Health inspection·September 14, 2022

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #13's admission Record revealed this resident was re-admitted to the facility on [DATE], and has diagnoses that included Alzheimer's disease, non-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecified severity, and anxiety. Residents Affected - Few Observations on 09/11/2022 at 12:45 p.m. of Resident #13 revealed the resident sitting in a reclined [geriatric chair]. The resident was noted to have a dressing to her left knee which was dated in black ink with a date of 09/06/2022. Observations on 09/12/2022 at 12:28 p.m. of Resident #13 revealed the resident lying in bed. The resident's bilateral legs were noted to have no dressings on either leg and a dried wound to the left knee with no dressing. Review of Resident #13's current physician orders revealed an order dated 09/062022 for right calf skin tear Wash with NS (normal saline), pat dry Apply collagen particles then cover with a dry dressing, every evening shift. Review of the Skin Check Weekly & PRN form, dated 09/06/2022 revealed skin tear to Right Calf (Lateral), in-house acquired, New. Review of the resident's care plan dated 08/12/2021 with a revision date of 01/19/2022 related to the risk of developing wounds due to fragile skin, severe PAD (peripheral arterial disease), immobility, contractures, nutritional Status, incontinence or increased moisture. The interventions included: Treatment as ordered, and observe wound location daily or if dressing change not daily observe dressing for presence of odor, color, drainage with color, & amount if present. Observations on 09/13/2022 at 12:52 p.m. of Resident #13 revealed the resident sitting up in bed being fed by staff. The resident was noted with an adhesive bandage to her right calf. An interview with Staff F, Certified Nursing Assistant (CNA) revealed she did not see the resident's legs this morning as the hospice aide came in and did the resident's bath. Staff F inspected the resident's bilateral legs and she confirmed that an adhesive bandage was present on the resident's right calf but no other dressings were present. An interview on 09/13/2022 at 12:56 p.m. with Staff E, Licensed Practical Nurse (LPN) revealed she does not do any dressings for this resident on the day shift. At this time Staff E checked the resident's orders and reported the resident has an order to clean with NS and apply collagen particles and cover with dry dressing every evening shift. She reported that an adhesive bandgage would not be considered a dry dressing. Page 1 of 16 105553 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 09/13/2022 at 1:13 p.m. with the Assistant Director of Nursing (ADON) revealed physician orders are to be followed, and he was not sure what was going on with Resident #13's orders for skin. An interview on 09/13/2022 at 1:51 p.m. with Staff A, Unit Manager/Registered Nurse (RN) revealed he helps coordinate wound care. He reported on 09/06/2022 he saw an open area on the resident's right lateral calf, took pictures and obtained a treatment order for the right lateral calf. Staff A reported the right chin where the adhesive bandage was noted was an old wound that re-opened, and the area to the right lateral calf as of today was resolved. He reported that he was not aware of who the initials RR belonged to on the dressing dated 09/06/2022. Based on observation, interview, and medical record review the facility failed to accurately assess and document a change in condition in accordance with professional standards of practice for three residents (#11, #45 and #13 ) out of three sampled residents for skin conditions. Findings included: 1. On 09/12/2022 at 11:06 a.m. Resident #11 was sitting up in his wheelchair and his left hand was noted with multiple intact scabs. The area between the thumb and index finger contained an intact scab. The middle finger was observed dark and ruby red in color. The knuckle just below the middle finger revealed paper tape stuck in place with dried bloody drainage. The fourth finger contained an intact scab. The fifth finger contained two intact scabs The first scab was below the nail bed. A second scab was just below the first one. Below the second scab contained an adhesive bandage. The adhesive bandage appeared old as it contained dried bloody drainage. Resident #11 stated, It hits the door when coming into the room. The resident denied the facility had provided hand protectors. Medical record review of Resident #11's admission Record form documented he resided at the facility for over a year. His diagnoses included fibromyalgia, acute embolism, and thrombosis of unspecified deep veins of right lower extremity, lack