Health inspection·March 8, 2023

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 Based on record review and staff interview, the facility failed to ensure nursing staff followed the facility protocol regarding unavailable medications for 1 of 6 sampled residents reviewed for medications, resulting in the resident not receiving physician-ordered medications as prescribed (Resident #72). Residents Affected - Few The findings included: A review of the facility's policy regarding Medication Errors (Reference #6084) documents: Definition: A Medication Error is any preventable event that may cause or lead to inappropriate medication use or resident harm . Types of medication errors include: Omission (not administered before next scheduled dose due . Procedure: When a medication error occurs, the following shall occur in this order: Notify the physician and evaluate the resident. Notify resident/responsible party. Perform any necessary clinical interventions, within the resident care provider's scope of practice to reduce negative effects of the identified error. Record the medication as given in the medical record if applicable. Record the observed and assessed outcome of the resident in the medical record. Record notification of physician in the medical record with any resultant orders. Record any actions and clinical interventions taken and the resident's response to same. Report the error in detail on a medication error incident report. The practitioner who identifies an error shall document all relevant particulars on the medication error report form. Page 1 of 5 105277 105277 03/08/2023 Stuart Rehabilitation and Healthcare 1500 SE Palm Beach Rd Stuart, FL 34994

F 0684 Level of Harm - Minimal harm or potential for actual harm All medication error reports shall be reviewed by the physician, pharmacist and DON/designee and categorized according to severity, type, cause and drug class involved. All medication error reports evaluated as significant (Level 4 or above) shall be referred to the Pharmacy and Physician. Residents Affected - Few Reports of actions taken and appropriate follow-up shall be made by the DON/designee to the Pharmacy and Physician. Resident #72 was admitted to the facility with diagnoses that included Parkinson's Disease, Hypertension, and Allergic Rhinitis. A review of the February and March 2023 electronic Medication Administration Record (eMAR) for Resident #72 revealed the following medication administration concerns: 1) Selegiline HCI 5 mg, was prescribed to treat Resident 72's Parkinson's symptoms, and was to be administered twice a day (9:00 AM and 9:00 PM). It was documented on the eMAR as Not administered / Item unavailable on the following dates and times: 02/25/23 at 9:00 AM; 02/26/23 at 9:00 AM and 9:00 PM; 02/28/23 at 9:00 PM; 03/02/23 at 9:00 AM and 9:00 PM; 03/03/23 at 9:00 AM and 9:00 PM; and 03/04/23 at 9:00 AM and 9:00 PM. 2) Spironolactone 50 mg was prescribed for treatment of high blood pressure and was to be administered once daily. It was documented on the eMAR as Not administered / Item unavailable on the following dates and times: 02/15/23; 02/25/23; 02/26/23; 03/02/23; 03/03/23; 03/04/23, and 03/05/23. 105277 Page 2 of 5 105277 03/08/2023 Stuart Rehabilitation and Healthcare 1500 SE Palm Beach Rd Stuart, FL 34994

F 0684 Level of Harm - Minimal harm or potential for actual harm 3) Ipratropium Bromide Nasal Spray 42 mcg for the treatment of allergic rhinitis was to be administered as 2 sprays twice daily (9:00 AM and 5:00 PM). It was documented on the eMAR as Not administered / Item unavailable on the following dates and times: 02/10/23 at 9:00 AM and 5 PM; Residents Affected - Few 02/21/23 at 5 PM; and 02/23/23 at 5 PM. A review of February and March 2023 Nursing / Progress Notes showed only one note made by nursing staff documenting steps taken to address one of the unavailable medications for Resident #72: On 03/04/23 at 3:14 PM, Called pharmacy to inquire when Selegiline HCI would be sent out. Pharmacy state that order was discontinued on their end and not showing up in their system. Pharmacy said medication will have to be discontinued and then re-entered. This writer discontinued and re-entered medication. On 03/07/23 at 3:52 PM, the Director of Nursing (DON) was advised of the concerns with the unavailable medications and lack of documentation by nursing staff addressing the medication availability. On 03/08/23 at 11:48 AM, the DON stated she had not been made aware that Resident #72's medication was unavailable prior to the surveyor notifying her of the issue. She stated, I immediately notified pharmacy and the physician. I completed a Medication Error Analysis Report for each of the medications. The Physician did discontinue the nasal spray, and I am having the nurses take the resident's vital signs daily to make sure he has no ill effects. A review of his vitals showed there have been no issues with his blood pressure, and the resident stated he has not had any issues with fine motor tremors as a result of the missing medications. On 03/08/23 at 11:50 AM, the DON notified Resident #72's ARNP (Advanced Registered Nurse Practitioner) while the ARNP was in the facility, and the ARNP stated she would visit Resident #72 that day. On 03/08/23 at 11:58 AM, the Administrator confirmed that according to policy, the nurses are to call the pharmacy to find out why a resident doesn't have their medication(s) available, look for missing medications in the E-kit, and if none of the medications are in the E-kit, notify the doctor. The DON stated, None of the nurses followed this protocol, except for [Staff D] when he called the pharmacy on 03/04/23. He did what he was supposed to do. I will be doing an in-service with the nursing staff on following this protocol. 105277 Page 3 of 5 105277 03/08/2023 Stuart Rehabilitation and Healthcare 1500 SE Palm Beach Rd Stuart, FL 34994

