Health inspection·January 31, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to provided physician ordered medications to one (Resident #2) of three residents sampled for pharmacy services. Findings included: A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Wilson's Disease, autistic disorder, borderline personality disorder, and generalized anxiety disorder. Resident #2 was discharged from the facility on 1/13/2024. A review of Resident #2's physician's orders revealed an order, dated 12/21/2023 for Lorazepam 1 milligram (mg) by mouth two times a day at 9:00 AM and 5:00 PM for anxiety. A review of Resident #2's care plan revealed a focus area, initiated 12/21/2023, Resident #1 used anti-anxiety medications related to a diagnosis of generalized anxiety disorder. Interventions included to administer anti-anxiety medications as ordered by the physician and monitor for side effects and effectiveness every shift. A review of Resident #2's Medication Administration Record (MAR) for December 2023 revealed Resident #2 did not receive Lorazepam 1 mg from 12/21/2023 at 5:00 PM until 12/25/2023 at 5:00 PM. The medication was documented as 2=Drug Refused on 12/24/2003 at 9:00 AM and 5=Hold/See Progress Notes on 12/24/2023 at 5:00 PM. The remaining entries during the time period were documented 9=Other / See Progress Notes A review of Resident #2 Progress Notes for December 2023 revealed the following MAR notes related to Resident #2's Lorazepam 1 mg not being administered: - A note dated 12/21/2023 at 10:10 PM: pharmacy notified. The note did not reveal notification of Resident #2's physician. - A note dated 12/22/2023 at 9:32 AM: on order. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 12/22/2023 at 7:54 PM: on order. The note did not reveal notification of Resident #2's physician or an attempt to contact the pharmacy. - A note dated 12/23/2023 at 12:11 PM: on order. The note did not reveal notification of Resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105634 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)