of coordination, iron deficiency anemia, diabetes mellitus due to underlying condition with diabetic polyneuropathy, disorders of peripheral nervous system, peripheral vascular disease, gout and acquired absence of left foot below knee. Review of the Skin Check Weekly & PRN (as needed) form with an effective date of 09/10/2022 documented, No new areas of Skin Impairment. The Skin Check Weekly & PRN form with an effective date of 09/02/2022 documented, No new areas of Skin Impairment. Review of nursing progress notes did not reveal documentation related to Resident #11's left hand. Review of care plans revealed: Focus of Wound Risk: The resident is at RISK of developing a wound due to impaired mobility, Pressure, Diabetes, peripheral vascular disease (PVD). Interventions included review with resident family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility. Focus of Skin Integrity Risk the resident has an actual impairment to skin integrity. The focus did not address the resident's left hand. Focus of: Anticoagulation: the resident is on anticoagulant therapy medication r/t (related to): 105553 Page 2 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Atrial fibrillation, History of DVT. Interventions included daily skin inspection and report abnormalities to the nurse. On 09/13/22 at 2:44 p.m. alongside Staff A, Unit Manager (UM)/Registered Nurse (RN) Resident #11 was observed sitting up in his wheelchair in his room with his right foot gauze dressing resting on the floor. No barrier was in place. Staff A confirmed the foot was on the floor. Staff A said he had not noticed the scabs on his hands before. He indicated he had only been working with his right foot. He stated, The heel is related to chronic deep vein thrombosis (DVT). Resident #11 stated to Staff A, The scabs are from the door. A review of Complications of Peripheral Neuropathy, found on https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061#:~:text=Complicat Burns and skin injuries. You might not feel temperature changes or pain on parts of your body that are numb. Infection. Your feet and other areas lacking sensation can become injured without your knowing. Check these areas regularly and treat minor injuries before they become infected, especially if you have diabetes. 2. On 09/12/2022 at 12:10 p.m. Resident #45 was sitting up in bed and appeared comfortable. Her right elbow was wrapped with a bulky gauze. No visual date was noted. Her right shin reflected bruises that were purple, brown, and yellow in color. Resident #45's speech was non-sensical and she was unable to verbalize what had occurred. Medical record review of Resident #45's admission Record form indicated she had resided at the facility for ten years. The diagnoses information listed unsteady on feet, lack of coordination, chronic kidney disease, anemia, peripheral vascular disease, and Type 2 diabetes mellitus. Review of the Skin Check Weekly & PRN form with an effective date of 09/09/2022 read as, No new areas of Skin Impairment. Review of nursing progress notes did not reveal documentation of bruises to Resident #45's right shin. Review of a care plan Focus on Skin Integrity Risk showed the resident has an actual impairment to skin integrity r/t impaired mobility and incontinence. Interventions included to observe for signs and symptoms swelling, tenderness, discoloration, report changes in discoloration area, and notify physician of new/increased discoloration pain regime/intervention not effective. On 09/13/22 at 2:12 p.m. Staff A, UM/RN confirmed the dressing to Resident #45's right elbow appeared tangled and unraveled without a date of service. At that time the Staff A observed the resident's right shin and indicated he was unaware of the bruises. On 09/13/2022 at 2:50 p.m. an interview was conducted with the Assistant Director of Nursing who confirmed it was his expectation a Situation, Background, Assessment and Recommendation (SBAR) should be performed with a change in skin condition. Review of a policy titled, Physician Notification, dated October 2021, revealed: Policy The facility strives to ensure that each resident's health is supervised by qualified attending Physician. The attending Physician in the facility is ultimately responsible for supervision and management of the care of the resident/patient. Procedure 1/ Licensed Nurses will ensure that Physicians are notified 105553 Page 3 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0684 of changes or diagnosis results that occur between visits. Changes may include but are not limited to: a change in condition mental or physical, the development of a new wound and events. