Health inspection·February 19, 2025

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. Based on observation interview and record review the facility failed to follow pharmaceutical procedures as per facility policy. As evidenced by during observations of one of two Medication storage rooms reviewed, the narcotics lock box in the medication refrigerator was noted unlocked. and Resident #180's medication was being given in tablet form and the order documented capsule. There were 74 residents residing at the facility at the time of the survey. The findings included: On 02/17/25 at 10:00 AM during observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON); the narcotic lock box in the medication refrigerator was left unlocked. The lock box contained an emergency kit with 5 vials of insulin and one (1) vial of Ativan The ADON, attempted to close the lock box with several keys available and was unsuccessful unable to close the lockbox. Interview on 2/17/25 at 10:00 AM, the ADON stated: The lock for the narcotic lock box in the refrigerator is warped (unable to be locked), I will need to put a work order in for it to be repaired, this issue was not reported to me prior to today. On 2/17/25 at 9:20 AM during medication administration observation for Resident #180 with Licensed Practical Nurse (LPN), (Staff B) the Electronic Medication Administration Record (EMAR) documented Meloxicam 7.5 Milligram (MG), give 1 capsule twice a day for pain. Review of Resident #180's Bingo Card for Meloxicam 7.5 MG documented Meloxicam 7.5 MG, give 1 tablet twice a day for pain. Interview on 02/17/25 at 10:32 AM regarding the Meloxicam 7.5 MG tablet, Staff B, LPN stated: I will call pharmacy to verify the order, if the order should be capsule or tablet. The resident has been administered tablets since 2/7/25 twice a day. Interview on 02/17/25 at 10:32 AM; the facility's Consultant Pharmacist stated: The Meloxicam 7.5 MG tablet can be given to the resident with physician authorization because it is the same dose, and we can get an order to correct the EMAR, chances are the documentation is human error. Review of the facility's policy and procedure titled Storage of Medications revised April 2007 states: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and Page 1 of 3 105508 105508 02/19/2025 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

F 0755 Level of Harm - Minimal harm or potential for actual harm boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the facility policy and procedure titled Administering Medications revision date 12/2012 states: Medications shall be administered in a safe and timely manner, and as prescribed. Residents Affected - Few Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right route of administration before giving the medication. 105508 Page 2 of 3 105508 02/19/2025 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

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. Based on observations interviews and record review, the facility failed to provide appropriate storage of medications on the medication cart for one (1) of three (3) medication carts observed. As evidenced by during observation of one out of three (3) medication carts loose pills were noted in different compartments of the medication drawer and in one out of two medication rooms Narcotics Lock Box was left unlocked. There were 74 residents residing at the facility at the time of the survey. The findings included: On 2/17/25 at 9:00 AM during observation of medication Cart # 3400 with Registered Nurse (RN), (Staff C), three (3) round white pills and several pieces of empty medication packaging were found in the second drawer of the medication cart. Interview on 02/17/2025 at 9:05 AM Registered Nurse (RN), (Staff C) revealed she would don gloves, pick up the pills, try to identify the pills and dispose them in the drug buster in the medication cart. Furthermore, the medication carts are cleaned daily on every shift. On 02/17/25 at 10:00 AM, observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON) (Staff A). The narcotic lock box in the medication refrigerator noted unlocked. The ADON, Staff A attempted to close the lock box with several keys available and was unable to close the lockbox. The lockbox contained an emergency kit with 5 vials of insulin and one (1) vial of Ativan. Interview on 2/17/25 at 10:00 AM ADON, Staff A stated: The lock for the narcotic lockbox in the refrigerator is warped (unable to be locked), I will need to put a work order in for it to be repaired, this issue was not reported to me prior to today. Review of the facility policy and procedures titled Storage of Medications revised April 2007 states: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1.Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 105508 Page 3 of 3