Health inspection·August 7, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to evaluate a resident by an Interdisciplinary team (IDT), including the physician, for self-administering of medications via a gastrostomy tube for one of two sampled residents (#1). Residents Affected - Few Findings included: Resident #1 was admitted on [DATE]. Record showed diagnoses included but were not limited to nontraumatic subarachnoid hemorrhage, dysphagia after Cerebrovascular Accident (CVA), weakness, dysphasia, epilepsy, gastrostomy tube (g-tube), right below knee amputation, anxiety, hypertension, depression, and asthma. Record review of the 5-day, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Section E, Behavior showed verbal behavioral symptoms directed toward others occurred 1 to 3 days. Section G, Functional Status showed he needed supervision with bed mobility, transfers, and toileting. Section N, Medications showed he was taking the following medications: antianxiety, antidepressants, diuretics, and opioids. Observed Resident #1 on 08/07/2023 at 9:25 a.m. sitting in his wheelchair in his doorway of his room. The resident appeared clean and dressed for the day. He stated he was waiting on the nurse to come and give him his medications. His g-tube was able to be observed. Record review of the physician orders showed the following: Diet clarification order for Puree texture and honey thick liquids as of 07/14/23 Clonazepam (Klonopin) 0.5 milligram (mg) via g-tube every 8 hours as needed for anxiety as of 06/13/23 to 06/23/23 Clonazepam (Klonopin) 0.5 mg via g-tube three times a day for anxiety as of 06/23/23 to 07/31/23 Clonazepam (Klonopin) 1 mg via g-tube three times a day for anxiety as of 07/31/23 Duloxetine (Cymbalta) delayed release 30 mg via g-tube, twice a day for depression from 06/13/23 to 07/27/23 Drizalma (Cymbalta) sprinkles delayed release 30 mg via g-tube twice a day for epilepsy as of 07/27/23 Gabapentin 600 mg via g-tube for polyneuropathy Page 1 of 14 105292 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0554 Lacosamide (Vimpat) 100 mg twice a day via g-tube for seizures Level of Harm - Minimal harm or potential for actual harm Levetiracetam (Keppra) 500 mg/5 milliliter (ml) via g-tube for seizures as of 06/13/23 Lisinopril-hydrochlorothiazide 20-12.5 mg via g-tube for hypertension as of 06/13/23 Residents Affected - Few Suboxone 8-2 mg sublingual three times a day for alcoholism and drug addiction Tizanidine 4 mg via g-tube for muscle spasms as of 06/13/23 Omeprazole delayed release 20 mg daily via g-tube for gastro-esophageal reflux May crush meds unless otherwise indicated Record review of the progress notes showed: Between 06/15 and 06/28 the documentation showed the resident tolerated medication without signs and symptoms (s/s) of adverse effects. On 06/29, the writer stated the resident came to the facility with the ability to administer his own tube feedings and water flushes. Nursing observed the resident performing self-feeding and verified that the resident knew how to tube-feed and hydrate himself. The resident preferred doing this procedure himself, while nursing observed to assure the resident was fed and hydrated. On 06/29, He does own g-tube flushes and care. Nurse gets medication ready and he self-administers via g tube. On 06/30, resident self-administered medications with nurse present. On 07/01, resident self-administers medications with nurse present. On 07/02, resident self-administers medications with nurse present. On 07/03, resident self-administers medications with nurse present. On 07/06, resident does own g-tube flushes hydration and administers medications. The nurse prepares the medications. On 07/09, resident self serves g-tube and does not allow staff to access. The nurse crushes and provides medications. On 07/10, resident self-administers hydration and nutrition via g tube. Medications pulled by staff and resident administers via g- tube. On 07/13, self-administers medications with nurse present. On 07/13, 4 p.m. Resident refused Gabapentin, it doesn't work for me and I don't want it I have the right to refuse. All medications via g-tube pulled by nurse. Will not allow nurses to administer. Resident was angry that nurse needed to watch him administer medications. Resident does own bolus and 105292 Page 2 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0554 flushes. Level of Harm - Minimal harm or potential for actual harm On 07/18-observations of self- administration evaluation by Staff A, Licensed Practical Nurse, Unit Manager (LPN, UM) performed Residents Affected - Few On 07/19, resident self-administers medications with the nurse present. On 07/27, 5 a.m., Resident told the writer in the hallway while the writer was giving him his meds, that he could make the writer