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105553 Page 4 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide appropriate care and services by not administering physician ordered medications for one resident (#55) dependent on dialysis on the resident's scheduled dialysis days out of the sampled four residents. Residents Affected - Few Findings included: A review of the admission Record showed Resident #55 was initially admitted into the facility on [DATE] with diagnoses that included dependence on renal dialysis and end stage renal disease. A review of Section O Special Treatments, Procedures, and Programs of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident was receiving dialysis services. A review of the Order Summary Report with active orders as of 09/12/22 revealed Resident #55 had dialysis days on Tuesday, Thursday, and Saturday. There were no orders to hold medications on scheduled dialysis days. A review of the Medication Administration Record (MAR) dated 07/01/22 to 07/31/22 revealed the following: Aspirin Oral Tablet Chewable- Give 1 tablet po (by mouth) one time a day for mild pain showed a 3 in the box on 07/26 (Tuesday), 07/28 (Thursday), and 07/30 (Saturday). Citalopram Hydrobromide Oral Tablet 10 MG (milligram) - Give 1 tablet po one time a day for behavioral disturbance showed a 3 in the box on 07/26, 07/28, and 07/30. Clopidogrel Bisulfate Oral Tablet 75 MG- Give 1 tablet po one time a day for clot prevention showed a 3 in the box on 07/26, 07/28, and 07/30. Cyanocobalamin Oral Tablet 1000 MCG (microgram) - Give 1 tablet po one time a day for supplement showed a 3 in the box on 07/26, 07/28, and 07/30. Folic Acid Oral Tablet 1 MG- Give 1 tablet po one time a day for folic acid showed a 3 in the box on 07/26, 07/28, and 07/30. Losartan Potassium Oral Tablet 100 MG- Give 1 tablet po one time a day for hypertension showed a 3 in the box on 07/26, 07/28, and 07/30. Multivitamin Oral Tablet- Give 1 tablet po one time a day for vitamins showed a 3 in the box on 07/26, 07/28, and 07/30. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG- Give 1 tablet po one time a day for GERD showed a 3 in the box on 07/26 and 07/28. Tamsulosin HCL Oral Capsule 0.4 MG- Give 1 capsule po one time a day for benign prostatic hyperplasia showed a 3 in the box on 07/26 and 07/28. 105553 Page 5 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0698 Level of Harm - Minimal harm or potential for actual harm Carvedilol Oral Tablet 6.25MG- Give 2 tablet po two times a day for hypertension showed a 3 in the box on 07/26, 07/28, and 07/30. Dorzolamide HCL Ophthalmic Solution 2%- Instill 1 drop in both eyes two times a day for dry eyes showed a 3 in the box on 07/26, 07/28, and 07/30. Residents Affected - Few Furosemide Oral Tablet 40 MG- Give 1 tablet po two times a day for diuretics showed a 3 in the box on 07/30. Furosemide Oral Tablet 40 MG- Give 2 tablet po two times a day for diuretics showed a 3 in the box on 07/26 and 07/28. Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG- Give 2 tablet po two times a day for hypertension showed a 3 in the box on 07/26, 07/28, and 07/30. Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 GM (gram)- Use 4.5 gram intravenously every morning and at bedtime for c-diff and osteomyelitis showed a 3 in the box on 07/26, 07/28, and 07/30. Timolol Maleate Ophthalmic Solution 0.5%- Instill 1 each in both eyes two times a day for glaucoma showed a 3 in the box on 07/26 and 07/28. Insulin Lispro Injection Solution 100 unit/ml (milliliter) Inject as per sliding scale showed a 3 in the box on 07/28. Monitor pain every shift and record pain number on a 0-10 scale showed a 3 in the box on 07/28. Right Heel cleanse area with wound cleanser, pat dry and apply betadine showed a 3 in the box on 07/28. Side Effect Monitoring showed a 3 in the box on 07/28. Balsam Peru Castor Oil External Ointment- Apply to back topically two times a day for itching showed a 3 in the box on 07/30. Nystatin External Ointment 100000 unit/gm- Apply to back topically three times a day for itching showed a 3 in the box on 07/30. Zinc Oxide External Paste 40%- Apply to buttocks topically every 8 hours for itching showed a 3 in the box on 07/30. The MAR dated 08/01/22 to 08/31/22 revealed the following: Aspirin Oral Tablet Chewable- Give 1 tablet po one time a day for mild pain showed a 3 in the box on 08/09 (Tuesday) and 08/18 (Thursday). Citalopram Hydrobromide Oral Tablet 10 MG- Give 1 tablet po one time a day for behavioral disturbance showed a 3 in the box on 08/09 and 08/18. 