Health inspection·March 12, 2021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and facility record review, the facility failed to ensure resident medications were stored and supervised in a manner that was free from access to other residents during one (3/11/2021) of four days observed, and on one (East wing) of two units. It was observed that loose pills and capsules were placed visibly in the space between the wall and the back of the handrail on a main hallway. Findings included: On 3/11/2021 at 1:00 p.m., the 200 East hallway was observed during the lunch meal service. While standing in the main hallway, between resident rooms [ROOM NUMBERS], the space between the wall and the back of the handrail was observed with loose pills and capsules. Further observations revealed one orange round tablet, one white round tablet, and one large white capsule. The medications were easily visible from the hallway and could easily be accessed by anyone who walked by. This area was observed with high traffic of both residents and staff members. There were three residents who were observed using the wall handrail to self propel up and down the hallway and had access to the loose medications. The surveyor stood in the area until 1:57 p.m. and during that period, no staff observed the loose medications. At 1:57 p.m., Staff C, Housekeeper was observed at the end of the hall and was wiping down the wall handrails. At 1:58 p.m., an interview with the East wing Unit Manager, Staff B confirmed the loose pills in the handrail area between rooms [ROOM NUMBERS]. She expressed surprised that the loose pills were there and unsupervised. She confirmed that when nursing staff do medication pass, they were to always ensure each resident receiving medications took the medications properly and swallowed them. She further confirmed that nurses were to supervise residents as they took their medications. She did not know how the loose pills got out in the hallway and in the handrail area and did not know how long they had been there. She immediately spoke with Staff A, Certified Nursing Assistant (CNA) and Staff C as they were in the immediate area. Staff A revealed that she did not know how the medications got there and that the staff look for items placed in between handrails and the hallway wall. Staff C said that she and the other housekeeping staff clean high touch surfaces to include wiping down of the hallway handrails about every two hours. Staff C could not recall if the loose medications were in that area earlier when she wiped down the handrails. Staff C could not recall any other time that she or other housekeeping staff had found loose pills. She indicated that if she had, she would immediately take them to a nurse for disposal. On 3/12/2021 at 8:00 a.m., the Nursing Home Administrator provided documentation that indicated Page 1 of 2 105451 105451 03/12/2021 Peninsula Health Center by Harborview 900 Beckett Way Tarpon Springs, FL 34689

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that they thought the medications belonged to a newly admitted resident and each of those medications combined were in her medication order sheet. However, it could not be verified that the medications that were loose, were indeed hers. The Nursing Home Administrator was made aware that the medications were loose, unsupervised, and out in the open with residents at and near them for at least one hour. The Nursing Home Administrator confirmed that all medications were to be passed and taken with nurse supervision prior to leaving the resident, and that there should not be any medications over the counter or prescribed left out in the open unsupervised. On 3/12/2021 the Nursing Home Administrator provided the Storage of Medication policy for review. The policy was last updated on 12/2008. However, the Nursing Home Administrator provided evidence that this policy was reviewed annually. Review of the policy revealed, Medications and Biologicals are stored properly, following manufacturer's recommendations of those of the supplier to maintain their integrity and to support safe administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy procedure #1 indicated, The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are kept in these containers in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 105451 Page 2 of 2