With initiated date of [DATE]. A goal of Resident #1's designated representative will be educated regarding Advance Directive options through the target date of [DATE]. Intervention showed Full Code. Resident #1's facesheet showed full code. Review of a progress note, written by Staff A, Registered Nurse (RN), dated [DATE] at 10:03 AM showed, At 1045 [p.m. on [DATE]] I went, and the resident refused the medication, which is crush, she did not want to open her mouth to take to take it. I continued with my rounds and at 1258 the CNA (Certified Nursing Assistant) came to tell me that the resident was not responding. I went to the room to see and confirm that she was not breathing active code [NAME] [Spanish word for blue] and I put the Cardiopulmonary Resuscitation (CPR) table[tablet] on the oxygen tank, and I started CPR when I went for the third cycle. The nurse and the supervisor tell me to stop not touching it, its Do Not Resuscitate (DNR), we stopped the CPR. I picked up the equipment when I come to the computer to make the report, I realized that was an error by the nurse and the supervisor because it is a full code, and I activated the blue code [generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest], and I ran to the room. I told the CNAs to activate the blue code by intercom and CPR continued until 911 arrived and relieved us. Review of Resident #1's medical record showed a minimum data set (MDS) dated [DATE] with Death in the Facility. 105140 Page 5 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility's documentation, the listing of all discharges for [DATE], showed Resident #1 had expired on [DATE]. A review of the facility's documentation Adverse Incident Tracker for the month [DATE] showed a [DATE] incident identifying Resident #1 with a description of CPR incident and report date of [DATE]. During an interview on [DATE] at 10:38 a.m., the Director of Nursing (DON) stated that she was notified of a Code Blue on [DATE] around 5:00 a.m. The DON stated she was told that the police were notified and already in the facility. DON remembered that around 8:00 a.m. on [DATE] RN Staff B informed the DON that a code blue was called on Resident #1. DON stated that the way she understood the code blue incident the morning of [DATE] was a CNA found Resident #1 and called for the Nurse (identified as RN Staff A). The DON stated that RN Staff A called a Code Blue and started CPR. The DON stated that LPN (Licensed Practical Nurse) Staff C obtained the wrong chart to verify code status and RN Staff B then informed RN Staff A that Resident #1 was a DNR and not to touch Resident #1 as it was verified that she was a DNR. The DON stated that upon investigation once RN Staff A quit CPR and went to the computer to document it was found that Resident #1 was a full code, so a code blue was called again, and CPR was resumed until EMS arrived. The DON stated that the incident was recorded as an adverse situation with neglect and reported within 24 hours of the incident. The DON stated that the incident occurred on [DATE] and the incident was reported on [DATE]. The DON stated that as of right now RN staff A and RN staff B were suspended but LPN Staff C was back to work already. The DON stated that LPN Staff C was cleared on the CPR incident already because the only involvement LPN Staff C had was pulling a Resident hard copy chart and giving the chart to the supervisor. A review of Resident #1's medical record showed a Code Blue Form dated [DATE]. The Code Blue Form showed chain of events dates that included: Time of Respiratory/Cardiac Arrest: [DATE] at 12:58 a.m. Code Blue Called: [DATE] at 12:59 a.m. Code Status Verified: [DATE] at 1:05 a.m. 911 Called: [DATE] at 12:59 a.m. CPR Initiated: [DATE] at 12:59 a.m. EMS Arrived: [DATE] at 1:35 a.m. Physician Notification: [DATE] at 2:00 a.m. Responsible Party Notified: [DATE] at 2:10 a.m. DON Notification: [DATE] at 1:45 a.m. Additional Comments: 10:45 (p.m.) the resident refused the acetaminophen and then the CNA at 1258 reported that the patient did not respond CPR was started and then they ordered to stop and not touch the patient because it was DNR when I returned to my computer to make the report I realized that is was an error full code and activate the blue and ran code for the room and we started CPR until the paramedics arrived. 105140 Page 6 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on [DATE] at 2:30 p.m., LPN Staff C stated that when code blue was called, everyone went running to the code blue unit. LPN Staff C stated that she pulled a medical chart by room number and handed it to RN Staff B who verified code status in the computer. LPN Staff C stated after handing the chart over to the supervisor she then went back to the assigned unit to check on all the residents on her assigned unit. LPN Staff C stated, I verified the Resident who coded based on room number. LPN Staff C was asked if Resident #1 was in a private room? LPN staff C stated no, Resident #1 had three to four people in the room she was assigned to. LPN Staff C stated that there was training on code blue and rapid response protocol prior (on [DATE]) to the incident on [DATE] and the protocol was followed but the issue was the wrong chart was pulled. LPN Staff C verified the chart that was pulled was Resident #7's chart the roommate of Resident #1. A review of Resident #7's medical record showed an admission date of [DATE] with admitting diagnoses of Multiple Sclerosis, other malignant neoplasm of skin of nose, hyperlipemia, Unspecified Dementia, Depression and Anxiety. A State of Florida Do Not Resuscitate Order was in place with a date of [DATE]. A physician order dated [DATE] showed DNR. The Comprehensive Care plan showed Resident #7 has expressed the following wishes regarding code status and has the following advance directives in place: DNR with initiated date of [DATE]. During an interview on [DATE] at 2:40 p.m., RN Staff B stated when code blue was called on [DATE] everyone responded. Staff B came from Southwest Hall to assist with the code on Northwest Hall. RN Staff B remembered going right to the computer to verify code status. RN Staff B stated the name of the Resident was given and the code status on point click care was matched with the name in the physical chart with a matching code status of do not resuscitate (DNR). RN Staff B explained that the name of the Resident that was given for code status verification was not correct, the name given for code verification was Resident #7's (Resident #1's roommate) information that stated DNR instead of Resident #1. Both nurses confirmed DNR status for Resident #7 and then we both yelled down she is DNR do not touch her. After cardiopulmonary resuscitation (CPR) was discontinued RN Staff B and LPN Staff C went to the room and called time of death. RN Staff B stated all nurses went back to their assigned units and began working again. RN Staff B stated maybe 10 to 15 minutes later a Certified Nursing Assistant (CNA) came running down the hall stating, it was the wrong the chart. RN Staff B remembered a second code blue was called and CPR was initiated again until the EMS arrived. RN Staff B stated that when looking for Resident #1's chart no one could find it at first as the medical chart was not located on the same unit where Resident #1 resided, but someone eventually found the chart on another unit. On [DATE] at 6:00 p.m., an interview was attempted with RN Staff A. The nurse's phone number was called and Staff A answered by saying what do you want? Staff A was told the call was to discuss an incident regarding a resident at the facility. Staff A RN said do you speak Spanish? and then said I only speak Spanish and call back when you can speak Spanish and the phone was disconnected. Review of the facility's documentation Risk Management Witness Statement written by RN Staff A dated [DATE] showed, At 1045 (p.m.) I went to the room and the patient refused the medicine and I continued with rounds. At 12:58 AM the CNA [CNA Staff E] tell me that the patient was not breathing. I went to the room with the crash cart and the oxygen when I get there the patient was not breathing and I started CPR and told [CNA Staff F and CNA Staff D] to activate code blue and to look the medical record but when I was in the middle of the CPR the [LPN Staff C] grab a book and says she was a DNR and the supervisor says stop CPR and when I went come back to the computer I look other record figured out that she was a full code and the nurse [LPN Staff C] did a mistake so I called [CNA Staff D] and tell her to activate the code blue for the second time so I went to the room and start CPR until 105140 Page 7 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 the paramedics was here. