Health inspection·September 1, 2022

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of the Food Committee meeting minutes and the facility policy on Grievances/Complaints, Filing; interview with the Dietary Manager, and interview and observation of eight residents (#157, #160, #159, #158, #38, #15, #30, #72) at meals, the facility failed to resolve a concern related to receiving condiments at meals voiced at the Food Committee meeting. Residents Affected - Few Findings included: An interview was conducted with Resident #157 on 08/29/2022 beginning at 10:30 a.m. He reported that the breakfast meal was always great with the lunch and dinner meal so-so. He said he was never given salt and pepper and was told he had to ask the aides for it when they brought his tray. He said he sometimes would remember to ask before they brought the tray, but if he forgot they often forgot also. He said he liked sandwiches at lunch, not the hot meal, but usually it didn't come with mayonnaise or mustard. He said sometimes he waited for someone to being him the condiment and sometimes he went without. A second visit with Resident #157 on 08/30/2022 at 12:30 p.m., during lunch, confirmed that salt and pepper were not delivered on the trays and only salad dressing for his salads was consistently provided. He said other kinds of condiments, such as ketchup or mayonnaise were not provided. On 09/01/2022 from 8:20 a.m. until 9:00 a.m., visits were made to seven residents who confirmed the meal trays never had salt and pepper. Resident #160 reported that there was no salt or pepper and usually no other condiment, like jelly at breakfast. The resident said there was only one margarine served as well. Resident # 159 reported that there was never any salt and pepper and even if you asked someone to bring you some, they usually forgot. Resident #158 reported that there wasn't any salt or pepper served but he confirmed he didn't really miss it either. Resident # 38 confirmed that she couldn't have the salt but there never was any pepper, so she did without. A small jar of mayonnaise was observed on her table and she smiled and confirmed that she liked her mayonnaise. Resident # 15 confirmed there never was any salt and pepper but commented that he ate everything this morning anyway. A small plastic cup of condiments was noted on his side table. Resident # 38 confirmed that there was never any salt and pepper or sugar. He confirmed he usually Page 1 of 13 105305 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0565 Level of Harm - Minimal harm or potential for actual harm got his salad dressing for his side salads. He reported that if the meal was a sandwich there was never any mayonnaise or mustard to use on the sandwich. Resident # 72 reported that he received many additional items to his main meal, but never any salt and pepper or any other kind of condiment. Residents Affected - Few A review was made of the Food Committee meeting minutes from March 2022 until August 2022. The 07/05/2022 meeting minutes included under New Meeting Information: Not enough condiments and Sugar in tea. The 07/19/2022 meeting listed a new concern (too many cold meals on menu) under Past Meeting Information/Follow up rather than the voiced concerns from the 07/05/2022 meeting. On 09/01/2022 at 1:30 p.m. the Dietary Manager was asked about the resolution to the two voiced concerns. She reported she spoke to her dietary aides during tray line to remind them to put condiments that were appropriate to the meal on the trays. She didn't think she had documented the discussion with the staff. When asked about the sugar in the tea, she reported that the sweet iced tea concern was specific to one resident and they had solved the concern for that one resident by ensuring she always got several sugar packets at meals to add to her tea. When asked what nursing said or did to assist in resolving the issue, she said she hadn't shared it with nursing. She confirmed that salt and pepper and sugar are on the top of the cart that delivers the meal trays to the units. A review of the facility policy, Grievances/Complaints, Filing revealed the Policy Statement indicated residents and their representatives have the right to file grievances . and the Administrator and staff will make prompt efforts to resolve the grievances to the satisfaction of the resident and/or representative. Point #3 under Policy Interpretation and Implementation read: All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. 105305 Page 2 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to implement their Weight Assessment and Intervention Policy by developing a care plan relevant to weight loss and failed to implement the care plan that had been developed on 02/19/2021 and revised on 04/09/2021 and 03/14/2022, for one (Resident #20 ) of 48 sampled residents related to weight loss. Findings included: Resident #20 was re-admitted to the facility on [DATE] with multiple diagnoses that included Multiple Sclerosis, heart disease, and depression. A review of the resident's monthly weights revealed weight loss from 179 lbs (pounds) on 01/06/2022 to 159 lbs on 08/03/2022. In six months, from 02/02/2022 when the resident was weighed at 175.5 lbs, until 08/03/2022, the resident sustained a weight loss of 16.5 lbs or 9%. Resident #20 weighed 173 lbs on 06/07/2022, 168 lbs