Health inspection·September 18, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to maintain a system of records to accurately account for all controlled medications in one of three medication carts inspected for six (Resident #2, #5, #6, #7, #8, and #9) of 15 sampled residents. Findings included: An inspection of a medication cart was conducted on 9/18/2023 at 1:00 PM on the Central Wing of the facility with Staff A, Registered Nurse (RN). Staff A was observed at the unit nurse's station with the medication cart's controlled medication log. Staff A stated she was in the process of signing out the controlled medications she administered to residents during the morning medication pass. Staff A stated she would normally sign the controlled medications out at the point of the medication being administered to the resident, but she was having trouble keeping up with her assignment and stated it was hard to stop and go during the medication pass. Staff A addressed several of the resident's controlled medication count sheets would be incorrect as a result of her not signing them out at the time they were administered. The following was revealed during the inspection of the medication cart: - 28 prefilled syringes of Ativan/Benadryl/Haldol (ABH) 0.5 milligrams (mg)/12.5 mg/1 mg cream prescribed to Resident #6. The medication monitoring/control record documented 29 doses remaining. Staff A stated Resident #6 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 11 tablets of Ativan 0.5 mg prescribed to Resident #2. The medication monitoring/control record documented 12 doses remaining. Staff A stated Resident #2 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 10 tablets of Clonazepam 0.5 mg prescribed to Resident #7. The medication monitoring/control record documented 11 doses remaining. Staff A stated Resident #7 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 6 tablets of morphine sulfate 15 mg prescribed to Resident #8. The medication monitoring/control record documented 7 doses remaining. Staff A stated Resident #8 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105248 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105248 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)