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility's documentation showed an In-service was conducted on [DATE] on the topics of Code Blue, Rapid Response, documentation, signs and symptoms of hyper and hypo glycemic and fall monitoring. Residents Affected - Few During an interview on [DATE] at 5:00 p.m., RN Staff B stated that she was told Resident #7's name instead of Resident #1's name to verify code status. RN Staff B stated it was a communication error. RN Staff B stated that when the code blue was called around 12:55 a.m. on [DATE] she went to assist. RN Staff B stated that RN Staff A was asked to identify the Resident who coded, and Staff A stood there looking at her like a deer in headlights frowned, and then shrugged. RN Staff B stated that RN Staff A began looking around for Certified Nursing Assistant (CNA) Staff D to translate for him because he did not understand what RN Staff B asked. RN Staff B again asked RN Staff A who coded and RN Staff A identified the Resident as Resident #7. RN Staff B stated that was when LPN Staff C pulled the medical chart and handed the medical chart to RN Staff B for verification of code status in the electronic medical record. RN Staff B stated the code status matched as a DNR so they yelled to RN Staff A to in the room performing CPR to stop CPR it had been verified she was DNR. RN Staff B stated that both she and LPN Staff C went to the room and called the time of death about 1:05 a.m. RN Staff B stated Resident #1 was clearly dead there was no pulse and no respirations. RN Staff B stated that both she and LPN Staff C went back to their assigned unit to care for their assigned residents. RN Staff B stated that lack of communication in English was the cause of the mix-up as RN Staff A could not understand the questions RN Staff B asked during the code blue. RN Staff B stated that was when she realized that RN Staff A was not bilingual in English and was solely Spanish speaking which was a barrier and safety issue during an emergency like a code blue. RN Staff B stated that it took her three times to write out her witness statement because the DON continued not to accept it and said the state would not accept the witness statements. RN Staff B stated after the third witness statement was written the DON approved it and accepted it. RN Staff B stated that once returning to the unit she was assigned to about 10 to 15 minutes later CNA Staff D came running down the hall and said, that was not the right person that Resident #1 was a full code. RN Staff B said she called the second code blue and asked for Resident #1's medical record to verify. RN Staff B stated that was when they discovered the hard copy medical record was missing. RN Staff B stated she asked everyone to go throughout the facility and look for Resident #1's hard copy medical record. RN Staff B stated it was CNA Staff D who eventually found Resident #1's hard copy chart on another unit. RN Staff B stated Resident #1's hard copy medical record and electronic medical record showed in fact that Resident #1 was a full code. RN Staff B stated that the code blue was called and so was 911 per facility protocol. RN Staff B stated that as a supervisor she felt RN Staff A's inability to understand the English language was more of a concern during the code blue as RN Staff A did not understand nor could answer questions quickly or accurately in a time of emergency. RN Staff B explained that CNA Staff D would come to her at the beginning of a shift, and request to be reassigned to work with RN Staff A. She said CNA Staff D would tell her it was because CNA Staff D needed to work on the same hallway as RN Staff A in order to translate English language to Spanish language. RN Staff B stated that as a new supervisor she wanted to make sure staff were where they needed to be, so she always honored CNA Staff D request to work on the unit with RN Staff A. RN Staff B stated that she knew CNA Staff D assisted RN Staff A with some translation but had no idea that the translation assistance was full time throughout the shift. RN Staff B stated that she reported this concern to the DON, and had a conversation with the DON about the lack of communication and miscommunication during the [DATE] code blue incident. RN Staff B stated she informed the DON that RN Staff A's English language barrier was very concerning that night when he did not understand 105140 Page 8 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few her. RN Staff B stated she had experience and training in CPR and Advanced Cardiovascular Life Support (ACLS) and believed the communication and the lack of understanding without a translator for RN Staff A caused the mix-up during the first code blue process. During an interview on [DATE] at 9:50 a.m., the DON stated that RN Staff A could speak English and that sometimes RN Staff A would have delayed thinking about what was being discussed but then RN Staff A could answer. The DON stated that RN Staff A did know the English language and could communicate with English speaking residents and staff. The DON was asked about any accommodations RN Staff A may have needed related to a language barrier. The DON stated RN Staff A had no accommodations because he could communicate in English just as well as speaking in Spanish. During an interview on [DATE] at 11:20 a.m., CNA Staff E stated that when doing rounds the morning of [DATE] Resident #1 when you touched her she was able to verbalize. CNA Staff E stated that when she touched Resident #1 later that morning, she was ice cold and did not move and was not breathing. CNA Staff E stated that she went to the door and yelled for RN Staff A to come. CNA Staff E stated when RN Staff A got to the door, she led RN Staff A to Resident #1 where he began to assess Resident #1. CNA Staff E stated that she knew Resident #1 but did not identify Resident #1 with RN Staff A, as she just led RN Staff A to Resident #1 when RN Staff A walked in. CNA Staff E stated that she knew Resident #1 prior to the code blue incident as CNA Staff E worked with Resident #1 over on the Southeast Unit. CNA Staff E was asked if RN Staff A was able to communicate well with staff and residents. CNA Staff E responded that RN Staff A did not speak English well, but everyone who worked with him helped him when he was working. CNA Staff E stated that RN Staff A would answer questions very slowly and it took time for RN Staff A to respond as he had to have time to think about what is being asked. CNA Staff E stated that she did not speak Spanish, so she was never much help to RN Staff A. CNA Staff E stated that the morning of [DATE] there were two staff members who could speak Spanish that night, so they helped him through that 11-7 shift. CNA Staff E stated that for instance, CNA Staff E watched RN Staff A write up his witness statement all in Spanish first and then the other staff helped him translate his statement over to English. CNA Staff E stated that RN Staff A was asking about words in Spanish and the staff would tell RN Staff A what the word was in English. During an interview on [DATE] at 12:09 p.m., the DON reviewed Resident #1's medical record with the survey team. The medical record showed Resident #1's census page. Resident #1's census page showed Resident #1 was moved off Southeast Unit on [DATE] to the Northwest unit. The DON was asked if Resident #1's medical record was placed back on the Southeast unit by accident or if the chart was left on the Southeast unit when Resident #1 was transferred to Northwest unit on [DATE]. The DON said that she just didn't know, there was no way of knowing that but confirmed the medical record was not on the correct unit when Resident #1 stopped responding on [DATE]. During an interview on [DATE] at 1:15 p.m., LPN Staff G stated that when receiving report from RN Staff A, he was a little hard to understand. LPN Staff G stated that RN Staff A did speak English, but it was very thick English. LPN Staff G stated that staff would have to listen very carefully. LPN Staff G stated that he did think RN Staff A knew what was talking about but was just a little difficult to understand. During an interview on [DATE] at 1:26 p.m., RN Staff H stated that RN Staff A did have broken English. RN Staff H stated that he could understand RN Staff A but when RN Staff A spoke English it was not always spoken in the correct form. RN Staff H stated a lot of the times, staff had to listen to what RN Staff A said and then try to figure out what RN Staff A meant. RN Staff H stated that he only knew of one complaint from a Nurse (identified as LPN Staff I) who had stated that she could not 105140 Page 9 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few understand what RN Staff A was saying. RN Staff H stated that LPN Staff I had discussed the communication barrier with him. RN Staff H stated he did feel that RN Staff A's English skills were a little bit of a communication barrier. During an interview on [DATE] at 3:09 p.m., LPN Staff I stated, RN Staff A, was a little hard to understand, especially during shift change and report. LPN Staff I stated that RN Staff A had some broken English and there was a language barrier there. During an interview on [DATE] at 6:48 p.m., CNA Staff F and CNA Staff D were interviewed. CNA