Health inspection·September 16, 2021

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure that each resident was accurately assessed for their Preadmission Screening and Resident Review (PASRR) needs for one (Resident #36) of 29 sampled residents. Residents Affected - Few Findings include: A review of Resident #36's record revealed that he was admitted to the facility on [DATE], with diagnoses that included depression; bipolar; and hallucinations. Further review of the record, revealed that a PASRR Level I Screen was completed at the hospital on 5/13/19. The PASRR Level I screen revealed that Section I: PASRR Screen Decision-Making was left blank, with no documentation of any mental illness or Intellectual disabilities. A review of the Psychiatric Periodic Evaluation with a date of service of 5/30/19, revealed that this resident had diagnoses that included Bipolar disorder, current episode depressed, moderate; chronic schizoaffective disorder; and generalized anxiety disorder. An interview on 9/14/21 at 1:21 p.m., with the Social Service Director revealed that residents usually come from the hospital with their PASRR Level I completed, She reported that if there was not one present at the time of admission, then the facility would complete one within 25 days. She said the Assistant Director of Nursing and the Social Service Director would review the PASRR Level I screen for accuracy, and if there was a change in the resident's diagnosis, they would re-do the PASRR Level I screen. An interview on 09/14/21 at 3:32 p.m. with the Social Service Director, revealed that the facility did not have a policy related to PASRRs, and that the facility, just follow the regulations. She reported that in this case, the resident was admitted in 2019 with existing mental illness diagnoses which was not reflected on the PASRR Level I Screen. She reported that the facility was in the process right now of completing a new PASRR Level I screen. Page 1 of 6 105725 105725 09/16/2021 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

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, policy review, and interviews, the facility failed to, (1) discard medications in an appropriate manner on one (2 East) of four units, (2) ensure Schedule IV medications were stored within a double-lock system in two of two medication refrigerators, (3) label medications with an open date and discard medications within the shortened shelf life on two (1 East and 2 West) of three medication carts, and (4) ensure one of three medication carts and one treatment cart were locked while unattended. Findings included: (1) On 9/14/21 at 1:41 p.m., a medication storage observation was conducted on the 2 East unit of the medication room/nursing station and medication cart with Staff D, Licensed Practical Nurse (LPN). In a locked upper cupboard in the left corner of the medication room/nursing station were six gallon-sized clear plastic bags which contained individual blister packages containing a tablet or capsule of medication. The plastic bags were labeled and contained the following: - Two of the bags labeled A, B, C, D, E, F, G, H contained an assortment of medications in individual blister packages such as 5 milligram (mg) tablet of Amlodipine, 20 mg tablet of Baclofen, 10 mg of Buspirone tablet, and 300 mg tablet of Bupropion; - Two gallon-sized bags, labeled I, J, K, L, M, N, O, P, Q contained an assortment of medications such as an individual package of a 7.5 mg tablet of Mirtazipine; - A bag, labeled R, S, T, U, V, W, X, Y, Z contained individual packages of medications such as 0.4 mg of Tamsulosin; - One bag, unlabeled, contained similar individual packages of medications such as Entresto and Isosorbide. None of the observed individual packages of medications identified which resident the medication had been prescribed. Photographic evidence was obtained. Staff D stated that the medications were extras for when we drop one. She stated that the medications were from residents who had been discharged or medications that had been discontinued. (2) An observation was conducted on 9/14/21 at 1:33 p.m. with Staff B, Licensed Practical Nurse (LPN), of the 1 East Nursing station/Medication room. The staff member confirmed that the nursing station was not locked and residents/visitors were able to enter the nursing station. One treatment cart was parked in the unlocked and easily accessible nursing station with multiple medicated ointments and creams that were stored within the cart. Staff B unlocked a small dorm-sized refrigerator and an observation was made of a small clear box closed with two plastic zip ties. The label on the box indicated the box contained two vials of Lorazepam (Ativan) 2 milligram/milliliter (mg/mL). The box was unaffixed to the refrigerator and easily removed from the refrigerator. Photographic evidence was obtained of the staff member holding the box and no affixed locked box within the refrigerator. Staff B confirmed that the box containing the Schedule IV medication, Lorazepam, was not protected by a two-lock system, just the locked refrigerator. 