Health inspection·March 10, 2022

F 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interviews and record reviews, the facility failed to ensure a monthly Medication Regimen Review (MRR) for 2 (#24 and #61) of 5 residents reviewed. Residents Affected - Few The findings included: The facility Policy for Medication Regimen Review (MRR) with an effective date of 12/1/07 noted, The Consultant Pharmacist will conduct MMRs if required under a Pharmacy Consultant Agreement . The facility should maintain copies of MRRs on file in the facility, either as part of the resident's permanent medical record or in a special file, in accordance with applicable law. Review of the clinical records showed Resident's #24 and #61 were admitted to the facility respectively on 6/12/20 and 3/19/21. The clinical records lacked documentation of a medication regimen review for September 2021. Review of the Consultant Pharmacy Reports for September 2021 showed MRRs were conducted for 17 residents without recommendation and for two residents with recommendations. Residents #24 and #61 were not included in the MMRs. Review of the facility Detailed Census Report for September 2021 showed there were between 84 and 93 residents at the facility during the month of September 2021. On 3/9/22 at 11:17 a.m., in an interview the Assistant Director of Nursing (ADON) confirmed there was no MRR for September 2021 for Residents #24 and #61. The ADON also confirmed there were Consultant Pharmacy MMRs conducted for only 19 residents during September 2021. The ADON said she discovered the problem in October 2021 and contacted the Consultant Pharmacist. The Consultant Pharmacist's reply was they were missed. On 3/9/22 at 03:22 p.m., in a telephone interview, the Consultant Pharmacy Supervisor confirmed MRRs were not conducted for Resident #24 and #61 in September 2021. Page 1 of 3 105538 105538 03/10/2022 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

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, record review and staff interview the facility failed to administer medications according to the physician's orders for 1 (Resident #283) of 5 residents observed for medication administration. Three Licensed nurses and 25 opportunities were observed. Two medication errors were identified resulting in an 8% error rate. Residents Affected - Few The findings included: The facility's Instructional Guidelines Manual for Medication Administration revised 08/05/2015 reads, . All medications must be ordered by the Physician . Administer medications within a two (2) hour time frame (one hour before to one hour after the time prescribed by the physician) . When administering medications, always check for the six R's. Right resident, right medications, right time, right route, right dosage, right documentation . On 3/7/22 at 12:00 p.m., Licensed Practical Nurse (LPN) Staff A was observed administering seven (7) different medications to Resident #283, including one tablet of Metoprolol 25 milligrams Extended Release and one tablet of Cefdinir 300 milligrams. The physician's orders dated 3/2/22 specified to administer one tablet of Metoprolol XL Extended release 25 milligrams every 12 hours at 9:00 a.m., and 9:00 p.m., related to hypertensive heart disease with heart failure. The physician's orders dated 3/2/22 specified to give one tablet of Cefdinir Capsule 300 milligrams by mouth every 12 hours at 9:00 a.m., and 9:00 p.m., related to urinary tract infection. On 3/7/22 at 12:00 p.m., at the time of the observation LPN Staff A verified she administered the Cefdinir and the Metoprolol late, three hours past the scheduled time. On 3/9/22 at 11:45 a.m., in an interview the Director of Nursing (DON) said the medications were late because the nurse administering the medications was a new agency nurse. 105538 Page 2 of 3 105538 03/10/2022 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

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 observation, record review, review of facility policy, staff and resident interviews, the facility failed to ensure proper storage of medications for 1 (Resident #7) of 1 resident observed with unsecured prescribed eye drops at the bedside. The findings included: Review of the Policy and Procedure for Storage and Expiration of Medication, Biological, Syringes and Needles with an effective of 12/1/07 (revised 1/1/13) documented . 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 . Facility should store bedside medications or biologicals in a locked compartment within the resident's room . On 3/9/22 at 9:30 a.m., observed a bottle of Dorzolamide HCL eye drops and a bottle of Timolol Maleate eye drops stored in an empty tissue box on Resident #7's overbed table. In an interview at the time of the observation Resident #7 said she has been using the drops for years and sometimes the nurses just leave the medications in her room and sometimes they pick them up and bring them back. Photographic Evidence Obtained. On 3/9/22 at 10:45 a.m., The Director of Nursing (DON) verified a bottle of Dorzolamide HCL eye drops and a bottle of Timolol Maleate eye drops were stored unsecured in an empty tissue box on Resident #7's overbed table. The DON removed the eye drops from the Resident's room and said they were not supposed to be in there. She said if Resident #7 was deemed competent to administer her own medications, they were supposed to be stored in a locked box. On 3/9/22 at 12:05 p.m., review of the clinical record showed a Self-administration of Medication Data Collection form completed on 5/27/20 noted Resident #7 could self-administer Dorzolamide HCL solution 2% and Timolol Maleate solution 0.5 % eye drops. The form noted the medication storage was with licensed staff. 105538 Page 3 of 3