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure proper indwelling urinary catheter care and services for 3 of 3 sampled residents, as evidenced failure to maintain Resident #81's urinary catheter tubing and drainage bag off the floor and failure to ensure proper urinary catheter anchoring for Residents #24, #43, and #81. All three residents had a history of Urinary Tract Infections (UTIs). The findings included: Review of the policy, titled, Indwelling Urinary Catheter Insertion and Maintenance - Female Resident, revised 10/2017, documented the process for placing the catheter followed by the instructions to keep the collection bag below the level of the bladder at all times, but do not rest the bag on the floor. This policy further instructed the staff to apply a catheter strap to the leg to prevent it from pulling. The Director of Nursing (DON) was unable to locate a policy that included these directions for the male resident but agreed it would be applicable to both. 1. Review of the record revealed Resident #81 was admitted to the facility on [DATE] and moved to his current room on 10/25/22. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #81 did have an indwelling catheter. Resident #81 had UTIs on 10/17/22 and 11/11/22 with subsequent antibiotic use. During an observation on 03/05/23 at 12:34 PM, Resident #81 was observed lying in a low bed. An indwelling urinary catheter bag was noted lying flat on the floor, with the wheel of an over-the-bed table on top of the bag. Photographic Evidence Obtained. At 12:47 PM, Staff A, Certified Nursing Assistant (CNA), delivered a lunch tray to Resident #81. While trying to position the over-the-bed table within reach of the resident, the CNA moved the table off the catheter bag, used her shoe to move the bag out of the way, and positioned the table for Resident #81. The CNA left the room with the urinary catheter bag still lying directly on the floor. During a subsequent observation on 03/05/23 at 2:31 PM, Resident #81 was sitting up in bed. The urinary catheter bag was now hooked to the bed frame, but the bottom of the catheter bag and part of the catheter tubing remained on the floor. Photographic Evidence Obtained. An observation of personal care for Resident #81 was made on 03/07/23 at 9:20 AM, with Staff A, CNA. The urinary catheter bag and tubing were noted off the floor and positioned properly. When Staff A removed the resident's adult brief, the catheter tubing was noted to be pulled taunt, and the tubing lacked any type of anchoring device. After the CNA completed the care, when asked if they use any type of anchoring device for the catheter tubing, the CNA stated yes, and that it must have fallen off. During an observation on 03/07/23 at 1:35 PM with Staff B, Registered Nurse (RN), the urinary catheter bag for Resident #81 was off the floor, but the catheter tubing was lying directly on the floor. The RN agreed the bag and tubing should not be on the floor. The RN was made aware of the above observations. 105277 Page 4 of 5 105277 03/08/2023 Stuart Rehabilitation and Healthcare 1500 SE Palm Beach Rd Stuart, FL 34994

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 03/08/23 at 11:41 AM revealed the urinary catheter bag and tubing were again noted lying directly on the floor. Photographic Evidence Obtained. Review of the current care plan for the resident's indwelling catheter lacked any intervention for anchoring or securing the tubing, which helps in the prevention of UTIs. Further review of the record revealed a current physician order dated 10/16/22 to anchor (urinary) drainage tubing to the resident's leg. 2. Review of the record revealed Resident #24 was admitted to the facility on [DATE] with an indwelling catheter, and UTI. Resident #24 had subsequent UTIs on 02/03/23 and 02/27/23, with the provision of an antibiotic each time. An observation on 03/07/23 at 11:29 AM revealed Resident #24 sitting up in her wheelchair, with a urinary catheter bag noted hanging from the wheelchair frame. When asked if there was any type of anchoring or device to secure the catheter tubing to her thigh, Resident #24 felt her thigh and stated there was nothing there. The resident then proceeded to pull up her shorts to reveal her left thigh, the catheter tubing, and a lack of anchoring device. Review of the current care plans lacked any intervention for anchoring or securing the urinary catheter tubing. Further review of the record revealed a current physician order dated 01/02/23 to anchor (urinary) drainage tubing to the resident's leg. During an interview on 03/08/23 at 12:39 PM, Staff C, RN, when asked about any anchoring device for Resident #24, stated she was told to put one on the resident before she left work the previous day (03/07/23). 3. Review of the record revealed Resident #43 was admitted to the facility on [DATE] with an indwelling urinary catheter. Resident #43 had a subsequent UTI on 12/31/22, with the provision of an antibiotic. A physician's order dated 12/23/22 documented to anchor the (urinary) drainage tubing to the resident's leg. During an observation on 03/07/23 at 11:47 AM, Resident #43 was sitting in a wheelchair and an urinary drainage bag was noted, with no anchoring device. At 11:52 AM, Staff E, Licensed Practical Nurse (LPN), was asked if the facility utilized anchoring devices for urinary catheters, and the LPN confirmed the use of the anchors. During a subsequent observation at this time, the LPN agreed to the lack of an anchoring device for the urinary catheter tubing of Resident #43. 105277 Page 5 of 5