Health inspection·August 11, 2022

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. Based on observation, interview, and record review, the facility failed to ensure that one (Resident #33) of 45 residents receiving respiratory care, from a total of 27 sampled residents, had a care plan in place for oxygen as ordered. The findings include: During a tour of the facility on 08/08/22 at 2:03 pm, Resident #33's oxygen concentrator was observed in her room at bedside. A closer observation revealed the concentrator was set to administer oxygen at 1.5 liters per minute (L/min). Resident #33 was observed wearing the nasal cannula and receiving oxygen at 1.5 L/min (Photographic evidence obtained of concentrator setting) On 08/09/22 at 11:21am, another observation of Resident #33's oxygen concentrator, revealed it was set to administer oxygen at 1.5 L/min. (Photographic evidence obtained) A review of Resident #33's medical record revealed an admission date of 05/24/22 and diagnoses including acute respiratory failure with hypoxia, major depressive disorder, anxiety disorder, and pneumonia. Physician's orders revealed that on 05/24/22, she was ordered oxygen at 3 L/min via nasal cannula continuously every shift, morning and night and change oxygen tubing every Sunday and as needed. On 05/25/22, an order was written to document shortness of breath (SOB) when lying flat, SOB at rest, and SOB with exertion. Head of Bed (HOB) was to be elevated every shift, starting in the morning at 7:00 am. (Photographic evidence obtained) Resident #33's July 2022 and August 2022 Medication Administration Records (MARs) revealed that oxygen was to be set with a flow rate of 3 L/min via nasal cannula continuously. Nursing initials indicated the oxygen had been provided per the order. (Photographic evidence obtained) Resident #33's vital signs for July 2022 revealed that her oxygen saturation was between 92 and 98 percent. Her vital signs for August 2022 revealed her oxygen saturation ran between 96 and 98 percent. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/31/2022, revealed the resident had a brief interview for mental status (BIMS) score of 99, indicating the resident was unable to complete the interview. She required extensive assistance for bed mobility and she was totally dependent for eating. Resident #33 was documented as receiving oxygen therapy. A review of her active care plan revealed no care plan addressing her oxygen therapy. Further review of the resident's medical record revealed a Progress Note dated 07/07/22 at 6:47am, which read, Respirations even and unlabored, no SOB, oxygen saturation at 93 percent on 3 L/min of oxygen. Further review revealed a Nursing Note on 07/10/2022 at 11:11am, revealing, The resident continues oxygen at 3 L/min for diagnosis of acute respiratory failure, HOB elevated to facilitate breathing, and becomes shortness of breath with exertion-rest periods provided. Orders in place for weekly change of oxygen tubing. Page 1 of 4 105423 105423 08/11/2022 Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/11/22 at 10:40 am, Employee B confirmed Resident #33 was receiving oxygen at 3 L/min. Employee B also confirmed Resident #33's order dated 05/24/2022 for oxygen to be administered at a flow rate of 3 L/min. She stated Resident #33 was receiving oxygen for shortness of breath. During an interview on 08/11/22 at 10:44 am, Employee A confirmed that nurses were responsible for reviewing oxygen orders each shift, each day. She confirmed that there was no care plan for oxygen administration and that the MDS Coordinators were responsible for reviewing and updating care plans quarterly and on an annual basis. During an interview on 08/11/22 at 10:49 am, Employee C confirmed Resident #33's order, dated 05/24/2022, for oxygen to be administered at a flow rate of 3 L/min. Employee C reviewed the progress notes for Resident #33. She identified that Resident #33's progress notes for August 2022 did not identify her as receiving oxygen. Resident #33's progress notes revealed that her oxygen saturation must be above 90 percent. Employee C stated Resident #33 had two orders for oxygen, and she would call the physician to clarify what Resident #33's oxygen order should be. Employee C confirmed that care plans were reviewed quarterly or as needed and Resident #33 had no care plan for oxygen. During an interview on 08/11/22 at 12:50 pm, the Director of Nursing (DON) confirmed that care plans were updated when there were changes to the resident's care, or when orders were discontinued. The facility reviewed physicians' orders and updated care plans daily or as changes occurred. A review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered (Revised December 2016 and November 2020), revealed, The comprehensive, person-centered care plan will include measurable objectives and timeframes and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. . 105423 Page 2 of 4 105423 08/11/2022 Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, and facility policy review, the facility had a medication error rate greater than 5%. The error rate was calculated based on 33 observations, in which there were a total of two errors observed. This resulted in an error rate of 6.06% involving one (Resident #64) of five residents observed. Residents Affected - Few The findings include: On 08/09/22 at 4:00pm, Employee G was observed preparing and administering medications for Resident #64. The four medications prepared included: Keppra 100 mg/ml (milligrams per milliliter): give 10ml via gastric tube twice a day for seizures Metformin 850 mg: give 850mg via gastric tube twice a day for type 2 diabetes Senna Plus 8.6-50 mg: give one tablet via gastric tube twice a day for bowel regimen Vimpat 50 mg: give one tablet gastric tube twice a day for seizures While preparing the medications, Employee G was observed crushing the Metformin tablet, the Senna Plus tablet and the Vimpat tablet. She placed them all together in one cup, mixed them with water, and aspirated them into a syringe. While administering the medications, Employee G was observed administering the liquid Keppra. She flushed with approximately 5 cc (cubic centimeters) of water, then she administered the mixture of the three remaining medications via gastric tube. This observation resulted in two medication errors, which were confirmed by facility policy, medical record review, and staff interview. On 08/10/22 at 1:10 pm, during an interview with Employee F, she was asked if the expectation during medication pass for a resident with an enteral feeding tube was to give each medication separately with a water flush between each medication. She stated, Yes, that's what the policy, unless there's a special order from the doctor that states otherwise. A review of the Physician's Orders for Resident #64 revealed the following order: 2/14/22: Gastric tube order: Flush gastric tube with 30 cc tap water before and after meds. Flush with 5 cc tap water between meds. A review of the facility's policy for Administering Medications through an Enteral Tube (revised [DATE],) revealed the following: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: 3. Administer each mediation separately and flush between medications. 105423 Page 3 of 4 105423 08/11/2022 Terrace of Jacksonville, The 10680 Old St Augustine Rd Jacksonville, FL 32257

F 0759 Steps in the procedure: Level of Harm - Minimal harm or potential for actual harm 10. Administer each medication separately. Residents Affected - Few 13. If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. . 105423 Page 4 of 4