lose her license. Resident did not take Gabapentin and Lipitor, stated that they don't do anything. Informed the on-call doctor regarding refusal of medication. Duloxetine (Cymbalta) was changed to Drizalma (same medication just in different form) to go down resident's g-tube. On 07/27, at 3:33 p.m. All medications were crushed by nurse and given to the resident to administer through g-tube. Resident administered drugs in front of the nurse and the nurse stayed until all drugs were dispersed through the g-tube. The resident refused Cymbalta because he stated, according to google it is not a good drug. Writer educated resident on the benefits of Cymbalta, but resident stated that he trusted google more than any nurse. On 08/06, at 1:16 p.m. the resident refused all his medications except Lacosamide (Vimpat), Clonazepam (Klonopin) and Suboxone On 08/07 at 10:38 a.m. the resident refused all his medications except Lacosamide (Vimpat), Clonazepam (Klonopin), Levetiracetam (Keppra)in the a.m. Record review of the Observation Detail List Report on 07/18/2023, performed by Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM) Does resident want to self-administer medications? Yes, all meds What is resident's daily decision-making ability? Independent Would the medication regimen be changed so frequently that resident may get confused? No Can resident name dosage, frequency, and reason for use of each medication? NA, facility will set up meds for resident Can resident tell time and state the time that each medication is due? N/A, facility will set up meds for resident Can resident read the prescription label and identify each medication? N/A, facility will set up meds for resident Can resident open each medication container (s) and pour pills out of bottle or punch out of card/package? No Can resident properly dispense eye drops, inhalers, nebulizers, and nasal sprays, etc.? No Can resident swallow medication without altering the dispensing form: No 105292 Page 3 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0554 Is resident at risk or have history of choking, aspiration, or other swallowing difficulties? Yes Level of Harm - Minimal harm or potential for actual harm Does resident have a history of non-compliance with medications or other treatments? Yes Based on the answers, is it appropriate for resident to self-administer any medications? Yes Residents Affected - Few If yes, what medications could resident self-administer? All Where will self-administered medications be stored? Nursing Medication Cart Indicate Care Plan action taken. Initiate Plan of Care Record review of the Care plans showed self-administering of medications was not found. Review of the Mood State care plan showed the resident has become very demanding when medication time and approaches nursing. Resident also verbally abusive and threatening to nursing staff during medication pass. Approach on 06/20/23 showed nursing will explain to resident he would get all meds as ordered. Approaches dated 07/26/23 showed crush meds in front of resident, observe resident take meds, show meds to resident prior to crush. Review of statement written Staff A, LPN, UM, not date, showed he spoke with the Advanced Practice Registered Nurse (APRN) a day or two after Resident #1 admit, ability to self-administer his medications. He stated Because of his past history of self-administration before he came to the facility and his refusal to allow us to administer meds through his g-tube. It was agreed we could crush the meds and observe him self-administer through the g-tube. Reviewed In-Service Education sheet dated 07/26/23 conducted by the Director of Nursing (DON) showing the program title objectives were to: ensure that medications are not left at resident bedside, signed by 5 LPNs. Reviewed In-Service Education sheet dated 07/26/23 conducted by the Director of Nursing (DON) showing the program title objectives were to: resident in room [ROOM NUMBER]B prefers medications whole and shown to him prior to crushing, signed by 4 LPNs. During an interview on 08/07/2023 with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), he stated that Resident #1 was very unhappy about everything. Speech Therapy (ST) evaluated the resident and concluded that he was not able to have a full diet. Staff A stated he had called the physician at some time, and it was okay for the resident to give his own medications. The resident was doing it on the streets before he got here. Staff A stated he had a conversation with the physician about the second day the resident came at the facility, he was unable to recall if he documented the conversation or not. Staff A, LPN reviewed the progress notes regarding self-administering medications and calling of the physician and was unable to locate any documentation. He