Staff D stated that the morning of [DATE] she was not Resident #1's assigned CNA. CNA Staff D identified CNA Staff E as the assigned CNA for Resident #1. CNA Staff D stated that CNA Staff E yelled that Resident #1 was not responding and was cold, so RN Staff A ran into the room with the crash cart. RN Staff A assessed Resident #1 and said no pulse or respirations and said activate a code blue and go find the chart. CNA Staff D stated that I went to look for the hard copy chart and was looking for room (Resident #1's room and bed). CNA Staff D stated the chart was missing and she could only find the charts for the other 3 residents in room (Resident #1's room). At this time, CNA Staff F stated, I wasn't even looking for the name. CNA Staff D stated that LPN Staff C came to the unit and pushed us CNAs out of the way, took one of the charts and said here is the chart. CNA Staff D stated that LPN Staff C opened the (wrong) chart and said she (Resident #1) is a DNR. CNA Staff D stated that RN Staff B took the chart from LPN Staff C and then opened the electronic medical record and said yes, they match she is a DNR. CNA Staff D stated that was when both LPN Staff C and RN Staff B yelled into the room not to touch her, she was a DNR. CNA Staff D stated that when RN Staff A got back to the nurses' station RN Staff B was making a list of what RN Staff needed to do next such as call the family, doctor, and DON. CNA Staff D stated that RN Staff A did not always understand a lot of things when people spoke in English, so I was always there to translate for him. CNA Staff D explained that was why she always made sure she was scheduled on that unit with RN Staff A every time he worked. CNA Staff D stated that RN Staff B made the to do list because of the communication barrier. When RN Staff A had the hard copy medical record in his hand and sat down at the computer to document RN Staff A stated, this is not the right Resident, Resident #1 is a full code. CNA Staff D stated that she remembered that Resident #1 had been on the Southeast Unit prior to being moved to the Northwest Unit two to three weeks prior. CNA Staff D stated that was where Resident #1's chart was found, it appeared the hard copy chart was never moved with the Resident #1 when transferred to Northwest unit. CNA Staff D stated by the time Resident #1's chart was found the paramedics were there. The paramedics were concerned that there could have been a delay in treatment and called the police to the facility. CNA Staff D stated that the police then decided to question each staff member one on one. CNA Staff D stated that she offered to help translate for RN Staff A when the police asked questions, but the police ended up getting their own officer who spoke Spanish to speak with RN Staff A. CNA Staff D stated that after the Resident #1 incident on [DATE] CNA Staff D was called in to speak with the Regional Nurse who asked CNA Staff D to come in and talk and make a witness statement regarding the incident. CNA Staff D stated the Regional Nurse asked her to write that Resident #1 was dead prior to the first code blue being called. CNA Staff D stated that she could not write that on the witness statement because as a CNA she could not assess or call a death. During an interview on [DATE] at 5:00 p.m., the Administrator stated that he had spoken with RN Staff A regarding the code blue incident and RN Staff A was able to tell the Administrator that he had started CPR on Resident #1 because RN Staff A knew Resident #1 was a full code and only stopped CPR because the Nurse Supervisor advised him to stop. A review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) not dated showed, 105140 Page 10 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Policy: It is the policy of the center to initiate CPR if the resident is without pulse or respirations and is a full code. Procedure: 1.Resident identified with lack of breathing and pulse. Residents Affected - Few 2. Responder calls for assistance (doesn't leave resident alone) 3. Team responds and brings medical record and code chart. 4. Vital signs taken. 5. Code status is verified from the medical record. 6. 911 (EMS) is called by staff members 7. Code chart is stocked with needed, easily accessible items. 8. Physician is notified. 9. Family is notified. 10. CPR is not stopped unless EMS arrives and takes over. 11. History/Paperwork is provided to EMS upon arrival. 12. Code procedure turned over to EMS as appropriate. 13. Appropriate transfer forms completed and give to EMS. Facility immediate actions to remove the Immediate Jeopardy included: On [DATE]th 2023, DON was informed that a resident had coded and CPR was ceased and restarted prior to EMS arrival. The Center has taken the following steps to ensure the safety of our residents who are at risk for Advance directive related to CPR and Code status compliance. Resident family was notified of outcome of CPR attempt at approximately 1:15 am on [DATE]th 2023 Physician notified of incident - At approximately 1:15 am on [DATE]th 2023 Administrator, DON, Nurse manager notified of incident and reported to facility on [DATE]th 2023 All residents in facility were audited for advance directives preferences to ensure accuracy, 100% on [DATE]th 2023 Facility-initiated code blue drill on [DATE]th 2023 105140 Page 11 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 All chart locations were audited to ensure in proper location on [DATE]th 2023 100% complete. Level of Harm - Immediate jeopardy to resident health or safety CPR competency plus competency quiz and proper identification of code status for resident via chart, and EHR (Electronic Health Record) and resident photo in EHR for all staff initiated on [DATE]. [DATE] - 75% complete Residents Affected - Few [DATE] - 90% complete [DATE] - 95% complete [DATE] -100% complete No employee will be permitted to work until they have completed in-services and competencies(nursing). Staff contacted via phone on [DATE] to contact facility for training prior to returning to work. DON or designee will be completing work on completion of training with competencies. This issue was taken to Quality Assurance Performance Improvement (QAPI) at an ad-hoc (when necessary) meeting on [DATE] to discuss the event and necessary adequate follow up. QAPI meeting discussed CPR Policy & Procedures, Education, Chart locations and disaster drills. Daily review of new admissions for code status and any code status change request will be completed by Nurse Management and Social Services for any concerns so that corrective actions can be identified/implemented as appropriate. CPR Drills completed at facility on [DATE] and will be on-going weekly for 1 month and biweekly for 1 month, then quarterly on all shifts. This Administrator is responsible for oversight of this plan. Verification of the facility's removal plan was conducted by the survey team on [DATE]. The Regional Nurse and the Administrator provided the State Survey team with documentation showing records of the facility actions to remove the immediacy: Bristol CPR Incident [DATE] Timeline included witness statements and five-day follow-up Audit conducted of all Resident code statuses, matching care plan and charts. Nurse CPR Certification Audit with all active CPR cards available CPR Policy QAPI Ad Hoc Meeting Minutes with CPR Policy In-Service Attendance Record with CPR Competency Quizzes Interviews were conducted with 47 Staff, 16 licensed nurses, 23 CNAs and 8 other staff. The staff members were able to state that they had been trained and were knowledgeable about the facility CPR 105140 Page 12 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0678 policy. Level of Harm - Immediate jeopardy to resident health or safety Based on verification of the facility's removal plan the immediate jeopardy was determined to be removed on [DATE] and the non-compliance was reduced to a scope and severity of D. Residents Affected - Few 105140 Page 13 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