105553 Page 6 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0698 Level of Harm - Minimal harm or potential for actual harm Clopidogrel Bisulfate Oral Tablet 75 MG- Give 1 tablet po one time a day for clot prevention showed a 3 in the box on 08/09 and 08/18. Cyanocobalamin Oral Tablet 1000 MCG- Give 1 tablet po one time a day for supplement showed a 3 in the box on 08/09 and 08/18. Residents Affected - Few Folic Acid Oral Tablet 1 MG- Give 1 tablet po one time a day for folic acid showed a 3 in the box on 08/09 and 08/18. Losartan Potassium Oral Tablet 100 MG- Give 1 tablet po one time a day for hypertension showed a 3 in the box on 08/09 and 08/18. Multivitamin Oral Tablet- Give 1 tablet po one time a day for vitamins showed a 3 in the box on 08/09 and 08/18. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG- Give 1 tablet po one time a day for GERD showed a 3 in the box on 08/09 and 08/18. Tamsulosin HCL Oral Capsule 0.4 MG- Give 1 capsule po one time a day for benign prostatic hyperplasia showed a 3 in the box on 08/09 and 08/18. Carvedilol Oral Tablet 6.25MG- Give 2 tablet po two times a day for hypertension showed a 3 in the box on 08/09 and 08/18. Dorzolamide HCL Ophthalmic Solution 2%- Instill 1 drop in both eyes two times a day for dry eyes showed a 3 in the box on 08/09 and 08/18. Furosemide Oral Tablet 40 MG- Give 1 tablet po two times a day for diuretics showed a 3 in the box on 08/09 and 08/18. Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG- Give 2 tablet po two times a day for hypertension showed a 3 in the box on 08/09 and 08/18. Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 GM- Use 4.5 gram intravenously every morning and at bedtime for c-diff and osteomyelitis showed a 3 in the box on 08/02 (Tuesday). Timolol Maleate Ophthalmic Solution 0.5%- Instill 1 each in both eyes two times a day for glaucoma showed a 3 in the box on 08/09 and 08/18. Insulin Lispro Injection Solution 100 unit/ml Inject as per sliding scale showed a 3 in the box on 08/02, 08/09, 08/13 (Saturday), 08/18, 08/20 (Saturday), and 08/30 (Tuesday). Side Effect Monitoring showed a 3 in the box on 08/18. Hydralazine HCL Oral Tablet 10 MG- Give 1 tablet po every 6 hours for hypertension showed a 3 in the box on 08/09, 08/13, 08/18, and 08/30. Sucralfate Oral Tablet 1 GM- Give 1 tablet po before meals and at bedtime for indigestion showed a 105553 Page 7 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0698 3 in the box on 08/09, 08/13, 08/18, and 08/30. Level of Harm - Minimal harm or potential for actual harm Balsam Peru Castor Oil External Ointment- Apply to back topically two times a day for itching showed a 3 in the box on 08/09 and 08/18. Residents Affected - Few Nystatin External Ointment 100000 unit/gm- Apply to back topically three times a day for itching showed a 3 in the box on 08/09, 08/18, and 08/20. Zinc Oxide External Paste 40%- Apply to buttocks topically every 8 hours for itching showed a 3 in the box on 08/09, 08/13, and 08/19. The MAR dated 09/01/22 to 09/30/22 revealed the following: Aspirin Oral Tablet Chewable- Give 1 tablet po (by mouth) one time a day for mild pain showed a 3 in the box on 09/01 (Thursday). Citalopram Hydrobromide Oral Tablet 10 MG- Give 1 tablet po one time a day for behavioral disturbance showed a 3 in the box on 09/01. Clopidogrel Bisulfate Oral Tablet 75 MG- Give 1 tablet po one time a day for clot prevention showed a 3 in the box on 09/01. Cyanocobalamin Oral Tablet 1000 MCG- Give 1 tablet po one time a day for supplement showed a 3 in the box on 09/01. Folic Acid Oral Tablet 1 MG- Give 1 tablet po one time a day for folic acid showed a 3 in the box on 09/01. Losartan Potassium Oral Tablet 100 MG- Give 1 tablet po one time a day for hypertension showed a 3 in the box on 09/01. Multivitamin Oral Tablet- Give 1 tablet po one time a day for vitamins showed a 3 in the box on 09/01. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG- Give 1 tablet po one time a day for GERD showed a 3 in the box on 09/01. Tamsulosin HCL Oral Capsule 0.4 MG- Give 1 capsule po one time a day for benign prostatic hyperplasia showed a 3 in the box on 09/01. Carvedilol Oral Tablet 6.25MG- Give 2 tablet po two times a day for hypertension showed a 3 in the box on 09/01 and 09/06 (Tuesday). Dorzolamide HCL Ophthalmic Solution 2%- Instill 1 drop in both eyes two times a day for dry eyes showed a 3 in the box on 09/01 and 09/06. Furosemide Oral Tablet 40 MG- Give 1 tablet po two times a day for diuretics showed a 3 in the box on 09/01 and 09/06. 