Health inspection·October 22, 2021

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to store respiratory equipment in a sanitary manner for one (#376), out of thirteen residents receiving respiratory treatments. Residents Affected - Few Findings Included: On 10/20/21 at 11:29 a.m., an interview was conducted with Resident #376. He confirmed that he received medication via a nebulizer. The nebulizer machine was observed in the first, open drawer of the nightstand. The mask was uncovered, sitting on top of the nebulizer machine (photographic evidence obtained). On 10/21/21 at 12:18 p.m., an interview was conducted with Resident #376. He stated that he used the nebulizer every four hours or as needed. He confirmed that he had used the nebulizer that day. The nebulizer machine was observed in the first, open drawer of the nightstand. The mask was uncovered, sitting on top of the nebulizer machine. (photographic evidence obtained). On 10/21/21 at 12:51 p.m., an interview was conducted with Staff K, Registered Nurse (RN). She confirmed that Resident #376 was currently receiving nebulizer treatments. She provided documentation of the order from the resident's medical record. The physician order revealed that Resident #376 received medication via the nebulizer every six hours or as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section O: Special treatments, procedures and programs; Respiratory Treatments, oxygen therapy. Review of the care plan, dated 09/30/21, revealed a focus area for oxygen therapy, related to Chronic Obstructive Pulmonary Disease (COPD). Goal: the resident will have no sign and symptoms of poor oxygen absorption through the review date. Intervention: Nebs (Nebulizer treatments) as ordered-proper PPE (personal protective equipment) during treatment as indicated. On 10/21/21 at 3:45 p.m., an interview was conducted with Staff J, Licensed Practical Nurse (LPN). Staff J came into resident #376's room and observed the nebulizer mask sitting in resident #376's drawer. She confirmed that the mask should be stored in a plastic bag and the nurse was responsible for putting it into the bag. Staff J stated that she did not know who placed the mask inside the drawer, she just started her shift, but said Resident #376 moved things around. She said when she had given Resident #376 his medication, she parked her cart in front of the door, and remained at the door until he was finished. Staff J retrieved gloves, put one glove on, and placed the mask into a Page 1 of 7 105248 105248 10/22/2021 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plastic bag that was attached to the handle of the first drawer of the nightstand. Staff J walked down the hall to her medication cart to confirm Resident #376's order for the nebulizer treatment. Staff J stated that the resident received the nebulizer treatment four times a day. She said the resident's next scheduled time to receive the nebulizer treatment was at 8:00 p.m. On 10/21/21 at 4:12 p.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN), Unit Manager. Staff H confirmed that the nebulizer mask should be stored in a plastic bag after the medication was administered by the nurse. She said the nurse must don (put on) full PPE and remain in the room until the resident finished the medication. She was going to Resident #376's room to remove the mask, tubing, and plastic bag to replace them with new ones. On 10/22/21 at 10:45 a.m., an interview was conducted with the Director of Nursing (DON). He confirmed that all residents that use respiratory equipment should have a bag with their name and date on it. He said the nebulizer mask for Resident #376 should have been in the plastic bag. He said that respiratory services came into the facility once a week and changed it out. He said it was the nurses' responsibility to make sure this was completed and to follow up with respiratory services as needed. Review of the facility's policy titled, Nebulizer Therapy, revised October 2021, revealed that it was the policy of the facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. The policy revealed under Care of the Equipment, 3. Disassemble parts after every treatment, 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 6. Air dry on an absorbent towel 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 105248 Page 2 of 7 105248 10/22/2021 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to have posted staffing information for all shifts readily accessible to residents and visitors at the main entrance. Residents Affected - Few Findings included: An observation was conducted on 10/19/2021 at 9:00 a.m. of the main entrance and exit in the facility. Daily staff posting was not observed to be posted anywhere in the main entrance and/or exit area. During a subsequent observation, staffing was not displayed to be posted and visible to residents and visitors at the facility's main entrance and/or exit. Staff A, Receptionist/Screener was asked where the day's staffing was located. She presented a clipboard that was near her at the reception desk which had a white sheet of paper on it that read, Daily Staffing Sheets. The clip board contained the staffing for all units. The posted staffing was not visibly seen, and would not have been known to a visitor or resident to be located on the clipboard that was covered with a piece of paper. An interview was conducted with Staff A, who stated, Someone must ask to see the staff posted numbers for the day. (Photographic Evidence Obtained.) On 10/19/2021 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON) related to posting of the daily staffing and accessibility to residents and visitors. The DON stated, Yes I agree it is not accessible, and I do know what you mean, I will get it corrected immediately. A facility provided policy titled, Nurse Staffing Posting Information,dated April 29, 2021, Page 01 of 01 reads under Policy It is the Policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident and to make staffing information readily available Policy Explanation and Compliance Guidance: 4. The information posted will be b. In a prominent place readily accessible to residents and visitors. 