stated the resident should have had a self-administering evaluation before 07/18/23, because he had been administering his medications from close to admission. He stated that he was unable to find a note that the Interdisciplinary Team (IDT), which should have included the Director of Nursing (DON), clinical nurse, and ST about the capability of self-administering his medications. He stated We would have discussed it in morning clinical meeting, but we do not document the clinical meetings. He stated that the ST did not write a note about his aspirations, and strong tendency to aspirate. He stated he was told during the clinical meeting that the self-administering of medications would be added to the care plan. He 105292 Page 4 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0554 reviewed the care plans and verified the self-administering of medications was not in the care plans. Level of Harm - Minimal harm or potential for actual harm Medication observation on 08/07/2023 at 9:25 a.m. with Staff C, LPN for Resident #1. She was located at the end of the hallway. She pushed her medication cart down the hallway to Resident #1's room. She removed Clonazepam (Klonopin) 1 mg via g-tube three times a day for anxiety; Lacosamide (Vimpat) 100 mg twice a day via g-tube for seizures; and Levetiracetam (Keppra) 500 mg/5 milliliter (ml) via g-tube for seizures. The resident refused all other medications. She handed the resident the crushed medications and he administered them via his g-tube in the hallway. Residents Affected - Few During an interview on 08/07/2023 at 1:12 p.m. with the Nursing Home Administrator (NHA) stated the resident thinks he knows more than the staff and the physician. Continuing, she said He will not stop talking to get provided any education. He threatens the staff and the building. We had a chat the middle of last week about his behavior and he apologized. He was disruptive the next day. During an interview on 08/07/2023 at 3:48 p.m. with Staff C, LPN stated she had cared for the resident. He was a difficult resident. She gives him his medication and he puts them in the g-tube himself. Record review of the facility's policy, Self-Administration of Medications, revised February 2011 showed residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. the medication is appropriate for self-administration; 3. If it deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and / or decision making status. Record review of the facility's policy, Care Planning - Interdisciplinary Team, not dated showed the interdisciplinary team is responsible for the development of resident care plans. 2. Comprehensive, person-centered care plans are based on resident assessments and developed by and interdisciplinary team (IDT). 3. The IDT includes but is not limited to: a. the resident's attending physician; b. a registered nurse with responsibility for the resident; c. a nursing assistant with responsibility for the resident; d. a member of the food and nutrition services staff; to the extent practicable, the resident and / or the resident's representative; and f. other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. 105292 Page 5 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to thoroughly investigate an allegation of neglect related to administration of medications inappropriately for 1 of 3 sampled residents (#1). Residents Affected - Few Findings included: Resident #1 was admitted on [DATE]. Record showed diagnoses included but were not limited to nontraumatic subarachnoid hemorrhage, dysphagia after Cerebrovascular Accident (CVA), weakness, dysphasia, epilepsy, gastrostomy tube (g-tube), right below knee amputation, anxiety, hypertension, depression, and asthma. Record review of the 5-day, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Section E, Behavior showed verbal behavioral symptoms directed toward others occurred 1 to 3 days. Section G, Functional Status showed he needed supervision with bed mobility, transfers, and toileting. Section N, Medications showed he was taking the following medications: antianxiety, antidepressants, diuretics, and opioids. Observed Resident #1 on 08/07/2023 at 9:25 a.m. sitting in his wheelchair in his doorway of his room. The resident appeared clean and dressed for the day. He stated he was waiting on the nurse to come and give him medications. His g-tube was able to be observed. Record review of the physician orders showed the following: Diet clarification order for Puree texture and honey thick liquids as of 07/14/23 Clonazepam (Klonopin) 0.5 milligram (mg) via g-tube every 8 hours as needed for anxiety as of 06/13/23 to 06/23/23 Clonazepam (Klonopin) 0.5 mg via g-tube three times a day for anxiety as of 06/23/23 to 07/31/23 Clonazepam (Klonopin) 1 mg via g-tube three times a day for