105725 Page 2 of 6 105725 09/16/2021 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/14/21 at 2:12 p.m., an observation was conducted of the 2 [NAME] Medication room/Nursing station, which was unlocked and accessible to residents and visitors. Staff C, Registered Nurse/Unit Manager (RN/UM), unlocked the dorm-sized medication refrigerator and confirmed that an unaffixed clear box located inside, contained a clear plastic box closed with plastic zip ties. As the larger box was removed from the refrigerator, the front side (with a lock) fell forward and the top fell completely off, allowing the smaller box which contained two vials of the Schedule IV controlled substance of Lorazepam to be accessible. Photographic evidence was obtained. Staff C stated that the pharmacy knew about the (broken) larger box. (3) An observation on 9/13/21 at 3:37 p.m., was conducted of the 1 East medication cart with Staff B, LPN. The observation revealed a bottle of Vanilla-flavored Pro-Stat (liquid protein), dated as opened on 5/28/21. Staff B turned the bottle over and indicated that the manufacturer's expiration date was imprinted on the bottom. The bottle label instructed that the contents were to be discarded 3 months after the bottle was opened. On 9/14/21 at 2:12 p.m., a review of the 2 [NAME] medication cart with Staff C, indicated that two boxes of Artificial Tears were opened and undated. An unopened Levemir Flex Touch insulin pen was observed in the cart with other insulin pens. The pharmacy label indicated that Refrigeration Preferred Before First Use. Photographic evidence was obtained. An inhaler, Combivent Respimat identified that it had been filled by the pharmacy on 3/24/21 and did not identify when it had been opened. The dose indicator was in red, which per combivent.com, indicated there was approximately 7 days of medication left. The box that contained the Combivent inhaler instructed users to Discard 3 months after first use. The manufacturer literature, obtained at combivent.com, instructed the user to write the discard date on the label (3 months from the date the cartridge is inserted. (4) During an observation of medication administration, on 9/14/21 at 8:56 a.m., with Staff D, she administered oral medications to a resident, returned to cart, removed the residents nasal spray, and returned to the room to administer the spray. After the administration, Staff D confirmed, by nodding head and stating, yes it was, that the cart was left unattended and unlocked in the hallway while she administered the nasal spray. On 9/14/21 at 1:33 p.m., an observation was made of an unlocked treatment cart inside the unlocked nursing station on the 1 East unit. The treatment cart contained multiple containers of prescribed ointments and creams for residents. Staff B, LPN, arrived to the nursing station, locked the treatment cart, and confirmed that the nursing station was not kept locked. **********On 9/14/21 at 2:12 p.m., Staff C, Registered Nurse/Unit Manager (RN/UM) stated upon discharge of a resident, staff first contact the pharmacy to notify them that the resident was discharged , then the resident's narcotic medications were removed from the storage. She stated that routine medications were sent daily and if staff had to discard medications or if they were discontinued, the staff used a drug destroyer, did not know the name but it came in a container like a milk jug. She stated routine meds were not returned to the pharmacy and if a medication was dropped and had to be wasted, the medications were destroyed the same way. She reviewed the nursing station/medication room of 2 East and found that the cupboard that contained the six bags of medications was locked. She stated she knew about the medications, that the medications were stored in the bags because they did not fit into the medication disposal box that the Infection Control (IC) nurse had provided them. The Director of Nursing (DON) stated, at 2:21 p.m. on 9/14/21, routine medications that were wasted were to be put into the medical disposal boxes. She stated narcotics and routine medications should 105725 Page 3 of 6 105725 09/16/2021 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be destroyed or a physician order be obtained for the medication to be given to the resident at the time of discharge. The DON stated that staff might be keeping the medications in case medications were not delivered by the pharmacy. An interview, on 9/14/21 at 4:44 p.m., was conducted with Staff E, Registered Nurse (RN). The RN stated that when she had to waste a medication she would crush it and put it in the sharps box, indicating the box attached to the side of the medication cart. She stated that the cart used to have a small disposable sharps box in the drawer but she did not have it in there anymore. On 9/15/21 at 5:05 p.m., Staff F, LPN, explained to waste a medication, if not a controlled substance, she crushed it and put it down the sink or in the sharps box. The staff member extracted a small red box from the top drawer of the medication cart. The box was manufactured labeled as a disposable sharp box and handwritten labeled Pills only. An interview was conducted, on 9/16/21 at 12:44 p.m., with the Consultant Pharmacist. She stated she had not physically visited the facility since COVID and did not know how often the Case Manager had visited. She stated that carts should be locked in an unlocked nursing station, the refrigerated Lorazepam should be double locked. She stated she was going to call pharmacy and notify them of the missing and broken narcotic refrigerator boxes. The Consultant stated the nurses should call the pharmacy and notify them of issues with the boxes. She stated Artificial Tears should be discarded 