F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review and interviews the facility failed to ensure that medications were
delivered in the manner prescribed for one resident (#21) of seven sampled residents. This resulted in
medications being administered as crushed without an order or approval from the prescribing physician.
The five errors observed during medication administration observations of 25 medications, represented an
error rate of 20%.
Residents Affected - Few
Findings included:
A review of the admission Record for Resident #21 revealed an admission date of 6/20/2020 and an initial
admission date of 05/26/2017 with the primary diagnosis of cerebrovascular disease. Other diagnoses
included Downs Syndrome, obesity, atherosclerotic heart disease, gastro-esophageal reflux disease
(GERD) without esophagitis, schizophrenia, and anxiety disorder.
A review of the active August 2021 physician orders for Resident #21 did not reveal an order stating, May
change medication form as warrants (solid, liquid, crushed). Further review of the physician orders for
Resident #21 did reveal orders for the following medications to be administered at 9:00 a.m.:
- Quetiapine Fumarate Tablet 25 mg (milligrams) Give 0.5 tablet by mouth two times a day for
schizoaffective disorder.
- Escitalopram Oxalate tablet 10 mg Give one tablet by mouth one time a day for depression,
- Acetaminophen 325 mg tablet Give two tablets by mouth every six hours as needed for pain management,
- BusPIRone Hydrochloride (HCL)Tablet 5 mg Give one tablet by mouth three times a day for anxiety,
- Divalproex Sodium capsule Delayed Release Sprinkle 125 mg Give one capsule by mouth three times a
day for seizures,
- Pantoprazole Sodium tablet delayed release 40 mg Give one tablet in the morning for GERD.
On 8/18/2021 at 8:50 a.m. a medication administration observation with Staff A, Licensed Practical Nurse
(LPN) revealed that Staff A, LPN crushed medications which included: Escitalopram Oxalate 10 mg tablet,
Acetaminophen two tablets 325 mg tablets, Docusate sodium tablet 100 mg, Buspirone 5 mg tablet, and
Quetiapine Fumarate 25 mg, half a tablet for Resident #21. Staff A, LPN stated that there was an order for
the medications to be crushed and that order is one of the batch orders that are
(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 2
Event ID:
105283
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
105283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakeland Hills Center
610 E Bella Vista Dr
Lakeland, FL 33805
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)
F 0759
completed for all residents on admission.
Level of Harm - Minimal harm
or potential for actual harm
On 08/18/2021 at 10:05 a.m. an interview with Staff A, LPN was conducted. Staff A, LPN reviewed
Resident #21's order sheet, and confirmed there was no physician order to crush the medications.
Residents Affected - Few
On 08/18/2021 at 10:22 a.m. an interview was conducted with the Director of Nursing (DON). The DON
stated that they completed a review of Resident #21's orders (physician) which revealed that the order to
crush medications was not there, and she stated that the resident needs her medications crushed.
Resident #21 had been sent to the hospital on 2/15/2021 and the prior order was discontinued. The order
was supposed to be included in the batch orders on readmission, but it was not there.
On 08/19/2021 at 1:30 p.m. a telephone interview was attempted with the facility's consultant pharmacist
regarding the medication administration observation, and a message was left requesting a return call. At
the time of exit from the facility no return call had been received.
A review of the facility policy titled, Medication Administration General Guidelines, updated September
2018, revealed in Section 5:
If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has
difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from the provider.
a. The need for crushing medications is indicated on the resident's orders and the Medication
Administration Record (MAR) so that all personnel administering medications are aware of this need and
the consultant pharmacist can advise on safety and alternatives, if appropriate, during Medication Regime
Reviews.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105283
If continuation sheet
Page 2 of 2