anxiety as of 07/31/23 Duloxetine (Cymbalta) delayed release 30 mg via g-tube, twice a day for depression from 06/13/23 to 07/27/23 Drizalma (Cymbalta) sprinkles delayed release 30 mg via g-tube twice a day for epilepsy as of 07/27/23 Gabapentin 600 mg via g-tube for polyneuropathy Lacosamide (Vimpat) 100 mg twice a day via g-tube for seizures Levetiracetam (Keppra) 500 mg/5 milliliter (ml) via g-tube for seizures as of 06/13/23 Suboxone 8-2 mg sublingual three times a day for alcoholism and drug addiction Tizanidine 4 mg via g-tube for muscle spasms as of 06/13/23 May crush meds unless otherwise indicated 105292 Page 6 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the investigation, on 07/26/23, regarding the accusation the nurse leaving the meds crushed at the bedside for him to self-administer. Review of the written statement from Staff B, Licensed Practical Nurse (LPN) dated 07/28/23 showed I, Staff B, spoke to the state agency. I was questioned about the care of Resident #1. I was questioned about the medication administration to which I answered to. The few times that I was on the South Cart and took care of Resident #1. I crushed the medication, followed him to his room where I observed him snorting medication. He became very belligerent and verbally abusive. After that I crushed and administered medication according to protocol and MD orders, even though he said he could do it himself, which is through g-tube and flush with H2O before and after medication. Review of Resident #1's written statement, dated 07/26/23 showed, I just wanted the nurses to watch me take my meds so that there would be no problem coming back to me, saying I was given them, taken back to my room and something happen to them. Do not want no one in trouble, just want things done right. So, nothing comes back on me. They are all good people. Review of the written statement from Staff A, LPN, dated 08/02/23, (event occurred after the allegation) which was included in the investigation showed the event occurred on 08/01/23. the document showed On the morning of August 1, I was doing the 6 a.m. medication pass on the South Hall when Resident #1 approached me and stated that he was ready for the 6 a.m. medications. I brought up his MAR and the only medication due was Suboxone, which I administered. Resident #1 began yelling that he wanted a Clonazepam. I double-checked the MAR (medication administration record) to ensure the due time, and it showed it was due at 9 a.m. I explained this to Resident #1, and he began yelling and cursing at me. He told me he was going to report me to state and that he would have them, take your f_____g license. Resident #1 kept yelling and ended up stating I won't be happy until I see that place shut down and all you f_____g nurses lose your licenses. I continued with my medication pass while Resident #1 placed a call on his cell phone. Reviewed In-Service Education sheet dated 07/26/23 conducted by the Director of Nursing (DON) showing the program title objectives were to: ensure that medications are not left at resident bedside, signed by 5 LPNs. Reviewed In-Service Education sheet dated 07/26/23 conducted by the Director of Nursing (DON) showing the program title objectives were to: resident in room [ROOM NUMBER]B prefers medications whole and shown to him prior to crushing, signed by 4 LPNs. During an interview on 08/07/2023 with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), he stated that Resident #1 was very unhappy about everything. Staff A stated they had ordered the sprinkled Cymbalta for him, but he will not take it because he looked it up on google and did not like what it said about the medication. Staff A stated We just changed the Cymbalta to sprinkles a couple of weeks ago (July 27) per the MAR. Staff A agreed that the Cymbalta but was now in sprinkle form, and he was refusing it. During an interview on 08/07/2023 at 1:12 p.m. with the Nursing Home Administrator (NHA) stated the resident thinks he knows more than the staff and the physician. The NHA stated the state agency came in on 07/26/23, while she was not at the facility, and the resident had told the state agency worker he had been given his medications whole. She stated the DON told her (NHA) there were certain medications he did not want crushed but the NHA did not know the names of the medications. The NHA stated they were opening the Cymbalta capsule and she did not know if you were supposed to open the 105292 Page 7 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few capsule or not, stating she was not a nurse. The NHA stated the DON interviewed Staff B, but nothing was in writing about that conversation with Staff B. The NHA reviewed Staff B's statement and agreed the statement was confusing or incomplete and the DON and / or Staff