Health inspection·August 4, 2022

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 interviews, record and policy review, the facility failed to ensure that antipsychotic medication had a clinical indication for use, that the ordering Prescriber had conducted a comprehensive assessment of the resident and that behaviours were adequately monitored for 1 of 5 sampled residents reviewed for the unnecessary medication (Resident #46). The findings included: A review of the facility's policy, titled, Psychotropic Medication Use, dated 12/01/2007, showed that the following: all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose and should be monitored for efficacy, risks, and benefits. It further showed that If the Prescriber orders a psychotropic medication for the resident, the facility should ensure that the Prescriber has conducted a comprehensive assessment of the resident as documented in the clinical records. Review of the F29, a billable/specific ICD-10-CM code, revealed it can be used to indicate a diagnosis for reimbursement purposes, and was indicitive of Unspecified Psychosis is not due to a substance or known physiological condition. Record review showed that Resident #46 was admitted to the facility on [DATE] with diagnoses to include: Heart failure, Insomnia, Depression, Cognitive Communication Deficit, and Muscle Weakness. Review of the Physicians' orders for Resident #46 showed an order for Quetiapine Fumarate (Seroquel) Tablet 25 milligrams and to give one tablet by mouth in the morning for Depression which was dated 06/27/22. The care plan, dated 07/14/22, showed that Resident #46 is on Psychotropic medication, and to monitor for and document any adverse reactions to the psychotropic medications. Further review did not show that Resident #46 was provided with an antipsychotic medication for the diagnosis of Depression or Psychosis. In an interview conducted on 08/03/22 at 8:30 AM, Staff D, Registered Nurse, stated that any monitoring for behavior is documented in the nurse's unit in a binder, titled, Monitoring Behaviors. Review of the 'Behaviors Monitoring Binder', located on the 3rd floor in the nurses' station, showed that monitoring behaviors was conducted on Resident #46 for the month to present for August 2022, but no behavior monitoring was documented for the entire month of July 2022. Page 1 of 6 105489 105489 08/04/2022 Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview conducted on 08/03/22 at 8:35 AM, Staff D, Minimum Data Set Coordinator (MDS), stated that when a resident is placed on Antipsychotic medication with a diagnosis in place, Staff E, Nurse Practitioner (NP), will update the diagnosis tab in the electronic system to reflect the new diagnosis that was identified. When asked by the surveyor if Resident #46's diagnosis was updated with Psychosis, he said 'no'. Staff D further stated that if a resident is placed on Antipsychotic medication, he would initiate a care plan for behavior monitoring that may be under another section named Psychotronic medication. He would also identify the diagnosis with the antipsychotic medication under the psychotropic medication section of the care plan. An interview was conducted on 08/03/22 at 9:00 AM with the facility's Director of Nursing (DON). The DON stated when Resident #46 was first admitted to the facility, he questioned Staff E (NP) when she prescribed Seroquel for diagnosis of Depression on admission. He further stated that Staff E reported that they would monitor Resident #46's behaviors and reassess him later when they get to know him better. The DON further said that he spoke to Staff F, Medical Director (MD), last night, who told him that he would update the diagnosis of Delusional Psychosis in the medical chart for Resident #46. In an interview conducted on 08/03/22 at 9:10 AM, Staff D, Registered Nurse (RN), stated she is unfamiliar with Resident #46 and is unsure of any behaviors that he may have exhibited in the past. She further noted that she is new to the unit and was not assigned to Resident #46 in the past. In an interview conducted on 08/03/22 at 9:15 AM with Resident #46, he stated that he did not know that he was on Seroquel and then said, what is this medication for. When told by the surveyor that it was prescribed to him for Depression, he said: I am not depressed. Resident #46 also reported that he does not remember speaking to Staff E, the Nurse Practitioner, or that she came to see him in his room while in the facility. Review of the Pharmacy recommendation report, dated 07/05/22, showed the following: Please discontinue Seroquel. If medication is to continue, please clarify the diagnosis. Depression is an inappropriate diagnosis for antipsychotics. It further showed that the physician response to keep the prescription and change Resident #46's diagnosis to code F29. The Consultation report did not include the date that Staff F (MD) wrote the answer and did not have his signature. A review of the Minimum Data Set (MDS), dated [DATE], showed that Resident #46 had a Brief Interview of Mental Status (BIMS) score of 14, which is cognitively intact. A review of Section E of the MDS for behaviors showed that Resident #46 did not exhibit any behavior symptoms. Section N of the MDS showed that Resident #46 was receiving Antipsychotic medication in the last 7 days. A review of the progress note, dated 07/14/22, completed by Staff E, showed that the following: 'Resident #46 is evaluated for evaluation of indication for Seroquel 25 mg at bedtime as it is indicated for Depression. The patient was noted to have nighttime dilutional thinking behaviors. It further showed that Seroquel is used for the management of delusional thinking patterns. Therefore the appropriate diagnosis is F 29.' Further review of Resident #46's medical chart did not show any psychology evaluation to this progress note that was written on 07/14/22. A review of the admission records did not show that Resident #46 was ever on Seroquel prior to this or that he had a prior diagnosis of Psychosis. A review of the Consultation report by the Pharmacy,, dated 06/30/22 showed that the Pharmacist 105489 Page 2 of 6 105489 08/04/2022 Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433

F 0758 Level of Harm - Minimal harm or potential for actual harm recommended discontinuing Seroquel for the diagnosis of Depression. Staff F, Medical Director, declined the recommendation stating that Resident #46 is new to the facility and will have a Psych evaluation. This information was provided to the surveyor on 08/04/22, which was the last day of the survey. Residents Affected - Few 105489 Page 3 of 6 105489 08/04/2022 Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433