105553 Page 8 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0698 Level of Harm - Minimal harm or potential for actual harm Nifedipine ER Oral Tablet Extended Release 24 Hour 30 MG- Give 2 tablet po two times a day for hypertension showed a 3 in the box on 09/01 and 09/06. Timolol Maleate Ophthalmic Solution 0.5%- Instill 1 each in both eyes two times a day for glaucoma showed a 3 in the box on 09/01 and 09/06. Residents Affected - Few Insulin Lispro Injection Solution 100 unit/ml Inject as per sliding scale showed a 3 in the box on 09/01, 09/03 (Saturday), 09/06, 09/10 (Saturday), and 09/13 (Tuesday). Monitor pain every shift and record pain number on a 0-10 scale showed a 3 in the box on 09/01. Side Effect Monitoring showed a 3 in the box on 09/01. Hydralazine HCL Oral Tablet 10 MG- Give 1 tablet po every 6 hours for hypertension showed a 3 in the box on 09/01 and 09/03. Hydralazine HCL Oral Tablet 10 MG- Give 1 tablet po every 4 times a day for hypertension showed a 3 in the box on 09/06, 09/10, and 09/13. Sucralfate Oral Tablet 1 GM- Give 1 tablet po before meals and at bedtime for indigestion showed a 3 in the box on 09/01, 09/03, 09/06, 09/10, and 09/13. Balsam Peru Castor Oil External Ointment- Apply to back topically two times a day for itching showed a 3 in the box 09/01. Nystatin External Ointment 100000 unit/gm- Apply to back topically three times a day for itching showed a 3 in the box on 09/13. The chart codes indicated a 3 meant absent from facility. A review of the Progress Notes revealed the following notes: 08/30/22 Resident LOA (Leave of Absence) to dialysis at this time. Medications well taken as ordered. There were no progress notes related to contact made with the physician in regard to the resident missing ordered medications due to being out to dialysis. A review of the care plan related to hemodialysis was initiated on 07/25/22. Interventions included but was not limited to dialysis days on Tuesday, Thursday, and Saturday. On 09/14/22 at 10:00 a.m., Staff E, Licensed Practical Nurse (LPN) confirmed the 3 on the MAR indicated the resident was out to dialysis. She stated the resident did not have an order to take medications with him. Staff E, LPN, stated they should contact the doctor when the resident had to miss a scheduled medication. On 09/14/22 at 12:16 p.m., the Assistant Director of Nursing (ADON) confirmed there should be documentation and the doctor should be contacted when the resident misses a scheduled medication. 105553 Page 9 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

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 interview, the facility failed to ensure the medication error rate was less than 5.00%. Twenty - six medication administration opportunities were observed, and five errors were identified for three residents (#89, #73, and #111) of five residents observed. These errors constituted a 19.23 % medication error rate. Residents Affected - Some Findings included: 1. On 09/13/2022 at 9:21 a.m. a medication observation was conducted alongside Staff B, Licensed Practical Nurse (LPN) as she prepared medications for Resident # 89. She said she had prepared all the ordered medications except one. She indicated at that time Olmesartan 40 mg (milligram) tablet was not in the medication cart. At that time Staff B went to the backup system and confirmed Olmesartan was not in the system. Staff B said she would need to reorder the medication so it would be available to be given later today. Medication reconciliation revealed a physician order for Olmesartan Medoxomil oral tablet 40 mg give 40 mg by mouth one time a day for hypertenison (HTN), order date 08/19/2022, was omitted at the physician ordered time. Indicating the medication was depleted and not reordered in a timely manner. 2. On 09/13/2022 at 9:50 a.m. a medication observation was conducted alongside Staff C, Registered Nurse (RN) as she prepared and administered the following medications for Resident #73: acidophilus 250 mg one tablet, stool softener 100 mg, Levofloxacin 500 mg one tablet, Montelukast 10 mg one tablet, multivitamin, and vitamin D3 25 mcg (microgram) /1000 international units (IU) one tablet. After the oral medications were given, Dulera 200 -5 mcg one puff was given. Approximately 15 seconds later the second Dulera puff was administered. Medication reconciliation revealed physician orders as: Acidophilus oral capsule 100 mg not 250 mg as given. Vitamin D3 tablet 1000 IU give two, only one was administered. Further review Dulera Aerosol 200-5 MCG/ACT 2 puff inhale orally two times a day for asthma. Rinse mouth with water after each dose of inhaler dated 09/08/2022. The Resident was not instructed to rinse her mouth out after the second dose of Dulera was administered. Additionally, manufacturer instructions state to wait at least 30 seconds to take your second puff of Dulera. DULERA® 200 mcg/5 mcg (mometasone furoate 200 mcg and formoterol fumarate dihydrate 5 mcg) Inhalation Aerosol. Wait at least 30 seconds to take your second puff of DULERA. After each dose (2 puffs) of DULERA, rinse your mouth with