B should have described the medications Staff B was referring to. The NHA stated she and the DON interviewed the resident. She asked the resident to tell her what happened and his concerns. She had a written statement from the resident. After the written statement, the DON changed the medication orders to include an order to show him his medications before crushing them, and to watch him take them via g-tube. She stated the DON educated the nurses on this order. The NHA reviewed the in-service sheets. The NHA stated that was the completion of her investigation and she did not substantiate the allegation; because she was not sure what the resident was complaining about. Staff B will be in-serviced when she returns to work and will be observed regarding medication pass. The DON will check off weekly the nurse observations. The NHA stated she was not aware of medications being given whole and placed in pudding. The resident wrote he wanted the staff to come back to his room and watch him take the medications. She was not aware how Cymbalta was to be given. Record review of the facility's policy, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 2023 showed it is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources . The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. 3. An alleged violation: a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect or abuse .6. Investigation: the facility will investigate all allegations and types of incidents as listed above in accordance to the facility procedure for reporting/responses as described below. Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: 2. The Administrator or designee will: f. within 5 days of the incident, report sufficient information to describe the results of the investigation, and indicates any corrective actions taken, if the allegation was verified. 105292 Page 8 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

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 observations, interviews, and record review the facility failed to provide pharmaceutical services including administration of all drugs accurately for 1 of 3 sampled residents (#1) related to crushing of Cymbalta before administering via gastrostomy tube and /or administering it whole. Findings included: Resident #1 was admitted on [DATE]. Record showed diagnoses included but were not limited to nontraumatic subarachnoid hemorrhage, dysphagia after Cerebrovascular Accident (CVA), weakness, dysphasia, epilepsy, gastrostomy tube (g-tube), right below knee amputation, anxiety, hypertension, depression, and asthma. Record review of the 5-day, Minimum Data Set (MDS) dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Section E, Behavior showed verbal behavioral symptoms directed toward others occurred 1 to 3 days. Section G, Functional Status showed he needed supervision with bed mobility, transfers, and toileting. Section N, Medications showed he was taking the following medications: antianxiety, antidepressants, diuretics, and opioids. Observed Resident #1 on 08/07/2023 at 9:25 a.m. sitting in his wheelchair in his doorway of his room. The resident appeared clean and dressed for the day. He stated he was waiting on the nurse to come and give him medications. His g-tube was able to be observed. Record review of the physician orders showed the following: Diet clarification order for Puree texture and honey thick liquids as of 07/14/23 Clonazepam (Klonopin) 0.5 milligram (mg) via g-tube every 8 hours as needed for anxiety as of 06/13/23 to 06/23/23 Clonazepam (Klonopin) 0.5 mg via g-tube three times a day for anxiety as of 06/23/23 to 07/31/23 Clonazepam (Klonopin) 1 mg via g-tube three times a day for anxiety as of 07/31/23 Duloxetine (Cymbalta) delayed release 30 mg via g-tube, twice a day for depression from 06/13/23 to 07/27/23 Drizalma (Cymbalta) sprinkles delayed release 30 mg via g-tube twice a day for epilepsy as of 07/27/23 Gabapentin 600 mg via g-tube for polyneuropathy Lacosamide (Vimpat) 100 mg twice a day via g-tube for seizures Levetiracetam (Keppra) 500 mg/5 milliliter (ml) via g-tube for seizures as of 06/13/23 Lisinopril-hydrochlorothiazide 20-12.5 mg via g-tube for hypertension as of 06/13/23 Suboxone 8-2 mg sublingual three times a day for alcoholism and drug addiction 105292 Page 9 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 Tizanidine 4 mg via g-tube for muscle spasms as of 06/13/23 Level of Harm - Minimal harm or potential for actual harm Omeprazole delayed release 20 mg daily via g-tube for gastro-esophageal reflux May crush meds unless otherwise indicated Residents Affected - Few Review of June 2023 Medication Administration Record (MAR) showed the following medication was given: Duloxetine / Cymbalta delayed release 30 mg twice a day for depression was given