on 07/04/2022, and 159 lbs on 08/03/2022. Weight loss for this resident was continuing without changes to the care plan or to the resident's diet order. The change in weight from 07/04/2022 when the resident weighed 168 lbs. to 08/03/2022 when the resident weighed 159 lbs, was a loss of 9 lbs or 5.3% , which is considered significant. Review of the resident's medical record revealed a Weight Warning note dated 08/30/2022 which documented the resident's weight at 159.1 lbs, which was a negative 5% change over 30 days. The note read: weight loss is questionable since resident has a good appetite and consumes more than 75% of most meals. Requested a re-weight from nursing. Diet is regular, thin liquids and tolerated well. Will follow up once re-weight. This weight warning was written 27 days after the weight was taken, which was identified as a negative 5% change in 30 days. A reweigh was documented on 09/01/2022 and indicated continued weight loss with weight documented at 158.6 lbs. A Nutrition Full Assessment was completed on 08/30/2022 . It was identified as a significant change assessment. The assessment documented the resident's diet as regular with thin liquids with an excellent intake . No supplements were in place. Diet history confirmed the resident independently consumed three meals per day with at least 75% intake at most meals. The resident had all his teeth and there were no chewing or swallowing difficulties noted. The resident's height was 72 with an ideal body weight range of 178 lbs +/- 5%. The assessment documented that the resident was at 99% of his ideal body weight. Weight history documented a 5% or more loss in one month. Estimated needs (2400 calories and 96 grams protein) were calculated for maintenance and his intake of his diet, supplement, nourishments, and snacks were noted to meet or exceed 100% of his needs. (The assessment identified that there were no supplements in place.) 105305 Page 3 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There were no labs to review and no request was made to order labs to help in determining why there had been significant weight loss. The assessment's Problem Etiology Statement (PES) read: at risk of weight loss due to diagnosis of MS (Multiple Sclerosis). The assessment summary read: Resident remains at nutrition risk r/t (related to ) MS, depression and HTN (hypertension). Resident remains on a regular diet. Tolerating diet. Skin remains intact. Weight loss of 5% in one month seems questionable , po (by mouth) intake of meals is 75% or greater. Asked nursing for re-weight since his po intake is good. The interventions and monitoring from the assessment were continue current plan of care. monitor weights monthly. An annual Minimum Data Set (MDS) Assessment was conducted on 03/02/2022 which identified the resident as having a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. He was able to eat his meals with supervision after being provided with set up assistance. A quarterly MDS was conducted on 06/01/2022 which identified the BIMS score as not having changed but the resident required supervision or encouragement at meals with one staff physically assisting him with his meal. In an interview on 08/31/22 at 9:00 a.m., the resident was observed sitting up in bed, watching television with his breakfast on the over the bed table in front of him. When asked how his breakfast was, he responded that it was good and he confirmed he had eaten most of it. When asked if he thought he had lost weight, as the record showed he had, he was thoughtful but then answered no, he didn't think he had lost weight. He reported that he thought he ate most of his meals. Later in the day on 08/31/22, at 12:35 p.m. the resident was observed sitting up in bed with his lunch in front of him. The resident hadn't eaten anything from the plate and he was just looking at it. Resident #20 said he wasn't hungry yet. The resident's Certified Nursing Assistant , Staff A, approached the doorway and reported that he ate a good breakfast and she would help him if he did not' eat some on his own. The care plan developed for Resident #20 for the Focus area of at risk for/has actual alteration in nutritional status r/t advancing disease process. H/o [history of] MS, weight loss. The Focus area was initiated on 02/19/2021 with a revision date of 04/09/2021. The first Goal of the care plan was for the resident not to exhibit any signs of aspiration (i.e. shortness of breath, fever, coughing, etc.) through next review. The second Goal of the care plan was for the resident to consume 50-75% of at least three meals every day through the next review. Relevant interventions included: document food choices and report changes; evaluate for reversible causes of weight loss, anorexia, or dehydration as appropriate (i.e. medication, pain, nausea, gastrointestinal disturbance, depression, oral pain, etc.); monitor lab work as ordered; Weigh weekly x 4 weeks (or until stable) subsequent to admission and monthly thereafter unless otherwise indicated. (The interventions were initiated on either 02/19/2021 or 04/25/2021.) An interview was conducted with one of two of the facility's Registered Dietitians (Staff E) on 09/01/2022 beginning at 10:57 a.m. She confirmed she had not assessed this resident but after reading the weight warning and the nutrition assessment confirmed that the resident had sustained a significant weight loss. She commented that there was no nutrition recommendation made except for a re-weight and both (the assessment and request for a reweigh) had occurred almost one month after the weight 105305 Page 4 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0656 of 159 lbs was documented. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy entitled Weight Assessment and Intervention revealed the Policy Statement read: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The Policy gave direction related to Weight Assessment that included: Residents Affected - Few 3. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss = (usual weight - actual weight )/(usual weight ) x 100: a. 1 month - 5% weight loss is significant; greater than 5% is severe. The policy gave direction for Care Planning which included: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. Resident #20's care plan did not include an identified cause of the weight loss, there were no specific goals or benchmarks for improvement and no parameters for monitoring and reassessment. 105305 Page 5 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) tasks for residents who required assistance to address soiled fingernails for one (Resident #207) of three residents sampled for ADL care. Residents Affected - Few Findings included: Review of Resident #207's record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated severe cognitive impairment. Review of the admission readmission Nursing Packet dated 08/12/2022, revealed under the ADL Evaluation section the resident was coded as X 1 Staff Total Dependence (Resident Does Not Participate In Activity At All) regarding how much assistance the resident required with personal hygiene. Review of the resident's care plan dated 8/12/22 with a revision on 8/29/22 related to OT (Occupational Therapy) evaluation complete. Resident requires assistance with ADL functions. Review of the Certified Nursing Assistant's (CNA) documentation of the resident's Personal Hygiene Self Performance for the past 30 days revealed this task was completed with mostly Total Dependence. Review of the North Shower Schedule revealed that Resident #207 had showers scheduled for Wed/Sat (Wednesday/Saturday). Observations of Resident #207 on 08/29/22 at 9:25 a.m., revealed the residents' bilateral hands had fingernails that were slightly above the top of the fingers and were noted to be soiled under the nails with a black/brown substance. An observation on 08/31/22 at 3:35 p.m., of Resident #207 revealed the resident was sitting in her room. The residents' nails on her bilateral hands were noted to be soiled with a black/brown substance under the nails. During an interview with Resident #207 at this time, she reported she could not get her nails cut because her hands did not work the same anymore, but the resident said the staff could clean her nails. An observation of Resident #207 on 09/01/22 at 12:21 p.m., revealed the resident was sitting in her room and the fingernails on her bilateral hands were noted to be soiled with a black/brown substance. An interview on 09/01/22 at 12:23 p.m., with Staff F, Registered Nurse (RN) revealed the residents' fingernails were cleaned by the CNA and if the residents' fingernails were dirty, they should be cleaned as needed including on the resident's shower days. An interview on 09/01/22 at 12:25 p.m., with Staff G, CNA revealed CNA's provided nail care, and if a resident's nails were dirty, she would wash the resident's hands, and typically clean their nails on their shower days. During an observation of Resident #207's bilateral hands on 09/01/22 at 12:26 p.m., with Staff F, RN and Staff G, CNA present, Staff F and Staff G confirmed Resident #207's nails were dirty. 105305 Page 6 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Activities of Daily Living (ADLs), Supporting with a revised date of March 2018 revealed the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents Affected - Few 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: A. Hygiene, (bathing, dressing, grooming, nail care and oral care); 105305 Page 7 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to assess scratches on a resident's shins for one (Resident #9) of two residents sampled for skin conditions. Residents Affected - Few Findings included: Review of Resident #9's record revealed she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. An observation of Resident #9 on 08/29/22 at 9:54 a.m., revealed the resident's bilateral shins were noted with scratches that were dry and red in color. An observation on 08/31/22 at 3:36 p.m., revealed Resident #9 sitting in her wheelchair in her room. The resident was noted to have scratches that were red in color on her bilateral shins. An interview with the resident at that time revealed she did not know how she got the scratches and thought she scratched herself. In an interview on 09/01/22 at 11:01 a.m., the Director of Nursing (DON) said she was not aware the resident had scratches on her bilateral shins. She reported the resident had fragile skin and she would sometimes scratch her skin. The DON said they keep the residents' nails trimmed and manicured to prevent sharp edges and encourage skin moisturizing to address dry itchy skin. In an interview on 09/01/22 at 