water. Spit out the water. Do not swallow it. This will help to lessen the chance of getting a yeast infection (thrush) in the mouth and throat. https://www.organon.com/product/usa/pi_circulars/d/dulera/dulera_ppi.pdf. 3. On 09/13/2022 at 11:45 a.m. a medication observation was conducted with Staff D, LPN as she prepared insulin for Resident #111. She said the insulin was Humulin regular and stated, Its 14 units. On observation the syringe reflected 20 units. Staff D was asked how many units were in the syringe. She repeated 14 units. Staff D was then asked at the time to visually verify the units. She responded a third time Its 14 units. Staff D was asked to wait at that time. Staff A, Unit Manager/RN was in the immediate vicinity and looked at the dosage of the insulin in the syringe. He stated, I see 19 units. Staff D expelled insulin from the syringe to reflect a total of 14 units. 105553 Page 10 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0759 Level of Harm - Minimal harm or potential for actual harm Medication reconciliation revealed a physician order for Insulin Regular Human Solution inject 10 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications, order date 12/25/2021. Additional insulin orders at that time read Insulin Regular Human Solution inject as per sliding scale. Sliding scale indicated an additional 4 units of insulin was to be administered along with the 10 units. Total of 14 units. Residents Affected - Some Insulin Human Regular (Intravenous Route, Subcutaneous Route) Too much insulin human regular can cause hypoglycemia (low blood sugar) https://www.mayoclinic.org/drugs-supplements/insulin-human-regular-injection-route/side-effects/drg-20060927?p=1. On 09/13/2022 at approximately 2:00 p.m. an interview was conducted with the Assistant Director of Nursing who confirmed it was his expectation medications are given as ordered. Review of facility policy titled, Medication Administration, dated 2007. 7.1 General Guidelines Policy Medications are administered as prescribed in accordance with the manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. On page 3 of 6 Medication Administration 1. Medications are administered in accordance with written orders of the prescriber. 105553 Page 11 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on observation, interview, and record review the facility failed to assure the plan of care for the coordination of care and services with the hospice provider was current for end-of-life care for one resident (#54) out of eleven residents receiving hospice services. Findings included: On 09/11/22 at 10:34 a.m. Resident #54's family member said he visits weekly but doesn't get to the facility as often as he would like. Resident #54's family member said she opens her eyes at times to eat and sometimes remembers my name. He went on to say she is receiving hospice services. A record review of Resident #54's admission Record revealed she has resided at the facility for over a year with diagnoses to include senile degeneration of the brain. Review of the Hospice Communication Binder reflected an Interim Plan of Care dated 04/15/2022. No further plans of care for hospice services were located. Progress notes, dated 07/26/2022, showed the Interdisciplinary Team (IDT) spoke with [family member] via phone for a scheduled care plan meeting. Resident care plan, current med (medications), weight, diet preferences, and advanced directives an all questions addressed and answered to family's satisfaction with appreciation verbalized. On 09/12/2022 at 4:30 p.m. an interview was conducted with the Minimum Data Set Coordinator (MDSC) she said she talks with the hospice nurse about the plan of care, and the activities of daily living (adls) schedule. She said our process is to have the hospice nurse attend the care plan meeting but sometimes they can't meet in person, so it's conducted on the phone. When asked if she had Resident #54's hospice plan of care she stated, I don't get their plan of care. It should be in the file in each binder. The MDSC went on to state that after the meeting is held with IDT I will contact the nurse for hospice to follow up with the family if needed. She denied documenting in Resident #54's medical record the follow up with the hospice nurse. On 09/13/22 at 12:49 p.m. the MDSC said at Resident #54's care plan meeting, conducted on 07/26/2022, our nurse and social worker were present. She said I called the hospice nurse for this meeting, but they did not answer. She went on to say the care plan meeting prior to the one that had occurred on 07/26/2022 the hospice nurse did not respond nor attend either in person or by phone. The MDSC stated, Our process is that we