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 observation, interviews, and record review the facility did not ensure proper diabetes management for three residents (#5, #6) out of four residents reviewed for diabetes care. Residents Affected - Some Findings included: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus without complications. A review of the resident's physician orders revealed an order for the blood test Hemoglobin A1C every three months on the 15th of the month with the start date of 02/15/2023. The resident's medications for her diagnosis of diabetes included: Bydureon Pen-Injector 2 mg subcutaneously once a day every Friday; Trulicity solution pen-injector 1.5 mg/0.5 ml, inject 1.5 mg subcutaneously one time a day every Thursday; Humalog solution 100 unit/ml, inject as per sliding scale, with the instruction to notify the doctor if the blood glucose was over 450; and insulin glargine 100 unit/ml, inject 35 units subcutaneously two times a day. A review of the Medication Administration Record (MAR) for April revealed the order for the Hemoglobin A1c had been noted on the MAR, however there were no results for the test found in the resident's medical record. A review of labs for Resident #6 revealed the last test for Hemoglobin A1c was on 10/10/2022 and the result was 11.9. According to the Mayo Clinic the Hemoglobin A1c test is a common blood test used to diagnose type 1 and type 2 diabetes. The test is used to monitor how well blood sugar levels are being managed. A Hemoglobin A1C level of less than 7% is a common treatment target with results of greater than 7% indicating poor blood sugar management. A review of the MAR for blood glucose values obtained three times a day (prior to meals) revealed 11 blood glucose tests were over 400 but under 451 so the physician did not need to be notified, according to the physician's order. The resident's blood glucose results before breakfast in April ranged from 128 to 450; her results before lunch in April ranged from 179 to 450; and her results before dinner in April ranged from 119 to 446. An interview was conducted with the Assistant Director of Nurses on 05/03/2023 beginning at 3:30 p.m. When reviewing the blood glucose values documented prior to the resident's meals, she confirmed that the values were high. She also confirmed that there were no results for the hemoglobin A1c noted in the MAR and she would have to look into why the test was not obtained. An interview was conducted with the resident's physician on 05/02/2023 beginning at 11:50 a.m. The physician confirmed that the goal for a resident with diabetes is to control their blood glucose. The physician confirmed after looking at the resident's medical record that she had two injectables ordered and two additional orders for insulin, one based on an accucheck and sliding scale. After reviewing the resident's blood glucose values, he concluded that her blood glucose was not in control. 105140 Page 14 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some He reviewed the labs and didn't find a recent hemoglobin A1c. He confirmed he wrote an order for the hemoglobin A1c to be done every three months with the start date of 02/15/2023. The care plan for Resident #6 was reviewed and noted to include a Focus area for diabetes with the potential for hypo/hyperglycemic reactions, dated 10/13/2014. The Goal had a target date of 06/19/2023 and the plan was to minimize the risks of the resident's hypo/hyperglycemic episodes. Interventions included accuchecks as ordered/indicated; administer medications/insulin as ordered; labs/diagnostics per order, notify MD of results as indicated; observe blood glucose/accu checks as ordered. 2. Resident # 5 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene, left below knee amputation, amputation of right forefoot and a right medial ankle ulcer, stage 4. A review of the resident's medications revealed several medications for the treatment of diabetes: Insulin Glargine Subcutaneous Solution 100 unit/ml, inject 45 units subcutaneously at bedtime for DM2 (Diabetes mellitus type 2); Januvia oral tablet 50 mg, give 50 mg by mouth one time a day related to diabetes mellitus; novolog flexpen subcutaneously solution pen-injector 100 unit/ml, inject 22 units subcutaneously before meals related to diabetes mellitus due to underlying condition with diabetic neuropathy, hold for blood sugar less than 150. A Review of the April Medication Administration Record (MAR) revealed the order for the Novolog, 20 units before meals, hold for blood sugar less than 150 was not followed for 5 of the 90 opportunities. Five of the 30 results of the resident's blood glucose obtained at 6:30 a.m. were less than 150, with only one following the physician's order of holding the insulin. On 04/11/2023, the 6:30 a.m. the resident's blood glucose was 144 and the nurse initialed that the insulin was given. On 04/15/2023 at 6:30 a.m. the resident's blood glucose was 141 and the nurse initialed giving the insulin. On 04/17/2023 at 6:30 a.m. the resident's blood glucose was 146. On 04/18/23 at 6:30 a.m. the resident's blood glucose was 142 and the nurse initialed that the insulin was given. One nurse's note documented the insulin was held at 5:11 a.m. on 04/2/23 due to the blood glucose falling below 150. A review of the resident's care plan revealed Focus area of the risk for complications related to the diagnosis of diabetes mellitus with an intervention to administer oral medications and/or insulin per the physician's orders. An interview was conducted with Resident #5 on 05/01/2023 beginning at 2:10 p.m. in his room. He reported he was ok, but his right foot hurt, and he was concerned that what happened to his left leg may happen to his right leg. 105140 Page 15 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility did not ensure follow up neurological checks were completed after falls for nine (#2, #4, #11, #12, #13, #14, #15, #16, #18) out of eleven residents sampled for falls in the month of April. Findings included: A review of the facility's Neurological Evaluation form showed the following instructions: This form should be completed for any unwitnessed fall or other accident/injury with possible head trauma, or when indicated by the resident's condition. The physician should be notified of any neurological change that requires further evaluation. This evaluation should be completed every 15 minutes x 4, then every 30 minutes x 4, then every 1 hour x 4, then every 4 hours x 4, then every 8 hours x 4. This totals 20 neurological (neuro) checks over three days post fall. 1. A review of admission records showed Resident #2 was admitted on [DATE]. A review of Resident #2's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 13, showing she was cognitively intact. Section G, Functional Status, showed she ate independently with set-up help only and for locomotion she needed limited assistance/one-person physical assist. A review of medical records for Resident #2 showed the following progress note, dated 4/13/23 at 4:00 a.m., written by Staff J, LPN: This writer called to room [#] observed resident sitting on the floor next to her bed, resident stated that she thinks she slipped out of bed but is unsure, resident denies pain, observed for injuries none noted. Resident vital signs stable able to move all extremities staff assisted resident back to bed, left message for daughter. Awaiting call back from MD. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 5/2/23 at 2:23 p.m. She stated she had Resident #2 on 4/13/23 at 4:00 a.m. when she had her fall. She said at 4:00 a.m. the resident was found sitting at her bedside. She said the resident was trying to get a drink and told them she was thirsty. She said she called the supervisor, Staff B, Registered Nurse (RN), over to look at the resident since she was very familiar with her. Staff J, LPN said the resident denied any pain. She said Resident #2 did have a ginger ale and Gatorade and drank some of those. She also had yogurt or apple sauce. A review of Resident #2's Neurological Evaluation form showed the resident was assessed from 4:00 a.m. until 7:00 a.m. per instructions. The resident's neurological check was not completed at 8:00 a.m. as needed. At 9:00 a.m. the resident was sent out to the hospital for a low blood glucose reading. 2. A review of medical records for Resident #4 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness. A progress note, dated 2/17/23 at 7:01 a.m., revealed Resident #4 was observed on the floor in her room near the bathroom. A progress note, dated 2/17/23 at 9:16 a.m., showed the Interdisciplinary Team reviewed the fall. The resident told them she was going to the bathroom and lost her balance. The resident told them she had pain in both knees and her right him. X-rays were ordered. A review of the Neurological Evaluation form, dated 2/17/23 at 1:45 a.m., showed neuro check #11 due on 2/17/23 at 7:30 105140 Page 16 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a.m. through neuro check #16 due on 2/18/23 at 12:30 a.m. were all signed off by the ADON. This covered a 17-hour spread. Neuro check #18, due on 2/18/23 at 8:30 a.m., through neuro check #20, due at 2/19/23 at 12:30 a.m., were also signed of by the ADON. This covered a 16-hour spread. Neuro checks #11-#20 were not signed off until 2/27/23. 