twice a day per documentation. Review of July 2023 MAR showed the following medication was given: Duloxetine / Cymbalta delayed release 30 mg twice a day for depression was given twice a day per documentation 1st through 22nd, 24th and 26th 2023 Record review of the progress notes showed: Between 06/15 and 06/28 the documentation showed the resident tolerated medication without signs and symptoms (s/s) of adverse effects. On 06/29, the writer stated the resident came to the facility with the ability to administer his own tube feedings and water flushes. Nursing observed the resident performing self-feeding and verified that the resident knew how to tube-feed and hydrate himself. The resident preferred doing this procedure himself, while nursing observed to assure the resident was fed and hydrated. On 07/06, resident does own g-tube flushes hydration and administers medications. The nurse prepares the medications. On 07/09, resident self serves g-tube and does not allow staff to access. The nurse crushes and provides medications. On 07/10, resident self-administers hydration and nutrition via g tube. Medications pulled by staff and resident administers via g- tube. On 07/27, 5 a.m., Resident told the writer in the hallway while the writer was giving him his meds, that he could make the writer lose her license. Resident did not take Gabapentin and Lipitor, stated that they don't do anything. Informed the on-call doctor regarding refusal of medication. Duloxetine (Cymbalta) was changed to Drizalma (same mediation just in different form) to go down resident's g-tube. On 07/27, at 3:33 p.m. All medications were crushed by nurse and given to the resident to administer through g-tube. Resident administered drugs in front of the nurse and the nurse stayed until all drugs were dispersed through the g-tube. The resident refused Cymbalta because he stated, according to google it is not a good drug. Writer educated resident on the benefits of Cymbalta, but resident stated that he trusted google more than any nurse. Review of the Mood State care plan showed the resident has become very demanding when medication 105292 Page 10 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few time and approaches nursing. Resident also verbally abusive and threatening to nursing staff during medication pass.Approaches dated 07/26/23 showed crush meds in front of resident, observe resident take meds, show meds to resident prior to crush. Record review of the facility's investigation, on 07/26/23, showed an accusation of the nurse leaving the medications crushed at the bedside, including Cymbala and narcotics for the resident to self-administer. Review of the written statement from Staff B, Licensed Practical Nurse (LPN) dated 07/28/23 showed I, Staff B, spoke to the state agency. I was questioned about the care of Resident #1. I was questioned about the medication administration to which I answered to. The few times that I was on the South Cart and took care of Resident #1. I crushed the medication, followed him to his room where I observed him snorting medication. He became very belligerent and verbally abusive. After that I crushed and administered medication according to protocol and MD orders, even though he said he could do it himself, which is through g-tube and flush with H2O before and after medication. Review of Resident #1's written statement, dated 07/26/23 showed as is stated, I just wanted the nurses to watch me take my meds so that there would be no problem coming back to me, saying I was given them, taken back to my room and something happen to them. Do not want no one in trouble, just want things done right. So, nothing comes back on me. They are all good people. Reviewed In-Service Education sheet dated 07/26/23 conducted by the Director of Nursing (DON) showing the program title objectives were to: ensure that medications are not left at resident bedside, signed by 5 LPNs. Reviewed In-Service Education sheet dated 07/26/23 conducted by the Director of Nursing (DON) showing the program title objectives were to: resident in room [ROOM NUMBER]B prefers medications whole and shown to him prior to crushing, signed by 4 LPNs. During an interview on 08/07/2023 with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), he stated that Resident #1 was very unhappy about everything. Staff A stated they had ordered the sprinkled Cymbalta for him, but he will not take it because he looked it up on google and did not like what it said about the medication. Staff A stated We just changed the Cymbalta to sprinkles a couple of weeks ago (July 27) per the MAR. Staff A agreed that the Cymbalta but was now in sprinkle form, and he was refusing it. During an interview on 08/07/2023 at 1:12 p.m. with the Nursing Home Administrator (NHA) stated the resident thinks