call them on the phone and leave a message if were unable to speak with them at the time. She denied a second attempt is made to verify if the first message had been received. On 09/13/2022 at 12:53 p.m. the Nursing Home Administrator confirmed they were unable to locate a hospice care plan for Resident #54. Review of the Nursing Home Facility Services Agreement, showed This Nursing Facility Services Agreement (Agreement) is effective on the (blank) day of (blank) 2017. (d) Coordination of Care: (i) General. Facility shall participate in any meetings, when requested for the coordination, supervision and evaluation by Hospice of the provision of Facility Services. Hospice and facility shall communicate with one another regularly and as needed for each particular Hospice patient. Each party is 105553 Page 12 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0849 responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105553 Page 13 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice identified on the recertification survey conducted 9/14/2022, regarding a medication error rate of greater than 5.0%. Findings included: 1. On 9/14/2022 during a recertification survey deficient practice was identified during medication administration and F759 was cited with a severity of D. Finding included: On 09/13/2022 at 9:21 a.m. a medication observation was conducted alongside Staff B, Licensed Practical Nurse (LPN) as she prepared medications for Resident # 89. She said she had prepared all the ordered medications except one. She indicated at that time Olmesartan 40 mg (milligram) tablet was not in the medication cart. At that time Staff B went to the backup system and confirmed Olmesartan was not in the system. Staff B said she would need to reorder the medication so it would be available to be given later today. Medication reconciliation revealed a physician order for Olmesartan Medoxomil oral tablet 40 mg give 40 mg by mouth one time a day for hypertenison (HTN), order date 08/19/2022, was omitted at the physician ordered time. Indicating the medication was depleted and not reordered in a timely manner. On 09/13/2022 at 9:50 a.m. a medication observation was conducted alongside Staff C, Registered Nurse (RN) as she prepared and administered the following medications for Resident #73: acidophilus 250 mg one tablet, stool softener 100 mg, Levofloxacin 500 mg one tablet, Montelukast 10 mg one tablet, multivitamin, and vitamin D3 25 mcg (microgram) /1000 international units (IU) one tablet. After the oral medications were given, Dulera 200 -5 mcg one puff was given. Approximately 15 seconds later the second Dulera puff was administered. Medication reconciliation revealed physician orders as: Acidophilus oral capsule 100 mg not 250 mg as given. Vitamin D3 tablet 1000 IU give two, only one was administered. Further review Dulera Aerosol 200-5 MCG/ACT 2 puff inhale orally two times a day for asthma. Rinse mouth with water after each dose of inhaler dated 09/08/2022. The Resident was not instructed to rinse her mouth out after the second dose of Dulera was administered. Additionally, manufacturer instructions state to wait at least 30 seconds to take your second puff of Dulera. DULERA® 200 mcg/5 mcg (mometasone furoate 200 mcg and formoterol fumarate dihydrate 5 mcg) Inhalation Aerosol. Wait at least 30 seconds to take your second puff of DULERA. After each dose (2 puffs) of DULERA, rinse your mouth with water. Spit out the water. Do not swallow it. This will help to lessen the chance of getting a yeast infection (thrush) in the mouth and throat. https://www.organon.com/product/usa/pi_circulars/d/dulera/dulera_ppi.pdf. On 09/13/2022 at 11:45 a.m. a medication observation was conducted with Staff D, LPN as she prepared insulin for Resident #111. She said the insulin was Humulin regular and stated, Its 14 units. On 105553 Page 14 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0867 Level of Harm - Minimal harm or potential for actual harm observation the syringe reflected 20 units. Staff D was asked how many units were in the syringe. She repeated 14 units. Staff D was then asked at the time to visually verify the units. She responded a third time Its 14 units. Staff D was asked to wait at that time. Staff A, Unit Manager/RN was in the immediate vicinity and looked at the dosage of the insulin in the syringe. He stated, I see 19 units. Staff D expelled insulin from the syringe to reflect a total of 14 units. Residents Affected - Some Medication reconciliation revealed a physician order for Insulin Regular Human Solution inject 10 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications, order date 12/25/2021. Additional insulin orders at that time read Insulin Regular Human Solution inject as per sliding scale. Sliding scale indicated an additional 4 units of insulin was to be administered along with the 10 units. Total of 14 units. Insulin Human Regular (Intravenous Route, Subcutaneous Route) Too much insulin human regular can cause hypoglycemia (low blood sugar) https://www.mayoclinic.org/drugs-supplements/insulin-human-regular-injection-route/side-effects/drg-20060927?p=1. 