3. A review of medical records for Resident #11 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness. A progress note, dated 4/7/23 at 4:32 a.m., revealed Resident #11 was found sitting on the floor at 3:00 a.m. Her body and head was leaning outside the bathroom door, her legs were stretched out with both hands on top of her lap. No complaints or signs of pain. A review of the Neurological Evaluation form, dated 4/7/23 at 4:16 a.m., showed neuro checks #10-20 were all signed off on 4/9/23 by the same staff member, Staff H, Registered Nurse (RN)/UM. The first neuro check Staff H signed off was for 4/7/23 at 7:45 a.m. and the last neuro check Staff H signed off was on 4/9/23 at 9:45 a.m., a 50-hour time frame. An interview was conducted on 5/3/23 at 12:45 p.m. with Staff H, RN/UM. He confirmed he did not work for 48 hours straight on 4/7-4/9/23. He said he was told by the Assistant Director of Nursing (ADON) and the DON to close up the evaluations. When asked what closing them up entails, he said it means he had to do the documentation even though he wasn't there. Staff H, RN/UM stated he felt pressured from his supervisors and felt like he had to do what he was told. 4. A review of medical records for Resident #12 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness and a history of falls. A progress note dated 4/23/23 at 9:49 a.m. revealed Resident #12 was found on the mat in her room at approximately 9:15 a.m. She was discovered on the right side of the bed with her back against the bed and buttocks on the mat. A review of the Neurological Evaluation form, dated 4/23/23, showed neuro checks were completed on 4/23 and 4/24/23. No checks were completed on 4/25/23 as needed per the evaluation form instructions. A change of condition for Resident #12 was documented on 4/28/23 related to a fall. The note showed the resident was lying supine (face up) on floor mat and floor. She was assessed to have an abrasion on her lower leg. She was assisted back to bed and neuro checks were started. A review of the Neurological Evaluation, dated 4/28/23, showed only 16 out of 20 neuro checks were completed. 5. A review of medical records for Resident #13 showed he was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to diagnosis of Parkinson's, and generalized weakness. The care plan showed the resident had falls on 4/4 and 4/27/23. The Neurological Evaluation form, dated 4/27/23 at 6:40 p.m., was reviewed. The form showed no neuro checks were signed off on 4/27/23 and 16 neuro checks were all signed off on 4/28/23. No neuro checks were signed off as completed on 4/27/23 or 4/29/23. Only 16 out of 20 neuro checks were completed. 6. A review of medical records for Resident #14 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness with a previous fall on 3/5/23. A progress note, dated 4/13/23, revealed the resident was observed sitting on the floor of her room with her back to the bed. The resident was unable to recall how she got to the floor but was able to verbalize that she had no pain. No injuries were noted, resident was assisted back to bed. A review of the Neurological Evaluation form, dated 4/13/23, showed neuro checks were completed for the first 7 hours. A total of 12 out of 20 neuro checks were completed. 105140 Page 17 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. A review of medical records for Resident #15 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness and history of falls. A progress note, dated 4/15/23, revealed the resident sat in a dining room chair and the chair went backwards and she fell on the floor. No injuries were noted. A review of the Neurological Evaluation form, dated 4/13/23, showed neuro checks were completed for the first six hours on 4/15/23. The next three neuro checks were signed off by Staff O, LPN/UM four days later on 4/19/23. Only 14 out of 20 neuro checks were signed off in total. A progress note on 4/27/23 showed Resident #15 slid out of her chair while trying to move the chair. The resident did not show any signs of pain. A review of the Neurological Evaluation from, dated 4/27/23, showed neuro checks were completed for the first seven hours on 4/27/23. No further neuro checks were signed off. A total of 12 out of 20 neuro checks were completed. 8. A review of medical records for Resident #16 showed he was admitted on [DATE] and was care planned for begin at risk for falls and/or fall related injury related to generalized weakness and a history of falls on 4/22 and 4/26/23. A progress note, dated 4/29/23 at 2:57 p.m., revealed the CNA altered the nurse that the resident was found on the floor. When the nurse arrived the resident was in bed and had a reopened abrasion on his right lower extremity. Resident was assessed for further injury and first aid was administered. Neurological checks were initiated. A review of the Neurological Evaluation form, dated 4/29/23, showed the first neuro check was done at 3:02 p.m. and no further neuro checks were signed off. A total of 1 out of 20 neuro checks were completed. 9. A review of medical records for Resident #18 showed he was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness. A progress note, dated 4/28/23, revealed the resident was observed on the floor by another resident. A head to toe evaluation was done with no injuries noted. Neuro checks were started. The Neurological Evaluation form, dated 4/28/23, showed neuro checks were completed for the first seven hours on 4/29/23 and no further neuro checks were signed off. A total of 12 out of 20 neuro checks were completed. An interview was conducted on 5/3/23 at 2:51 p.m. with Staff O, LPN/UM. She stated neuro checks are completed for 3 days after a resident has a fall. Staff O, LPN/UM stated notes or assessments should be locked when they are done and if they are unlocked staff are asked to go back and lock them or the managers will lock them. An interview was conducted on 5/3/23 at 3:20 p.m. with the ADON. She stated any fall that is unwitnessed or a fall when a resident hits their head is cause for automatic neuro checks. The ADON said neuro checks continue for 72 hours after a fall. She said falls are reviewed every day at the morning meeting and the unit managers make sure neuro checks are being done. The ADON said she had not noticed any issues with neuro checks being completed. She said she only signs off things for her residents that she has done. A facility policy titled Falls-Clinical Protocol, revised March 2018, was reviewed. The policy showed the following: Monitoring and Follow-Up 1. The staff, with the physician's guidance, will follow up on any fall with associated injury 105140 Page 18 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0689 Level of Harm - Minimal harm or potential for actual harm until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematoma or other intracranial bleeding could occur up to several weeks after a fall. Residents Affected - Some 105140 Page 19 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to post an updated daily nurse staffing data form for one day (05/01/23) of five days observed. The posting observed was dated 4/27/23. Residents Affected - Some Findings included: An observation on 05/01/23 at 9:00 a.m., showed the facility's Daily Nurse Staffing Posting Form titled, Report of Nursing Staff Directly Responsible for Patient Care was displayed at the front desk area and dated 04/27/23. Photogenic evidence obtained. An observation on 05/01/23 at 11:00 a.m. showed the facility's Daily Nurse Staffing Posting Form titled, Report of Nursing Staff Directly Responsible for Patient Care was displayed at the front desk area and dated 04/27/23. An additional observation on 05/01/23 at 12:20 p.m. showed the facility's Daily Nurse Staffing Posting Form titled, Report of Nursing Staff Directly Responsible for Patient Care displayed at the front desk area, was dated Thursday 04/27/23. During an interview, on 05/01/23 at 12:20 PM, Regional Registered Nurse (RN) confirmed the facility's daily nurse staffing posting form was outdated and took the posting down to have it updated. 105140 Page 20 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, interviews and policy review the facility did not ensure medications were stored properly in four out of five medication carts audited, three treatment carts, and three out of five medication storage rooms. Findings included: An observation was conducted on 4/26/23 at 10:30 a.m. of a medication storage room on the Southwest Unit. The storage room was unlocked with medications inside including Aspirin, Vancomycin, Miralax, stool softener, and 0.9% Sodium Chloride fluid bags. The medication refrigerator had no lock and contained Veltassa, three insulin pens, and Trulicity injections. The narcotic box was not attached to the refrigerator but contained no narcotics at that time. This medication storage room remained unlocked at 12:00 p.m. on 4/26/23. (Photographic evidence obtained.) An observation was conducted on 4/26/23 at 10:32 a.m. of a treatment cart on the Southwest Unit that was unlocked with prescription medication inside. No nursing staff were in sight of the cart. (Photographic evidence obtained.) The Southeast Unit medication storage room was audited with Staff P, Licensed Practical Nurse (LPN) on 4/26/23 at 11:59 a.m. The narcotic box inside the refrigerator was unlocked with narcotics inside. Staff P, LPN said the box should be locked and usually is, but sometimes the lock gets too cold and doesn't work right. (Photographic evidence obtained.) The Central Unit medication storage room was audited with Staff Q, LPN on 4/26/23 at 12:36 p.m. The refrigerator contained Hydrocortisone Acetate 25mg