105248 Page 3 of 7 105248 10/22/2021 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure that medications were stored according to current accepted professional principles as evidenced by 1. Failure to secure medications in six of six medication carts and 2. Failure to appropriately store respiratory medication for one (Resident #376) of thirteen residents that received respiratory treatments. Findings included: 1. On 10/21/2021 at 3:15 p.m., an observation of medication cart #2 located on Central Hall included 1/4 piece of a white tablet, and three medications punch cards, which were seen to be in the back of the fourth drawer from the top of the medication cart, when the drawer was pulled all the way out. Staff B, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured piece of tablet and three medication punch cards behind the fourth drawer. The Director of Nursing (DON) retrieved the three punch cards out from the back of the medication cart. The three medication punch cards were unseen by the DON and Staff B,LPN until the surveyor informed them both that they were unsecured. On 10/21/2021 at 3:30 p.m., an observation of medication cart #1 on Central Hall included three loose pills. Staff C, LPN confirmed the presence in the second drawer from the top of the medication cart of one round white tablet, one pink oval tablet, and in the 3rd drawer, one clear capsule. (Photographic Evidence Obtained.) An observation was made of the medication cart #1 on [NAME] Hall which included 1/4 piece of white tablet loose in the second drawer. Staff D, LPN confirmed the presence of the unsecured piece of tablet. An observation was made on 10/21/2021 at 4:00 p.m. of medication cart #1 on the East Hall. During the observation a clear plastic bag was observed containing a resident's Nitroglycerin medication, located behind the fourth drawer from the top of the medication cart when pulled out. Staff L, LPN confirmed the presence of the unsecured medication. On 10/21/2021 at 4 :15 p.m., an observation of medication cart #2 located on East Hall included one loose tablet. Staff E, (Agency LPN) confirmed the presence of the unsecured white tablet in the second drawer from the top of the medication cart. On 10/21/2021 at 4:40 p.m., an observation of medication cart #3 on the East Hall included one loose yellow tablet, behind the fourth drawer from the top of the medication cart when pulled out. The DON confirmed the presence of the unsecured tablet. On 10/22/2021 at 9:16 a.m., an interview was conducted with the DON. During the interview, the DON was informed of all observations made and stated, I did not realize pills can fall behind drawers. There should never be loose pills in the medication carts. A review of the facility's Polaris Pharmacy Policy and Procedure titled, Medication Storage in the Facility, dated April 2018, Pages 47, read under Policy, Medications and Biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The 105248 Page 4 of 7 105248 10/22/2021 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: A. The provider pharmacy dispenses medications in containers that regularly meet requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. 2. On 10/21/21 at 3:45 p.m., an interview was conducted with Staff J, Licensed Practical Nurse (LPN). Staff J was called to Resident #376's room to observe an inhaler that sat in a cart filled with Resident #376's personal belongings, next to his bed. She stated that she was not sure whether the resident was supposed to have the inhaler in his possession. Staff J immediately removed the inhaler from the cart with a napkin. When Resident #376 was asked where the inhaler came from, he stated that a nurse gave it to him to use while waiting to receive his nebulizer treatment, but he could not recall who. Staff J stated that the inhaler may have been brought in by a family member. She said the resident had a lot of visitors and received care from hospice services. Staff J walked down the hall to her medication cart to review Resident #376's current orders. She confirmed that he did not have an order to self-administer any medication. Staff J retrieved Resident #376's inhaler from inside the medication cart and confirmed that the inhaler removed from the residents' room was not the facility provided inhaler, that was given to him by the nurses. Staff J placed the two inhalers side by side on her cart (photographic evidence obtained). She checked the inhaler and stated that it was a new inhaler because it had a remainder of 70 out of 80 puffs left in it, indicating it may have been used about five times. Staff J stated that the activities department is responsible for completing the residents initial inventory list, she would check with them to see if the resident came into the facility with the inhaler. Staff J stated that she had never given the resident his PRN (as needed) inhaler that was kept inside the medication cart. Staff J stated that she would find out if the resident would like to self-administer his inhaler. She said she would try to get a physician's order. She said she would educate the resident and watch him use it to ensure that he was able to use it properly. On 10/21/21 at 4:12 p.m., an interview was conducted with Staff H, LPN, Unit Manager. Staff H stated that Resident #376 did not have the inhaler yesterday. She said she checked his room Monday and Tuesday; it was not there. She said the resident had a visit from his stepson yesterday and he could have given it to him. She said hospice also came to see the resident twice a week and last saw him Monday. She said effective immediately, she would place the resident's inhaler in a locked box. She said she informed the Nurse Practitioner (NP) about the inhaler found in his possession and asked for an order to allow the resident to self-administer his inhaler. She said the NP said that it was ok and provided a verbal telephone order. The activities department provided a copy of Resident #376's inventory sheet and the inhaler had not been recorded. Review of Resident #376's medical record revealed an initial admission date of 09/28/21. Diagnoses included chronic obstructive pulmonary disease, personal history of nicotine dependence, and cachexia. Physician orders revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/ml, 3 ml inhale orally four times a day related to Chronic Obstructive Pulmonary Disease (COPD), unspecified. Albuterol Sulfate Aerosol Powder Breath Activated 108 (90 Base) Mcg/Act, two inhalations, inhale orally every four hours as needed for shortness of breath. Administer oxygen at 3 liters via nasal cannula, every 105248 Page 5 of 7 105248 10/22/2021 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0761 shift for respiratory management. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section O: Special treatments, procedures and programs; Respiratory Treatments, oxygen therapy. Residents Affected - Few Review of the care plan, dated 09/30/21, revealed a focus area for oxygen therapy, related to COPD. Goal: the resident will have no sign and symptoms of poor oxygen absorption through the review date. Intervention: Nebs (Nebulizer treatment) as ordered-proper PPE during treatment as indicated. The Care plan revised on 10/21/21, revealed a focus area for Strength: Resident can self-administer handheld inhaler and self-administer per Dr. orders. Teaching and training given by Unit Manager. Goal: Resident will safely administer inhaler treatment through next review date. Interventions: Instructions and education by nurse given to the resident and signed by resident of understanding on proper procedure. Inhaler must be kept in a locked box with key and instructions, that after use return inhaler to the locked box. On 10/22/21 at 10:20 a.m., an interview was conducted with Resident #376. He was observed in bed, wearing a bracelet with a key on his wrist. The locked box was observed on the second shelf of the resident's cart, that held personal items, next to his bed. Resident #376 stated that he knew how to access the inhaler by putting the key in. He said he felt better now that it had been contained so no one else could get into his box besides himself. Resident stated that he was happy. On 10/22/21 at 10:31 a.m., a follow up interview was conducted with Staff H, LPN, Unit Manager. She stated that Resident #376 told her that he received the inhaler from hospice. She said she had reinforced teaching with the resident and placed the lock box in his room. She explained that Resident #376 had a copy of the medication administration record (MAR) inside a binder in his room, that he must sign and log the time when he administered the medication. She said she had provided him with instructions on how to use it. On 10/22/21 at 10:45 a.m., an interview was conducted with The Director of Nursing (DON). The DON stated that he was notified by Staff H, that Resident #376 got the inhaler from Hospice. He said the resident was educated about self-administration of the inhaler and returned demonstration on how to self-administer. He said the resident was given a lock box with a key. Review of Resident #376's progress notes, dated 10/21/21 revealed, Resident found with inhaler at bedside. Resident made this writer aware that he was given this inhaler on the other side meaning Hospice. This writer asked the resident if he desires to self-administer his prn Albuterol inhaler. Resident verbalizes to self-administer prn inhaler but not nebulizer treatments. This writer made resident aware that nebulizer treatments must remain in bag if not in use. Resident verbalizes understanding, Nurse Practitioner (NP) notified. Order received for resident to self-administer prn inhaler. Medication to remain at bedside in locked box. Lock box obtained. Review of Resident #376's progress notes, dated 10/21/21 revealed, Medication Self Administration: Re-enforced teaching done with resident regarding inhaler use. Resident able to read instructions on medication box. Resident able to make this writer aware that medication is every 4 hours as needed. Resident instructed to rinse and spit after use. This writer made resident aware that medication must be kept in lock box in room. Resident verbalizes understanding. 105248 Page 6 of 7 105248 10/22/2021 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0761 Level of Harm - Minimal harm or potential for actual harm Review of Resident #376's progress notes, dated 10/21/21 revealed, Nursing spoke with son regarding inhaler at bedside. He denies bringing any kind of meds in house. Understands rules and regulations. Review of Resident #376's medical record revealed, a Self-administer assessment was completed 10/21/21 and will be reevaluated on 11/07/21. Residents Affected - Few Review of Resident #376's current physician orders dated 10/22/21, revealed Albuterol Sulfate Aerosol Powder Breath Activated 108 (90 Base) Mcg/Act, two puffs inhale orally every four hours as needed for shortness of breath, Resident may keep at bedside in locked box to self-administer. Review of Resident #376's current physician orders dated 10/21/21, revealed Resident able to self-administer as needed Albuterol Inhaler, as needed (two puffs every four hours as needed) Per Primary care physician order. Medication must be kept in locked box at bedside. Review of the facility's policy, titled Bedside Medication Storage, dated April 2018, revealed that Bedside medication storage is permitted for resident's who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. Procedures: A) A written order for the bedside storage of the medication is present in the resident's medical record. B) Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medications. C) For residents who self-administer medications, the following conditions are met for bedside storage to occur. 1) The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate. Facility management should have a copy of the key in addition to the resident. 2) The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy or in the original container if a non-prescription medication. 3) The bedside medication record is reviewed on each nursing shift, and the administration information is transferred to the MAR kept at the nurse's station. Notation of each self-administered dose is made by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who obtained the information from the resident. 105248 Page 7 of 7