Health inspection·June 16, 2022

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, staff interview and review of facility policies the facility failed to ensure medications were not left unattended at the resident's bedside for 1 of 5 residents sampled for unnecessary medications (Resident #20) and failed to ensure that medications were stored in locked compartments accessible only to authorized personnel for 1 of 5 medication carts observed. The findings include: Resident #20 On 6/13/22 at approximately 11:37 AM, during an interview with Resident #20, it was noted that there were two cups of pills sitting on her bedside table. A few minutes into the interview she stated, Oh, let me take my medicine, and then picked up both cups and took the medications. (Photographic evidence obtained) A review of physician orders failed to reveal an order for self-administration of medications. A review of assessments conducted by the facility failed to reveal any for self-administration of medications. A review of Resident #20's care plan failed to reveal care planning for self-administration of medications. On 6/16/22 at approximately 11:38 AM, an interview was conducted with the Administrator. At that time she stated that the nurses should not be leaving medications unattended with residents at the bedside. A review was conducted of the facility policy, Medication Administration: 7.3 Self-Administration by Resident, dated 11/2017. Under the procedures section it stated, item number 1, If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical and visual ability to carry out this responsibility, during the care planning process. Under item number 3 it stated, The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Unlocked Medication Cart On 6/16/22 at approximately 8:44 AM, an observation of medication pass was conducted with Licensed Practical Nurse Z. After pulling all of the medications for Resident #520, she asked another nurse to get for her Vitamin B12 500 micrograms because it was not available on the cart. On 6/16/22 at Page 1 of 3 105626 105626 06/16/2022 Chautauqua Springs Health Center 785 S 2nd Street Defuniak Springs, FL 32435

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8:46 AM staff Z, proceeded to take Resident #520's other medications to him while she waited for the other nurse to return with the Vitamin B12, and left the medication cart unlocked. Resident #520's room was located down the hall and around a corner from where the medication cart was left unattended. She returned to the cart on 6/16/22 at 8:48 AM, and she acknowledged that she should have locked the cart and that it was a mistake. On 6/16/22 at 8:52 AM, she went to take the missing B12 medication to Resident #520. She again left the medication cart unlocked and unattended while she went to the resident's room, out of the sight of the cart (Photographic evidence obtained). A review was conducted of the facility policy, Medication Administration: 7.1 General Guidelines, dated 1/2021. Under the, Procedures Section, subsection, Medication Administration, item number 17, it stated, During Administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administering medications when unlocked. 105626 Page 2 of 3 105626 06/16/2022 Chautauqua Springs Health Center 785 S 2nd Street Defuniak Springs, FL 32435

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, posted menu review and policy review, the facility failed to follow the preapproved menu during 2 of 5 meal observations, failed to ensure approval was received prior to making meal substitutions, failed to keep record of those substitutions, and failed to post the daily menu in accordance with facility policy. The findings include: On 6/13/22 at approximately 12:10 PM, the posted menu outside of the facility's dining room was observed. The menu was dated for the previous Wednesday (6/8/22) and indicated lunch would consist of hamburger on bun, cucumber onion salad, [NAME] tots and oranges. An observation of the facility's lunch service revealed the residents were served ham, sweet potatoes, and collard greens. (Photographic evidence obtained) On 6/15/22 at approximately 9:11 AM, the posted menu outside of the facility's dining area room was observed. The posted menu for Wednesday (6/15/22) indicated dinner would consist of turkey pot pie, biscuit, peas and carrots. A review of the weekly menu indicated dinner on Wednesday (6/15/22) would consist of breaded fish on bun, peas and carrots, and [NAME] tots. (Photographic evidence obtained) On 6/15/22 at approximately 1:29 PM, an interview was conducted with the Registered Dietician (RD) who stated that the Manager in Training (MIT) will substitute preapproved menu items without approval. The RD stated the MIT requested she authorize a menu substitution two weeks after the substitution was made. On 6/15/22 at approximately 3:08 PM, an interview was conducted with the MIT, who stated she does not post the menu anywhere in the facility and that there are too many changes to the menu. When asked to review the facility's documentation of meal substitutions, the MIT stated, she had no record, and was not aware she needed to keep track of menu changes. A review of the facility's Dining Services Policy and Procedure dated 5/2014 revised 9/2017, Menus Policy 004 revealed: menus will be posted in the Dining Service department, dining rooms and resident/patient care areas, and menu substitutions log will be maintained on file. 105626 Page 3 of 3