suppositories that expired February 2023. Staff Q, LPN confirmed the medication was expired and said the rooms are often cleaned out of expired medications. (Photographic evidence obtained.) An interview was conducted on 4/26/23 at 12:21 p.m. with the Director of Nursing (DON.) The DON stated the medication storage room should always be locked. She said the unit managers should be going through the medication rooms and taking out expired medication at least once a week. She stated she was going to see why the medication storage room had been unlocked. An interview was conducted on 4/26/23 at 12:36 p.m. with Staff O, LPN/Unit Manager (UM.) Staff O, LPN/UM confirmed she is the UM for the Southwest Unit. She said the medication storage room is usually locked but she thinks someone on night shift unlocked the door from the back, so they didn't have to put the code in. She said no one had been in the medication storage room yet today but she usually checks to make sure it is locked. An observation was conducted on 4/26/23 at 1:25 p.m. on the Northeast Unit. There was a treatment cart sitting in the corner of the common area, unlocked with prescription medication inside. Five residents were nearby. On 4/27/23 at 11:02 a.m. this same cart was observed to be unlocked again. (Photographic evidence obtained.) On 4/26/23 at 1:35 p.m. an audit was completed of a medication cart on the Northeast Unit. The cart contained a bottle Vitamin E that expired 3/2023. The drawers of the cart had debris in them. There 105140 Page 21 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0761 were a total of 14 loose pills found in the drawers of the medication cart. (Photographic evidence obtained.) Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff L, LPN. On 4/26/23 at 1:40 p.m. He stated medication carts are cleaned on night shift. Residents Affected - Some On 4/26/23 at 1:49 p.m. an audit was completed of a medication cart on the Northwest Unit. The cart contained a lighter, jewelry, nail clippers, a key, a pen, a cell phone, and cigarettes being stored with resident medications. The bottom drawer had a sticky substance that had spilled under the medication bottles. There was a total of 19 loose pills in the drawers of the medication cart. (Photographic evidence obtained.) On 4/26/23 at 2:08 p.m. an audit was completed of a medication cart on the Southeast Unit. The cart contained a screwdriver, a pencil, a screw, a lighter, a hearing aid, and a plastic bag with money being stored with resident medications. There was a total of 6 loose pills in the drawers of the medication cart. (Photographic evidence obtained.) An interview was conducted with Staff P, LPN on 4/26/23 at 2:10 p.m. She stated she did not know why the miscellaneous items were in the medication cart on the Southeast Unit. She said there should not be any loose pills in the cart. On 4/26/23 at 2:17 p.m. an audit was completed of a medication cart on the Southwest Unit. There were a total of 4 loose pills in the drawers of the medication cart. (Photographic evidence obtained.) On 5/3/23 at 12:40 p.m. an observation was made on the Northwest Unit. A treatment cart in the hall was unlocked with prescription medication inside. Residents were in the hallway and no nursing staff were in sight. (Photographic evidence obtained.) A follow-up interview was conducted on 5/5/23 at 4:00 p.m. with the DON. She confirmed all medication carts, treatment carts, and medication storage rooms should be locked when a nurse is not using them. She said there should not be loose pills in the medication carts. The DON said they just got new medication carts a couple of months ago. A facility policy titled Storage of Medications, revised November 2020, was reviewed. The policy stated the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked area, under proper temperature, light and humidity controls. Only persons authorized to order, store, manage, prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Over the Counter medications or supplies handled by authorized facility personnel are discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy, or source or destroy. 105140 Page 22 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 8. Schedule II-V controlled medications are stored in a separately locked, permanently affixed compartments. Access to controlled medications is separate from access to non-controlled medications. 105140 Page 23 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 4. Resident #10 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis. The resident had a colostomy present upon admission. A review of a PRN (as needed) Skin Check form with the effective date of 04/13/2023 revealed the presence of the colostomy at the right iliac crest (front). The document was signed on 04/13/2023 by the nurse. The form included no other information about the colostomy or the appearance of the resident's skin. Continued record review revealed a Weekly Skin Check assessment with the effective date of 04/14/2023. The Skin Check documented under #2. Skin Check Observations, A1 Does the resident have NEW skin impairments that have not been previously noted? The answer was Yes, with the site identified as Abdomen and the Description: redness to abdomen with ostomy in place, present on admission. The document was signed by the nurse on 04/24/2023. A Progress note written by an Advanced Practice Registered Nurse (APRN), dated 04/19/2023, identified the visit reason as Comprehensive skin and wound evaluation for new admission to facility. A ROS (review of systems) included Skin with the comment, Patient reports no rashes or known dermatologic conditions at the time of the exam. Under the section Wounds, the documentation showed: There are no open wounds on today's comprehensive skin examination. Fungal rash to bilateral buttocks. Thick toenails. Neither the assessment nor the plan of care addressed the reddened area at the colostomy site. The resident was sent to the hospital on [DATE] after sustaining a fall at the facility. During the hospital stay, the facility was notified of the hospital's concern related to a reddened area on the resident's abdomen around the colostomy site. An interview was conducted on 05/04/2023 beginning at 1:50 p.m. with the APRN who had conducted the new admission assessment of Resident #10 on 04/19/2023. During the interview, the APRN reported that she assesses the skin of all new admissions but the assessment is based on information the facility provides. She reported that she had not been made aware on 04/19/2023 of the resident's reddened skin around his colostomy site and had not observed the area. An interview was conducted with the resident and his nurse on 05/03/2023 at 1:05 p.m. When asked about the colostomy site, the resident reported that the reddened area had been present for awhile and it wasn't painful to him. He agreed to an observation of his abdomen and the colostomy site. The area was a rectangle approximately 6 long and 4 wide with his colostomy dressing and site in the middle of the rectangle. The area was red, with rough-looking skin, but without any open or weeping areas. The nurse who was present reported that the area was present on admission, that he reported it wasn't painful, and he was not able to say how it had gotten so red. An admission Minimum Data Assessment was completed on 04/19/2023 which identified the resident's Brief Interview for Mental Status (BIMS) as a 6, indicating the resident's cognition as severely impaired. 105140 Page 24 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A facility policy titled Charting and Documentation, revised July 2017, was reviewed. The policy stated the following: Policy statement Services provided to the resident, progress toward the care plan goals, or changes in the resident's medical, physical, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response of care. Policy Interpretation and Implementation 1. Documentation in the medical record may be electronic, manual, and or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations b. Medication Administration c. Treatments or services provided d. Changes in the resident's condition e. Events, incidents or accidents involving the resident f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Based on record review, interviews, and policy review facility failed to maintain complete and accurate documentation for four residents ( #4, #11, #15, #10) out of eighteen sampled residents. Findings included: 1. A review of medical records for Resident #4 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness. A progress note, dated 2/17/23 at 7:01 a.m., revealed Resident #4 was observed on the floor in her room near the bathroom. A progress note, dated 2/17/23 at 9:16 a.m., showed the Interdisciplinary Team reviewed the fall. The resident told them she was going to the bathroom and lost her balance. The resident told them she had pain in both knees and her right hip. X-rays were ordered. A review of Resident #4's Neurological (neuro) Evaluation form, dated 2/17/23 at 1:45 a.m., showed neuro check #11 due on 2/17/23 at 7:30 a.m. through neuro check #16 due on 2/18/23 at 12:30 a.m. were all signed off by the Assistant Director of Nursing (ADON.) This covered a 17-hour period. Neuro check #18, due on 2/18/23 at 8:30 a.m., through neuro check #20, due at 2/19/23 at 12:30 a.m., were also signed of by the ADON. This covered a 16 hour spread. Neuro checks #11-#20 were not signed off until 2/27/23. 