11:45 a.m., the DON revealed she took a look at Resident #9's shins and confirmed the resident had scratches on her bilateral shins. She reported the resident said she did not know how she got them and she probably scratched herself in her sleep. The DON reported the direct care staff were to document in their tasks document if scratches were observed and should notify the nurse who would assess the skin. She reported this should be done each time the skin was observed. Review of the resident record revealed no documentation that indicated the scratches on the residents' bilateral shins were identified by the facility staff. Review of the Certified Nursing Assistant (CNA) task data for the past 30 days revealed for skin observations the staff consistently documented None of the above observed which included the areas of Scratched, Red Area, Discoloration, Skin Tear, Open Area Review of the facility policy titled Prevention of Skin Impairments, with a revised date of April 2020, revealed under the sub-heading of Skin Assessment the following: 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Under the sub-heading of Monitoring the following: 1. Evaluate, report and document potential changes in the skin. 105305 Page 8 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility did not identify the specific behaviors to monitor related to the administration of psychotropic medications for two (Residents #1 and #9) of six residents sampled for unnecessary medications. Findings included: 1. A review of Resident #9's record revealed that she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. Resident #9 had diagnoses that included Major Depressive Disorder, Mood Disorder, and Anxiety Disorder, according to her face sheet. A review of the resident's physician orders revealed current orders for the use of Depakote Tablet Delayed Release 125 MG give 125 mg by mouth in the evening related to UNSPECIFIED MOOD (AFFECTIVE) DISORDER; Escitalopram Oxalate Tablet Give 10 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED; Lorazepam Tablet 0.5 MG Give 0.5 mg by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED Review of the August 2022 Medication Administration Record (MAR) revealed the monitoring of the Depakote, Escitalopram and Lorazepam were combined into one monitoring tool on the MAR. When behaviors were documented, it was noted that there was no way to decipher which behaviors were associated with which medication. Review of the resident's progress notes for the month of August 2022 revealed no entries related to what behaviors exhibited were associated with which of the three medications. An interview on 08/31/22 at 12:54 p.m. with the Director of Nursing (DON) revealed the residents' behaviors were all monitored together and each behavior number referred to the behavior. She reported the behavior was identified by what the medication was prescribed for and was different for every resident. 2. A review of the admission Record for Resident #1 revealed she was admitted on [DATE] with a Re-entry date of 08/08/22. Her diagnoses included Persistent Mood [Affective] Disorder, Major Depressive Disorder Recurrent, and Anxiety Disorder. A review of the physician orders revealed the following: Ziprasidone HCI Capsule 60 mg (milligram). Give 1 capsule by mouth two times a day for mood. Start date: 08/09/22; an order for Citalopram Hydrobromide Tablet 40 mg. Give 1 tablet by mouth one time a day for depression. Start date: 08/02/22; and an order for clonazePAM tablet 0.5 MG. Give 1 tablet by mouth two times a day for anxiety. Review of the electronic Medication Administration Record (eMAR) and the electronic Treatment Administration Record (eTAR) for the month of August included one behavior and side effects monitoring tool for use of psychoactive medication. An interview was conducted on 08/31/22 at 9:01 a.m. with Staff C, Licensed Practical Nurse (LPN), 105305 Page 9 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0758 Level of Harm - Minimal harm or potential for actual harm stating there was behavior monitoring in place for medications that cause side effects like antipsychotics, narcotics, and depression. Review of the Subsequent Psychiatric Evaluation dated 07/08/22 for Resident #1 revealed under the subsection titled Additional Recommendations: Monitor her mood, behavior, and appetite. Residents Affected - Few Review of the Psychiatric Progress Note dated 08/25/22 for Resident #1 revealed under the subsection titled Treatment Plan: Monitor for changes in mood or behaviors. An interview was conducted on 08/31/22 at 11:00 a.m. with the Director of Nursing (DON) who stated behavior monitoring was done for anxiety, depression, and psychotropic medication. During the interview, the DON looked through Resident #1's chart for behavior monitoring for depression. The DON pointed to the behavior monitoring indicated use for a psychoactive medication. DON stated the nurses would indicate for example, agitation for anxiety medication on the one behavior monitoring. Resident #1 had orders for depression, anxiety, and psychoactive medications, with one behavior monitoring order in place. An interview was conducted on 08/31/22 at 12:54 p.m. with the DON, stating they used to have behavior monitoring in place for every medication that was in place for residents, but now one monitoring