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 observation, interview, record review of policy & procedure review, the facility failed to properly dispose of a remaining powder medication packet for 1 of 6 sampled residents observed during a Medication Administration Observation, Resident #149; failed to ensure it maintained the resident's medication in line of sight, during a Medication Administration Observation, for 1 of 6 sampled residents observed, Resident #149; failed to properly dispose of an unsecured, expired over-the-counter (OTC) medication at the resident's bedside for 1 of 13 residents observed during an observational tour, Resident #17; and failed to ensure it properly secured medication as a 'loose' pill was observed on the dining room patio floor during a facility residents' activity. The findings included: Review of facility policy and procedure on [DATE] at 1:08 PM for 'Storage of Medications', provided by the Director of Nursing (DON), revised [DATE] for Long Term Care (LTC) Facility's Pharmacy Services and Procedures Manual, Storage and Expiration Dating of Medications, Biologicals. Applicability documented in part: .sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) .or (3) , are separated from other medications until destroyed or returned to the pharmacy or supplier 8. Facility should ensure that resident medication and biological storage areas are locked 13. Bedside Medication Storage 13.1 Facility should not administer / provide bedside medications or biologicals without a Physician / Prescriber order and approval by the Interdisciplinary Care Team and Facility administration 16. Facility should destroy or return all discontinued, outdated / expired or deteriorated medications or biologicals in accordance with Pharmacy return / destruction guidelines and other Applicable Law, . 1. On [DATE] at 9:28 AM, during a Medication Administration Pass Observation of Staff H, a Licensed Practical Nurse (LPN), for Resident #149, the LPN was observed tossing the 'remaining' Cholestyramine 4gm 1/2 medication packet (powder) into the trash bin located on the medication cart Team I Riverbend Road neighborhood Memory Care . A brief interview was conducted with the nurse on [DATE] at 9:30 AM and she was asked why she tossed this in the medication cart trash bin. Staff H stated and acknowledged that the medication packet should not have been tossed in there. 2. On [DATE] at 9:42 AM, during a Medication Administration Pass Observation of Staff H, the LPN was observed leaving both of Resident #149's eye drops and nasal spray unattended, out-of-her-line-sight and accessible at the bedside on the overbed table with the resident while she went into the bathroom to wash her hands. The nurse also acknowledged that she should not have left the medications unattended at the resident's bedside. During a brief interview conducted on [DATE] at 9:42 AM with the LPN, she was asked why she had left the two (2) medications unattended at the resident's bedside. She acknowledged that she should not have left the medications unattended. 105489 Page 4 of 6 105489 08/04/2022 Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. On [DATE] at 10:55 AM, Resident #17's room was observed as having a used expired visible bottle of (OTC) Saline nasal spray with an expiration date of 02/17 located in his bathroom on the shelf above the toilet. The (OTC) Saline Nasal spray medication was unsecured and accessible to other residents, employees and visitors. Resident #17 was originally admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Myasthenia Gravis, Lymphedema and Acute Kidney Failure. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence was obtained of the used/expired bottle of (OTC) Nasal spray medication. During a brief interview with Resident #17 on [DATE] at 11 AM, Resident #17 stated, regarding the (OTC) Saline Nasal Spray medication bottle on the shelf in his bathroom above the toilet, that his wife brought in the bottle for him to use as he needs it. On [DATE] at 2:09 PM, Resident #17's room was observed as having the used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet. This was confirmed by second surveyor. On [DATE] at 10:12 AM, Resident #17's room was again observed as having a used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet On [DATE] at 2:31 PM, Resident #17's room was observed as having a used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet. [DATE] 09:41 AM Resident #17's room still observed as having a used expired bottle of (OTC) Saline nasal spray located in his bathroom on the shelf above the toilet. An interview was conducted on [DATE] at 10 AM with Resident #17's nurse, Staff I, LPN, regarding the (OTC) Saline Nasal spray medication bottle observed on Resident #17's bedside table and she acknowledged that the medication bottle should not have been there. A side-by-side record review was conducted with Staff J, a Registered Nurse Unit Manager (RN/UM) for the 1st and 3rd floors. The record indicated that neither Resident #17's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for him to be able to administer his own medications. There was no physician order on the Resident #17's Medication Administration Record (MAR) for this (OTC) Saline Nasal Spray medication to be administered to this resident. The bottle of expired (OTC) nasal spray medication was not removed from this resident's bedside, until after surveyor intervention. 4. On [DATE] at 2:05 PM, during a resident bingo game observation conducted of the Activity Room off the main dining on the first floor, it was noted that there was a loose, unidentified white tablet on the floor in the presence of nine (9) vulnerable residents who were all seated at the Activities Bingo table. This boservation of the pill was confirmed by a second surveyor. Photographic evidence was obtained of the single, loose, unidentified white table on the Activity room floor. 105489 Page 5 of 6 105489 08/04/2022 Willowbrooke Court Skilled Care Center - Edgewater 23305 Blue Water Circle Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview conducted on [DATE] at 10:20 AM with Staff J, she indicated this resident does not self-administer any of his own medications and was not assessed to be able to do so. On [DATE] at 10:45 AM, the Director of Nursing (DON) further acknowledged and recognized that the remaining packet of medication should not have been tossed into the medication cart trash bin, indicated that the nurse should not have left the resident medication unattended at the bedside, that the pill should not have been on the floor, and the (OTC) Saline Nasal Spray medication should not have been left at the resident's bedside. 105489 Page 6 of 6