105140 Page 25 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted on 5/3/23 at 3:20 p.m. with the ADON. When asked about signing off neuro checks for Resident #4 for 17 hours straight then again for 16 hours straight she said, I think I just signed and locked it, it was already done. The ADON later added, I only sign off for ones that I have if I work the cart. She confirmed she did not work all of the hours during the times the neuro checks were signed off. 2. A review of medical records for Resident #11 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness. A progress note, dated 4/7/23 at 4:32 a.m., revealed Resident #11 was found sitting on the floor at 3:00 a.m. Her body and head were leaning outside the bathroom door, her legs were stretched out with both hands on top of her lap. No complaints or signs of pain. A review of the Neurological Evaluation form, dated 4/7/23 at 4:16 a.m., showed neuro checks #10-20 were all signed off on 4/9/23 by the same staff member, Staff H, Registered Nurse (RN)/UM. The first neuro check Staff H signed off was for 4/7/23 at 7:45 a.m. and the last neuro check Staff H signed off was on 4/9/23 at 9:45 a.m., a 50-hour time frame. An interview was conducted on 5/3/23 at 12:45 p.m. with Staff H, RN/UM. He confirmed he did not work for 48-50 hours straight on 4/7-4/9/23. He said he was told by the ADON and DON to close up the evaluations. When asked what closing them up entailed, he said it means he had to do the documentation even though he wasn't there. Staff H, RN/UM stated he felt pressured from his supervisors and felt like he had to do what he was told. 3. A review of medical records for Resident #15 showed she was admitted on [DATE] and was care planned for being at risk for falls and/or fall related injury related to generalized weakness and history of falls. A progress note, dated 4/15/23, revealed the resident sat in a dining room chair and the chair went backwards and she fell on the floor. No injuries were noted. A review of the Neurological Evaluation form, dated 4/13/23, showed neuro checks were completed for the first six hours on 4/15/23. The next three neuro checks were signed off by Staff O, LPN/UM four days later on 4/19/23. Only 14 out of 20 neuro checks were signed off in total. A progress note on 4/27/23 showed Resident #15 slid out of her chair while trying to move the chair. The resident did not show any signs of pain. A review of the Neurological Evaluation from, dated 4/27/23, showed neuro checks were completed for the first seven hours on 4/27/23. No further neuro checks were signed off. A total of 12 out of 20 neuro checks were completed. An interview was conducted with Staff M, LPN on 4/26/23 at 1:05 p.m. She stated she was a Unit Manger at the facility recently. She said she was not allowed to write true to form. She said the DON would have staff put notes in as drafts and she would read them and tell you to change them if she didn't like what you wrote. Staff M, LPN said the DON and ADON would tell unit managers to sign off documentation that they did not do or where not in the building for, like neurological checks or other assessments. She said she left because she was not going to risk her license and she told them she would not sign off things she did not do. An interview was conducted with the DON on 5/5/23 at 3:55 p.m. She stated the expectation is documentation should be completed each shift. She said she reviews documentation and records daily. The DON said she had not noticed any issues with things being signed off at times a staff member was not working. She said you can not sign something you weren't working for. The DON said she has never asked anyone to sign off something they didn't do. An interview was conducted on 5/5/23 at 4:02 p.m. with the Nursing Home Administrator (NHA.) He 105140 Page 26 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0842 stated he would expect staff to be signing off on documentation on the shift they work, and they should not sign off for things they didn't do. He said he had not heard any issues with this happening. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 105140 Page 27 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a complaint survey that was conducted 4/26/23 thru 5/5/23 and was cited F684 and F761. From 6/26/23 thru 6/28/23 a revisit survey was conducted, and the facility was recited F684 and F761. The Findings included: The facility developed a plan of correction that included: Unit Manager and or designee audited facility resident records with a diagnoses of type II diabetes mellitus to ensure physician orders are followed according to facility policy for Diabetes Management. The facility developed a plan of correction that included: DON and or designee to review this process during the facility clinical management meeting to ensure proper diabetes management. DON and or designee to perform weekly audits of resident records with diagnosis of type 2 diabetes to ensure proper management of diabetes and physician orders are followed for 4 weeks and monthly thereafter. Results of the audit to be presented to the facility monthly QAPI committee meeting for review and for continued compliance. During the revisit survey conducted 6/26/23 thru 6/28/23 the facility failed to ensure that three (#116, #5, and #6) of three residents sampled for Diabetes Management received diabetic medications as ordered by the physician. An interview was conducted on 6/26/23 at 11:59 a.m. with Staff N, Licensed Practical Nurse (LPN) on the Northwest wing. Staff N reported not knowing if any blood glucose levels were to be done or not, I didn't prioritize them for that and added that 9:00 a.m. medications were still being administered. The staff member reported having 30 residents and that going fast caused mistakes. A review of Resident #116's admission Record identified an admission date of 5/12/23 and included diagnoses of unspecified Type 2 Diabetes mellitus with diabetic neuropathy, end stage renal disease, dependence on renal dialysis, and unspecified hypoglycemia. Staff N stated, on 6/26/23 at 12:54 p.m., that Resident #116 was supposed to get insulin at 11:30 a.m. but had not gotten 9:00 a.m. medications either. An observation was made on 6/26/23 at 1:00 p.m. with Staff N, Licensed Practical Nurse (LPN) of a lunch tray sitting on the over bed table of Resident #116. The resident was not in the room. The staff member confirmed that a couple bites of the meat and the entire cup of mixed fruit had been eaten. The review of Resident #116's Order Summary Report indicated that the resident was to be administered Novolog (Insulin Aspart) per a sliding scale before meals related to unspecified Type 2 Diabetes mellitus with diabetic neuropathy. The Medication Administration Record for the resident identified a blood glucose level of 229 and had received 4 unit of Novolog. The MAR indicated that the residents before lunch blood glucose level was below 200, 16 times out of 20 opportunities. 105140 Page 28 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/27/23 at 4:40 p.m. the Regional Nurse Consultant (RNC) reviewed the times that Resident #116 had received the 11:30 a.m. dose of Novolog and stated that it had been given at 1:38 p.m. The admission Record for Resident #5 indicated a recent admission date of 2/7/23 and included diagnoses not limited to Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, acquired absence of other right toe(s), and acquired absence of left leg below knee. Resident #5 was observed at 10:41 a.m. on 6/27/23 lying in bed with eyes closed. A review of Resident #5's June 2023 Medication Administration Record (MAR), the Blood Sugar summary, and progress notes, identified the following medications and related to the resident's diagnosis of Type 2 diabetes mellitus (DM): - Novolog FlexPen subcutaneous solution pen-injector 100 unit/mL - Inject 25 unit subcutaneously before meals related to DM due to underlying condition with unspecified diabetic neuropathy, *** Hold if blood sugar less than 140**. The order was dated 6/3/23 and discontinued on 6/8/23. The MAR indicated that staff had administered insulin on 6/6/23 for a BG (Blood Glucose) level of 121. - Novolog FlexPen subcutaneous solution pen-injector 100 unit/mL. Inject 25 unit subcutaneously two times a day related to DM due to underlying condition with unspecified diabetic neuropathy, **Before breakfast and lunch, *** HOLD for blood sugar less than 140***, started 6/8 and discontinued on 6/15/23. The MAR identified that insulin was