was in place for all medications. She said the nurses would document the behavior and what each behavior was monitored for in the notes. The DON said for Resident #1 she showed agitation with anxiety and the nurse would document it. She noted if agency nurses were not sure about behaviors for residents such as crying, the agency nurse would ask and clarify if it was a normal behavior. At 2:53 p.m. on 09/01/2022, an interview with the Consultant Pharmacist was conducted by phone. The Pharmacist stated the expectation was for the nurses to monitor behavior that was related to the type of medication the residents were taking. For example, for an anxiolytic, nurses would monitor for anxiety or other symptoms related to anxiety. She reported behaviors such as restlessness, repeating the same question, nervousness that the resident was exhibiting could be specifically monitored for anxiety or whatever behaviors the doctor had ordered the drug for. The Pharmacist reported that notes in the healthcare provider software, by facility staff such as the Unit manager might read: this is what we have been seeing,' or the APRN (Advanced Practice Registered Nurse) might make changes and document why the changes were made. The Pharmacist said she would expect the APRN to observe the resident for symptoms and then document and maybe change the medication or dose. It was pointed out that documentation of 'anxiety' was made, but not the actual behavior - such as restlessness. The Pharmacist was reminded that only one set, or area on the eMAR was monitored, and there was no differentiation between symptoms that were documented as having occurred. Review of the policy entitled Behavioral Assessment, Intervention, and Monitoring Revised in March 2019 revealed under subsection titled Management: 10. When medications are prescribed for behavioral symptoms, documentation will include: e. Specific target behaviors and expected outcomes; 105305 Page 10 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

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, interview, and record review, the facility did not ensure the medication error rate was below 5 % for three (Residents #35, #257, and #96) of four sampled residents who were observed during medication administration. This resulted in 8 errors from 31 medication administration opportunities for a medication error rate of 25.81%. Residents Affected - Few Findings Included: 1. On 08/31/2022 at 8:47 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #35. Staff D prepared and administered the following medications: Brimonidine Tartrate 0.2% solution one drop in both eyes, multivitamin with mineral one tablet, Plavix 75 mg one tablet, Lisinopril 40 mg tablet, Duloxetine HCL capsule delayed release 60 mg, Spironolactone 25 mg one tablet, Timolol maleate solution 0.5% one drop into each eye, and Lasix 40 mg tablet one tablet. Staff D stated the resident had an ordered dose of Amitiza capsule 8 mcg give 1 capsule by mouth every 12 hours for constipation dated 07/01/2022, but it was not in the medication cart. The nurse further checked the facility contingency system, and it was not available. Medication reconciliation revealed multivitamin tablet was not ordered with mineral. 2. On 08/31/22 9:57 a.m., a medication administration observation was conducted alongside Staff B Registered Nurse as she prepared the medications for Resident #257. She performed a blood pressure that revealed systolic at 108 diastolic at 55 and pulse 72. The following medications were administered: Amlodipine besylate tablet 5 mg one tablet, Combivent aerosol solution 20-100 mcg/act 2 puffs, Eliquis 2.5 mg one tablet, Lexapro 10 mg one tablet, vitamin C 250 mg one tablet, multi-vite liquid 15 cc, and iron supplement 220/ 5 ml liquid. Reconciliation revealed: Amlodipine besylate tablet 5 mg per gastroesophageal tube (g-tube) one time a day for hypertension hold for Hold for systolic blood pressure (SBP) Less than 100 or diastolic blood pressure (DSP) Less than 60 or pulse less than 60 start date 08/17/2022 thus indicated the Amlodipine should have been held related to the DSP was less than 60. Additionally, orders were to administer Famotidine suspension reconstituted 40 mg/5 ml give 2.5 ml via G-tube two times a day for gastroesophageal disease (GERD) start dated 08/25/2022. The medication was not available to be given. 3. On 08/31/2022 at 10:40 a.m., medications were prepared by Staff C Licensed Practical Nurse for Resident # 96. The following medications were prepared: vitamin C 500 mg one tablet, Ferrous sulfate tablet 325 mg one tablet, Senna 8.6 mg one tablet, multivitamin with mineral one tablet, Pantoprazole 40 mg pak mixed was mixed in applesauce, Losartan potassium 75 mg one tablet, Doxazosin Mesylate 4 mg one tablet, Memantine HCL 5 mg two tablets, Metoprolol Tartrate 25 mg one tablet, Risperidone 1 mg one tablet, Zoloft 25 mg one tablet and Zoloft 100 mg one tablet, and Lorazepam 0.5 mg one tablet. Staff C confirmed she had crushed all medications and that was all that was due at that time. 105305 Page 11 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medication reconciliation revealed order for Ferrous sulfate tablet 325 mg give one time a day for hemoglobin, Swallow whole do not crush, or chew start date 6/11/2022. Folic Acid tablet 1 mg give 1 tablet by mouth one time a day for anemia start date 5/28/2022 was not administered, nor was the Systane solution 0.4-0.3 % instill 1 drop in both eyes two times a day for dry eyes dated 05/28/2022. Further review Lorazepam 0.4 mg order read to Hold if sedated, dated Resident #96 was observed tired and did not respond to verbal stimuli after multiple attempts to open his eyes, and mouth. And would not swallow his medications until water was poured into his mouth. Ativan (Lorazepam), an antianxiety agent. Elderly or debilitated patients may be more susceptible to the sedative effects of Lorazepam. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017794s044lbl.pdf. On 08/31/2022 at 1:51 p.m., an interview was conducted with Staff C as she reviewed the resident medication administration record. She confirmed that she had signed for the administration of Folic acid 1 mg. At that time, the medication cart was searched. Neither a bottle nor blister card was located that contained Folic acid 1 mg. When asked about the ordered Systane eye drops, Staff C indicated she was unaware of any ordered eye drops, yet the MAR indicated it was administered. On 08/31/22 at approximately 2:17 p.m. an interview was conducted with the Director of Nursing who was informed that concerns were identified with the medication administration observation after reconciliation. Errors included not following ordered blood pressure parameters, crushing medications that were indicated not to crush, omitted medications, and the omission of medications due to unavailability. Review of the facility policy titled 1:0 Medication Dispensing System did not contain a date. Policy All medications will be prepared (blister card, vials Artomic box) and administered in a manner consistent with the general requirements outlined in this policy. E. Crushing oral medications REQUIRES a physician's order since some medications are not designated to be crushed. I. If required, obtain vital signs before medication administration. 105305 Page 12 of 13 105305 09/01/2022 Fairway Oaks Center 13806 N 46th St Tampa, FL 33613

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to provide dental services to one (Resident #35) of three residents sampled for dentures. Residents Affected - Few Findings Included: On 08/29/22 at 11:09 a.m., an interview was conducted with Resident #35 as she was observed edentulous when she opened her mouth. She stated, I had dentures, but it was years ago. She said when she was hospitalized about 4 or 5 years ago, I had to call an ambulance to pick me up. I wish I had taken my dentures with me. Resident #35 stated When I was in the hospital, they threw out everything in my apartment. My dentures and everything I owned. She denied having issues with chewing but if the meat, especially the pork chops, were dry it took a while to chew them. When asked, Resident #34 smiled broadly and stated, I would love dentures. She confirmed she would wear them if she had them. Resident #35 denied the facility had ever asked about obtaining dentures. She said she could not recall the last time a Dentist had performed an oral examination. Medical record review of the admission Record Resident Information form indicated Resident #35 was admitted to the facility three years ago. The diagnosis information listed diabetes mellitus, chronic ischemic heart disease, cerebral vascular disease and dysphagia, oropharyngeal phase. Review of Quarterly /Annual Significant Change Nursing Evaluations-V4 A. Evaluation revealed 2. Teeth: the box was checked that indicated Some natural teeth 3. Wears dentures: was omitted. B. Notify MD for possible Dental Consult was checked no. Further medical review revealed no Dental consult nor Dental examination had been provided in three years. On 09/01/22 11:30 a.m. an interview was conducted with the Social Services Director (SSD). The SSD confirmed she knew the resident well and she talked with her almost daily. The SSD went to Resident #35's room and asked her if she would like dentures. Resident #35 stated I would love dentures. The SSD asked the resident why she never told her. The resident stated, no one has ever asked me. The SSD confirmed she had never asked resident #35 if she wanted dentures. On 09/01/22 at 12:15 p.m., an interview was conducted with the Director of Nursing that confirmed dental needs should be addressed by nursing evaluations that were performed and the evaluations should be accurate. On 09/01/2022 at approximately 12: 36 p.m., the SSD provided a copy of a Dental visit dated 03/09/2022. The SSD said she had called the dental services they use and received a report of a dental visit. The SSD said it was the first time she had seen the report. The report read [name of resident] is eligible to enroll. She is interested in a complete upper and lower denture. Will call power of attorney (POA) to discuss. Review of the policy titled Routine Dental Care dated April 2007. Policy Statement Each resident will receive routine dental care. 3. The Attending Physician will include, as part of his/her initial medical assessment, an assessment of the resident dental needs. 4. Our facility routine dental care includes, but is not limited to: a. An initial evaluation of the dental needs: b. Consultation with the resident, staff, and dental consultant. Preventative care and treatment. 105305 Page 13 of 13