Health inspection·May 5, 2025

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 record review and interviews, the facility failed to ensure one resident (#1) out of three residents sampled were assessed immediately by a nurse after being found on the floor by facility staff. Residents Affected - Few Findings included: Review of an admission Record dated 5/6/2025 showed Resident #1 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to nontraumatic intracerebral, hemorrhage in hemisphere, subcortical, and flaccid hemiplegia affecting right dominant side. Review of a Nurse Progress note dated 4/22/2025, authored by Staff A, Registered Nurse (RN), showed The [Certified Nursing Assistant,] CNA found the resident lying in the resident restroom. The CNA stated that two CNA placed the resident on the toilet as resident requested and 5 min[utes] later they found the resident on the floor in the resident restroom. It was noted when the nurse entered the resident's room, she observed the CNA lifting the resident to bed. The nurse assessed Resident #1 for pain or injuries after the resident was placed in bed. During an interview on 5/6/2025 at 12:40 p.m., with Staff A, RN, Staff A, RN stated on the day Resident #1 fell she was in another room administering medication. When she was coming out of the room, someone told her Resident #1 was on the floor. When she went to the room, two CNAs were in the bathroom picking Resident #1 up from the floor and placed him in his wheelchair. Staff A, RN stated she assessed Resident #1 after the CNAs placed him back in his chair, she did an incident report, and notified the resident's daughter. Staff A, RN stated whenever a resident has a fall, the nurse is supposed to assess the resident before a CNA can move the resident. During an interview on 5/5/2025 at 1:30 p.m., with Staff B, CNA, Staff B, CNA stated she assisted Resident #1 to the bathroom on the day of his fall. Staff B, CNA stated her and the orientee placed Resident # 1 on the toilet and left him in the bathroom because he asked for privacy. She stated she left his room because she overheard another resident screaming in another room. When she got to the other room she had to assist the other resident on the toilet. She stated when she was headed back to Resident #1's room, a housekeeper told her Resident #1 was on the floor in the bathroom. Staff B, CNA stated her and the orientee assisted Resident #1 off the floor and placed him in his wheelchair. The nurse assessed him before they assisted him back to his bed. Staff B, CNA stated the nurse was standing in the room while they were picking the resident up off the floor. During an interview on 5/5/2025 at 1:27 p.m. with Staff C, License Practical Nurse/ Unit Manager (LPN UM), Staff C, LPN UM stated on 4/22/2025, Resident #1 wanted to use the bathroom and two CNA staff placed him on the toilet and gave him his call light. She stated Resident #1 had fallen off the Page 1 of 5 105140 105140 05/05/2025 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 - Few toilet, but she was not present on the unit when he fell. Staff C, LPN UM stated the protocol is if the nurse is not present, the CNAs are supposed to notify the nurse, the nurse does her assessment on the resident, and they notify the doctor and the family. The CNAs are not allowed to move the patient and they must wait until the nurse assesses the resident. During an interview on 5/5/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated when a resident falls, the CNAs notify the nurse, the nurse conducts an assessment and completes an incident report, they notify the primary care provider and the family, and Emergency Services if needed depending on the situation. The DON stated CNAs are not allowed to move a resident after a fall until the nurse assesses the resident. Review of the facility in-service titled Reporting Falls dated 4/21/2025 showed under Objective, anytime a resident is observed on the floor, witnessed falling to the floor, or assisted to the floor by staff, it is a facility requirement that a Fall Protocol is followed. 1. While on the ground, assess resident for injuries; Range of Motion (ROM), pain, vitals with blood sugar, and skin. 4. Notify the unit manager/supervisor, or nurse leadership present in the building at the time of the incident and the risk manager. 105140 Page 2 of 5 105140 05/05/2025 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide physician ordered medication for one resident (#1) out of three residents reviewed. Findings included: Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] and discharged on 4/23/25. His medical diagnoses included nontraumatic intracerebral hemorrhage in hemisphere, subcortical and flaccid hemiplegia affecting the right dominant side. Review of Resident #1's hospital discharge medication list revealed Pregabalin 75 mg [milligrams] oral capsule three times a day. Next dose: 4/21/25 at 8:00 PM. Review of Resident #1's April 2025 physician orders revealed an order with a start date of 4/22/25 and an end date of 4/23/25 for Pregabalin Oral Capsule 75 MG (Pregabalin) Give 1 capsule by mouth three times a day for neurogenic pain due to central nervous system. Review of Resident #1's April Medication Administration Record revealed in five out five medication administration opportunities, Resident #1 did not receive the ordered Pregabalin 75 milligrams three times a day from 4/21/25 through his discharge on [DATE]. All five medication administration opportunities were documented as 9. Review of the chart codes revealed 9=Other/See Nurse's Notes. Review of Resident #1's electronic medication administration record (eMAR)-Administration Note dated 4/22/25 at 6:43 AM