administered however no blood glucose levels were documented. The Blood Sugar summary for the period between 6/8 to 6/15/23 did not include blood glucose levels for the period of breakfast and lunch. - Novolog FlexPen subcutaneous solution pen-injector 100 unit/mL - Inject 28 unit subcutaneously one time a day related to DM due to underlying condition with unspecified diabetic neuropathy, ** Before dinner *** Hold if blood sugar less than 140**, ordered 6/8/23 and discontinued 6/15/23. The MAR indicated that insulin was administered (except for 6/11) and did not identify any BG levels. The Blood Sugar summary did not include before dinner blood glucose levels. - Novolog FlexPen subcutaneous solution pen-injector 100 unit/mL - Inject 28 unit subcutaneously two times a day related to DM due to underlying condition with unspecified diabetic neuropathy, ***Before breakfast and lunch, *** Hold if blood sugar less than 140**. The MAR indicated staff had administered insulin for a blood glucose (BG) of 88 at 8:00 a.m. on 6/16/23, a BG level of 85 on 6/16/23 at 12:30 p.m., a BG level of 127 on 6/18/23, and for a BG level of 131 on 6/24/23. - Novolog FlexPen subcutaneous solution pen-injector 100 unit/mL - Inject 30 unit subcutaneously one time a day related to DM due to underlying condition with unspecified diabetic neuropathy, ** Before dinner *** Hold if blood sugar less than 140**, ordered 6/15/23. The MAR indicated staff administered insulin for a BG level of 133 on 6/20/2023, a level of 139 on 6/22/2023, and 131 on 6/25/23. - Ozempic (0.25 or 0.5 mg/dose) subcutaneous solution pen-injector 2 mg/1.5 mL - inject 0.25 mg subcutaneously one time a day every Thursday (Thu) related to DM due to underlying condition with unspecified diabetic neuropathy. The MAR indicated this medication was not administered on 6/13 or 6/22/23. A progress note dated 6/1/23, indicated the medication was on order and a note dated 6/22/23 indicated that a new pen ordered but did not reveal that the physician had been notified that the medication was not available. 105140 Page 29 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0867 Level of Harm - Minimal harm or potential for actual harm On 6/26/23 at 4:40 p.m., during an interview with the Regional Nurse Consultant (RNC), she said facility had done (staff) education regarding watching the parameters when doing diabetic medications. The admission Record for Resident #6 indicated that the resident was admitted on [DATE] and included a diagnosis not limited to Type 2 Diabetes mellitus without complications. Residents Affected - Some The June 2023 Medication Administration Record (MAR) for Resident #6 included an order for Bydureon Pen-injector 2 mg (Exenatide Extended Release (ER) - Inject 2 mg subcutaneously one time a day every Friday (Fri) related to Type 2 Diabetes mellitus without complications. The order was dated 6/5/20. The MAR indicated the medication was not administered on 6/16 or 6/23/23. The progress notes dated 6/16 and 6/23/23, did not include the reason Resident #6 did not receive the medication, Bydureon, nor that the physician was notified the medication was not administered. During an interview at 4:40 p.m. on 6/27/23 the Regional Nurse Consultant stated that if a medication was not available, staff were to call the physician and get an order, call the physician to ask to hold (the medication) till it arrived or to give something else. On 6/27/23 at 4:40 p.m., the Regional Nurse Consultant reported the facility had done education regarding watching the parameters when doing diabetic medications, that residents (with diagnosis of Diabetes) had labs for A1C, and the RNC did an audit regarding parameters for Glucagon. The RNC stated if a medication was not available, staff were to call the physician and get an order to hold till the medication arrived or something else. The RNC reported giving a list to the interim Director of Nursing (DON) to look at and make sure that parameters were in the orders. A review of audits included with the Plan of Correction identified that Resident #6 was audited the week of 6/5/23. The facility developed a plan of correction that included: On 4/26/23 facility medication carts and treatments carts checked by DON and medications were properly stored and secured. On 4/26/23 Unit Manger and or designee performed an audit of the facility medication storage areas to ensure medications were properly stored and secured. Unit Mangers and or designee to review to this process during facility clinical management meeting to ensure proper storage of drugs and biologicals. The Assistant Director of Nurses (ADON) and/or designee educated facility licensed nurses as it related to the facility policy for Storage of Medications; education to be completed by 6/5/23. DON and or designee to perform random weekly audits of facility medication storage rooms and carts to ensure compliance for 4 weeks and monthly thereafter Results of the audit to be presented to the facility monthly QAPI committee meeting for review and for continued compliance. During the revisit survey conducted 6/26/23 through 6/28/23 the facility failed to ensure that medications and biologicals were stored in an orderly and appropriate manner in five out of seven sampled medication carts and in one of three observed medication rooms. An observation was conducted at 11:02 a.m. on 6/28/23 with Staff F, LPN/Unit Manager, of the refrigerator in the medication room of the NW unit. The refrigerator was cluttered with labeled and unlabeled packages of medications. The medication inside the refrigerator was not organized. The staff member confirmed the findings. On 6/28/23 at 10:36 a.m., a review of the NE Team 1 medication cart was conducted with Staff I, Licensed Practical Nurse (LPN). An opened vial of Lantus was in an orange medication bottle, neither the bottle or vial were labeled with an open date. Both the bottle and vial had areas to document the 105140 Page 30 of 31 105140 05/05/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0867 Date opened. Staff I confirmed the findings. Level of Harm - Minimal harm or potential for actual harm On 6/28/23 at 10:42 a.m., an observation was conducted with Staff J, LPN, of the NW Team 1 medication cart. The observation identified 3 pharmacy labeled bags containing one insulin pen each were rubber banded together, neither the bags or the pens were dated as opened, the labels were very worn and each of bags were labeled to refrigerate. The staff member stated that the 3 pens were not opened. The cart contained another insulin pen that was identified as unopened and was labeled to refrigerate. An unopened bottle of Humalog was observed in the cart, the medication bottle instructed to REFRIGERATE. A vial of Levemir was dated as opened on 5/30/23 and the plastic medication bottle that it was contained in indicated that EXPIRATION DATE 5/28/23. The bottom drawer contained a container of bleach wipes and a bottle of hand sanitizer stored in the same compartment with a bottle of liquid medication, another container of bleach wipes was stored in the same compartment with inhalation and oral medications. Staff J reported not working that hall and the girl keeps them like that (rubber banded together) must have been night shift. Residents Affected - Some On 6/28/23 at 11:12 a.m., a review was conducted of the SW Team 1 & 3 medication cart with Staff K, LPN. The review identified one white capsule with a black stripe and a white tablet in the bottom of the second drawer. Staff K removed them from the cart. An observation was conducted on 6/28/23 at 11:18 a.m., of the SW Team 2 & 3 medication cart with Staff L, Registered Nurse (RN). An opened bottle of Citrus flavored ProStat (liquid protein) was not labeled with an open date. The manufacturer of the ProStat identified to Discard the bottle 3 months after opening. On 6/28/23 at 11:30 a.m., an observation was conducted with Staff M, RN, of the SE Team 2 medication cart. The cart contained an opened bottle, dated 3/22/23, of Vanilla flavored ProStat liquid protein. The manufacturer labeled the bottle to discard 3 months after opening. The staff member confirmed the finding. During an interview on 6/28/23 at approximately 2:00 p.m. with the Nursing Home Administrator stated on 6/28/23 at approximately 2:00 p.m. that during a recent Quality Assurance meeting the issue with medication storage was discussed and if an issue was observed staff would fix it immediately. The Administrator agreed that a cluttered packed refrigerator, as seen on NW unit, would not keep proper temperature. The NHA reported that no follow up Quality Assurance meeting had been held, was supposed to be held the week that the revisit was conducted. The policy - Storage of Medications, revised November 2020, indicated that The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The interpretation and implementation portion of the policy described the following: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 105140 Page 31 of 31