he knows more than the staff and the physician. The NHA stated the state agency came in on 07/26/23, while she was not at the facility, and the resident had told the state agency worker he had been given his medications whole. She stated the DON told her (NHA) there were certain medications he did not want crushed but the NHA did not know the names of the medications. The NHA stated they were opening the Cymbalta capsule and she did not know if you were supposed to open the capsule or not, stating she was not a nurse. The NHA stated the DON interviewed Staff B, but nothing was in writing about that conversation with Staff B. The NHA reviewed Staff B's statement and agreed the statement was confusing or incomplete and the DON and / or Staff B should have described the medications Staff B was referring to. The NHA stated she and the DON interviewed the resident. She asked the resident to tell her what happened and his concerns. She had a written statement from the resident. After the written statement, the DON changed the medication orders to include an order to show him his medications before crushing them, and to watch him take them via g-tube. She stated the DON 105292 Page 11 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few educated the nurses on this order. The NHA reviewed the in-service sheets. The NHA stated that was the completion of her investigation and she did not substantiate the allegation; because she was not sure what the resident was complaining about. Staff B will be in-serviced when she returns to work and will be observed regarding medication pass. The DON will check off weekly the nurse observations. The NHA stated she was not aware of medications being given whole and placed in pudding. The resident wrote he wanted the staff to come back to his room and watch him take the medications. She was not aware how Cymbalta was to be given. During an interview on 08/07/2023 at 3:34 p.m. with the consultant pharmacist he stated that the capsule for Cymbalta can be opened, but the medication should not be crushed. The medication can be given via g-tube, but not crushed. The capsule dissolves when it hits the stomach anyway but the medication inside is the extended-release part. During an interview on 08/07/2023 at 3:48 p.m. with Staff C, LPN stated she had cared for the resident. She stated he will pick and choose which medications he wants to take. He is only taking three medications currently. She stated that she took the Cymbalta capsule apart and put it in with the other medications and crushed them all together. She gives him his medication and he puts them in the g-tube himself. Record review of the facility's policy, Medication Administration, revised 05/30/2023 showed medications are administered by licensed nurses in a manner to prevent contamination or infection. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. A refer to drug reference material if unfamiliar with the medication, including the mechanism of action or common side effects. 14. Administer medication as ordered in accordance with manufacturer specifications. C. crush medication as ordered. Do not crush medications with do not crush instructions. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Do not Crush Medications: slow release; enteric coated; crushed meds are not to be combined an given all at once, if via feeding tube. 105292 Page 12 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to follow infection control protocols related to medication administration and transmission based isolation protocol on one (08/07/2023) of one survey days. Residents Affected - Few Findings included: Medication observation on 08/07/2023 at 9:25 a.m. with Staff C, Licensed Practical Nurse (LPN) for Resident #1. She was located at the end of the hallway. She pushed her medication cart down the hallway to Resident #1's room. She removed Clonazepam (Klonopin) 1 mg (milligrams) via g-tube three times a day for anxiety; Lacosamide (Vimpat) 100 mg twice a day via g-tube for seizures; and Levetiracetam (Keppra) 500 mg/5 milliliter (ml) via g-tube for seizures. The resident refused all other medications. She handed the resident the crushed medications in the same cup and he administered them himself via his g-tube in the hallway. She was then seen pouring up Resident #10's medications at 9:40 a.m., Amlodipine 10 mg daily and Duloxetine 60 mg daily and handing them to the resident. When asked about hand hygiene which she had not done before administering Resident #1s medications nor after and not after administration of Resident #10's medication. She stated that she washes her hands in the resident's rooms. Staff C, LPN (licensed practical nurse) was observed continuing to administer medications without hand hygiene. During an observation on 08/07/23 at 9:15 