revealed Pregabalin Oral Capsule 75 MG Give 1 capsule by mouth three times a day for Neurogenic pain due to central nervous system. New admit [admission]. Awaiting script [prescription]. MD [Medical Doctor] made aware. Review of Resident #1's eMAR-Administration Note dated 4/22/25 at 1:35 PM written by Staff A, Agency Registered Nurse (RN) revealed Pregabalin Oral Capsule 75 MG Give 1 capsule by mouth three times a day for neurogenic pain due to central nervous system. I called the pharmacy and the customer services stated: They don't have script for lyrica. MD should be notified. Review of Resident #1's eMAR-Administration note dated 4/22/25 at 9:00 PM. revealed Pregabalin Oral Capsule 75 MG Give 1 capsule by mouth three times a day for neurogenic pain due to central nervous system. on order Review of Resident #1's eMAR-Administration note dated 4/22/25 at 5:08 AM revealed Pregabalin Oral Capsule 75 MG. Give 1 capsule by mouth three times a day for Neurogenic pain due to central nervous system. There was no documentation for this dose. Review of Resident #1's eMAR-Administration note dated 4/23/25 at 1:40 PM revealed Pregabalin Oral Capsule 75 MG. Give 1 capsule by mouth three times a day for Neurogenic pain due to central nervous system. medication [sic] not on hand med [medication] not available in ekit [emergency medication kit] pharm [pharmacy] called md [sic] notified. Review of the facility's emergency medication drug list revealed pregabalin 25 mg was available in 105140 Page 3 of 5 105140 05/05/2025 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0755 the emergency drug kit. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 5/5/25 at 1:00 PM with Staff A, Agency RN. She said Resident #1 was a new admission when she was assigned to him, within his first 24 hours. She said when resident's medications are not in the medication cart, she calls the pharmacy to see where the medication is. She said she called the pharmacy about Resident #1's missing pregabalin medication and the pharmacy said they did not have the prescription, but she does not remember if she called the physician to get a prescription. Residents Affected - Few An interview was conducted on 5/5/25 at 1:22 PM with Staff C, Licensed Practical Nurse (LPN), Unit Manager. She said when there is a new admission the medications are put into the electronic record and sent to the pharmacy. Paper prescriptions for controlled medications are faxed to the pharmacy and the medications should be administered according to when the hospital recommends when the next dose is supposed to be given. If the pharmacy has not delivered the medications by the time it is due the medication should be pulled from the emergency drug kit and if the medication is not in the emergency drug kit, the physician should be notified and there should be documentation the physician was notified, and the pharmacy should be contacted. She said Resident #1 did not receive his pregabalin because a prescription was not sent to the pharmacy but the physician was notified about it on 4/23/25 per the documentation. An interview was conducted on 5/5/25 at 2:18 PM with the Director of Nursing (DON). She said for new admissions the nurses get the medication list from the hospital and it is transcribed into the electronic record and sent to the pharmacy electronically. If the medication is a controlled medication and the nurse has the paper prescription the paper prescription is faxed to the pharmacy. If the nurse does not have a paper prescription for a controlled medication the physician is notified and the physician will call the pharmacy and order the medication. The nurse should document the notification to the physician that a prescription was needed for a controlled medication. The DON confirmed pregabalin is a controlled medication and required a prescription. She said if medications are not onsite the nurses will see if the emergency drug kit has the medication. Any controlled medication the nurse would have to get a code from the pharmacy to pull the medication. If the medication is not in the emergency drug kit the physician should be notified and there should be documentation the physician was notified and any orders they may give. An interview was conducted on 5/5/25 at 3:11 PM with the DON. She said she spoke with the pharmacy and during the weekdays the medication cut off time to put in physician medication order is 12:00 AM. If the medication is ordered by 12:00 AM the pharmacy will try to get the medications delivered by 4:00 PM the next day. If it is not on the 4:00 PM delivery the medication should be on the 3:00 AM delivery. The DON said she called the pharmacy and they confirmed they did not get a prescription for the pregabalin, therefore, the medication was not delivered to the facility, and the nurses could not pull it out of the emergency drug kit because there was no prescription at the pharmacy. She said Resident #1 should have received his pregabalin medication and the nurses should have kept calling the physician until the medication was delivered. Review of the facility's Administering Medications policy, reviewed March 2023, revealed: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 105140 Page 4 of 5 105140 05/05/2025 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0755 Policy Interpretation and Implementation: Level of Harm - Minimal harm or potential for actual harm . 2. The director of nursing [sic] services supervises and directs all personnel who administer medications and/or have related functions. Residents Affected - Few . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choice and preferences, consistent with his or her care plan . 105140 Page 5 of 5