2. During the revisit survey on 11/17/2022 additional medication administration errors observed were: An observation was made on 11/17/22 at 9:07 a.m. of Staff C, Licensed Practical Nurse (LPN) preparing and administering medication to Resident #8. Staff C administered Amlodipine 5mg, Aspirin 325mg, Finasteride 5mg, Lisinopril 20mg, Memantine HCL 10mg, and Tamsulosin 0.4mg. Prior to preparing the medication, Staff C retrieved a new bottle of Aspirin, opened, and dated the bottled. A reconciliation with provider orders revealed the following order: Aspirin EC Tablet Delayed Release 81mg. Once a day for Cerebrovascular Accident (CVA.) Resident #8 did not have an order for Aspirin 325mg. A review of admission records indicated Resident #8 was admitted on [DATE] with diagnoses including cerebrovascular disease, atherosclerotic heart disease, and cerebral infarction. An observation was made on 11/17/22 at 11:55 a.m. of Staff C, LPN preparing and administering medication to Resident #11. Staff C administered Amlodipine 10mg, Carvedilol 12.5mg, Hydralazine HCL 50mg, Meloxicam 7.5mg, Aspirin 81mg, Cyanocobalamin 1000mcg, and Folic Acid 1mg. A reconciliation with provider orders revealed all seven of these medications were ordered to be given at 9:00 a.m. A review of admission records indicated Resident #11 was admitted on [DATE] with diagnoses including atherosclerotic heart disease, and hypertension. On 11/17/22 at 12:05 p.m. an interview was conducted with Staff C, LPN. Staff C stated she has 1 ½ halls of residents. She stated she had a lot of medications to give and couldn't get it all done on time. She confirmed she had not yet given medications to the residents in rooms 209, or 211 yet either. On 11/17/22 at 12:10 p.m. a review of medications was conducted for Residents #12, #13, and #14 who reside in rooms [ROOM NUMBERS]. 105553 Page 15 of 16 105553 09/14/2022 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #12's orders and electronic medication administration record (eMAR) revealed orders for Fosamax 35mg, Lovenox injection 10mg/0.4ml, and a multivitamin. These three medications were scheduled to be administered at 9:00 a.m. and had not yet been signed off as given. A review of admission records revealed Resident #12 was admitted on [DATE] with diagnoses including atherosclerosis of coronary bypass graft, multiple fractures, and osteoporosis. A review of Resident #13's orders and eMAR revealed orders for Amlodipine 10mg, Clopidogrel Bisulfate 75mg, Enoxaparin Sodium injection 40mg/0.4ml, Metoprolol Tartrate 50mg, Gabapentin 100mg, and Hydralazine HCL 50mg. These six medications were scheduled to be administered at 9:00 a.m. and had not yet been signed off as given. A review of Resident #14's orders and eMAR revealed orders for Cholecalciferol 50mg, Folic Acid, Potassium Chloride ER 10meq, Docusate sodium 100mg, Nitrofurantoin microcrystal 100mg, Rufinamide 400mg, and Topamax 100mg. These seven medications were scheduled to be administered at 9:00 a.m. and had not yet been signed off as given. A review of admission records revealed Resident #14 was admitted on [DATE] with diagnoses including altered mental status, urinary tract infection, cerebral infarction, and Lennox-Gastaut syndrome. On 11/17/22 at 6:32 p.m. a Quality Assurance (QA) meeting was held with the NHA, DON, and the Regional Clinical Nurse Consultant. The NHA stated they held two QAPI meetings and held multiple IDT team meetings to review the annual survey findings. The NHA stated they reviewed the POC book, discussed the audits, reviewed trends, and provided education. She stated part of the process included identifying staff who were still struggling and finding ways to help them. The DON stated the facility observed every nurse completing medication pass and did random medication observation audits including PRN nurses. She stated all nurses were educated on the Five Rights of Medication and notifying the provider if a medication is not administered as ordered. The Regional Clinical Nursing Consultant stated she felt they had improved, but acknowledge it is a work in progress. The NHA stated they have another QAPI meeting scheduled and will discuss this survey's findings and ways to improve their medication administration process. 105553 Page 16 of 16