a.m. Staff D, Certified Nursing Assistant (CNA) exited room [ROOM NUMBER] which was an isolation room with her Personal Protective Equipment (PPE) on and crossed the hallway. She then re-entereed the isolation room and shut the door. After exiting the room, she was also observed walking the halls throughout the day with her mask off or under her nose. Staff D, CNA was standing outside room [ROOM NUMBER], isolation room, conversing with another staff member, when asked about her mask being off; she stated she was showing the other aide which mask to wear. Record review of the In-service Education Sheet dated 08/01/2023 showed it was presented by Staff A, LPN, Unit Manager (UM) and Staff E, the Kitchen Manager / Infection Preventionist related to infection control, including the glove policy, handwashing, COVID prevention, and testing on Wednesdays. Staff C, LPN attended the in-service on 08/07/23 and Staff D, CNA attended on 08/01/23. During an interview on 08/07/2023 at 2:14 p.m. with Staff E, Kitchen Manager / Infection Preventionist stated she had worked for the facility for just over a year. She stated she did the Infection Prevention course through the Centers for Disease Control, and said she divides the Infection Control responsibilities with the Director of Nursing (DON) and the Unit Manager (UM). She stated one resident was positive with COVID-19 on 07/24/23, 3 more positive on 07/30/23, 3 more on 08/02/23, 5 more on 08/03/23. She said resident retesting would occur on 08/08/23 and 08/09/23. Staff E said they have had 17 staff members test positive since 07/24/23. She confirmed COVID-19 residents are placed on airborne precautions, and staff was required to wear all the PPE (personal protective equipment) when going in the isolation rooms. She stated the staff member (D) should not have entered the isolation room and exited with her PPE on and reentered, stating That was unacceptable. She stated masks were to be worn at all times on the floor, and the staff are to perform hand hygiene before, between and after resident's medication administrations. She stated they had been providing education to both the residents and staff related to Infection Control, which consisted of hand washing, wearing masks, and donning and doffing of PPE. She was only able to provide one in-service education sheet which 105292 Page 13 of 14 105292 08/07/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0880 Staff D, CNA did attend. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy, Medication Administration, revised 05/30/2023 showed medications are administered by licensed nurses in a manner to prevent contamination or infection. 4. Wash hands prior to administering medication per facility protocol and product. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. A refer to drug reference material if unfamiliar with the medication, including the mechanism of action or common side effects. 14. Administer medication as ordered in accordance with manufacturer specifications. C. crush medication as ordered. Do not crush medications with do not crush instructions. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Do not Crush Medications: slow release; enteric coated; crushed meds are not to be combined an given all at once, if via feeding tube. Residents Affected - Few Record review of the facility's policy, Policies and Practices - Infection Control, dated 2001 showed the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. 2. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility; b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions. 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, Record review of the facility's policy, Infection Control Guidelines for all Nursing Procedures, dated 2012 showed 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and / or mucous members. Transmission - Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. A. before and after direct contact with residents; d. before preparing and handling medications; 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. Record review of the facility's policy, Monitoring Compliance with Infection Control, not dated showed routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices. 1. The infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and practices. 2. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies . Record review of the facility's policy, Handwashing/Hand Hygiene, dated 2001 showed this facility considers hand hygiene the primary means to prevent the spread of infection. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 7. Use an alcohol-based hand rub or alternatively soap and water for the following situations: c. before preparing or handling medications; n. before and after entering isolation precaution settings. 105292 Page 14 of 14