60 days after being opened. The Consultant Pharmacist stated, you and I both know that's not the proper way to dispose (regarding the bags of medications). She stated that nurses do not like to be wasteful but (storing medications in bags) was not the proper procedure and the pharmacy did not instruct nurses to dispose of meds in that manner. During a return call, on 9/16/21 at 1:03 p.m., the Consultant stated she had spoken with the pharmacy and they informed her that the refrigerator box for narcotics on the second floor was replaced on Tuesday (9/14/21) and that they would place a lock box in the first floor (1 East) refrigerator. On 9/16/21 at 2:00 p.m., the DON stated Lorazepam vials should be double-locked in the refrigerator and Artificial Tears should be discarded after 30 days. The policy 4.1 General Guidelines for Medication Storage, effective 7/23/2019, identified that Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members authorized to administer medications. The policy indicated the following procedures: - Only licensed nurses, the Consultant Pharmacist, and those authorized to administer medications (e.g. medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. - Schedule III-V medications may be stored along with non-controlled drugs, but may be under more strict storage controls at the Facilty's discretion or as required by state regulations. - Outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. 105725 Page 4 of 6 105725 09/16/2021 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to ensure that food was prepared in a clean and sanitary manner in the kitchen related to 1) Food left uncovered and exposed to contaminates and 2) Non dietary staff in the kitchen without a hairnet. The kitchen was used to prepare meals for residents on two of two floors of the facility. Findings Included: On 09/13/21 at 09:57 a.m. an initial tour of the kitchen with the Certified Dietary Manager (CDM) was conducted. During the tour, dough that had been formed into rolls was observed, uncovered, sitting on top of an oven. The dough was observed to be sitting, uncovered, underneath a stained, greasy substance, and peeling rust. The CDM confirmed that the rolls were placed there by the cook for proofing (to allow the dough to rise) and would be used for lunch. The observation of peeling rust and the greasy substance was shown to the CDM. Following the observation, the CDM stated that he would not serve the rolls, he would just throw them out. On 09/13/21 at 10:05 a.m., a staff member was observed in the kitchen without a hairnet. An interview was conducted with the staff member. He stated that he was the Admissions Director. He said that he was new to the facility and was just getting ice for his drink. He said that he usually called the kitchen for ice and a staff member brought it to him. He verified that he knew he was supposed to wear a hairnet while in the kitchen but just forgot. Review of the facility policy titled Sanitization, revealed, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Highlights: Kitchen Areas, Policy Interpretation and Implementation. Equipment/Utensils: 2) All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. 105725 Page 5 of 6 105725 09/16/2021 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain kitchen equipment in a safe, operating condition, related to one burner on the stove. The stove was used to provide meals for residents on two of two floors of the facility. Residents Affected - Some Findings included: On 09/13/21 at 09:57 a.m., during the initial kitchen tour, the stove was being used to prepare lunch. The Certified Dietary Manager (CDM) was asked to ignite the back left burner. On the first attempt, the knob was turned to the on position, the burner failed to ignite. A second attempt was made, which was also unsuccessful. The CDM walked away and returned with a handheld, multipurpose lighter. He turned the knob, allowing gas to flow, struck the lighter, pointed it towards the burner, at which time the burner ignited. Following the observation, an interview was conducted with the Cook, Staff A, she stated that the burners are always pre-lit, but she has had to blow on the burner to make the fire come on. On 09/16/21 at 1:09 p.m., an interview was conducted with the CDM, he stated that he noticed the pilot light was out about a week ago. The CDM said the process was to notify the Maintenance Director when things were not working. He said, in this case, he had other things going on so he just verbally notified the Maintenance Director. The CDC said he had a logbook that he used to document requests, but he forgot to log it. On 09/16/21 at 1:19 p.m. an interview was conducted with the Maintenance Director. He stated that he, found out about the pilot light not working, Friday. The Fire Department came to the facility because of an alarm that went off. When the alarm goes off, the pilot light goes off, that may be why the light did not ignite, it probably did not reset. He called the gas company to report the incident. He called three other places but they could not come in any earlier than Monday. The Maintenance Director stated that he had not received training regarding the pilot light, but he knew it was a bad thing. He said it was possible that gas could have been coming out since it was not working. He said he would look into getting a regular vendor for equipment maintenance. 105725 Page 6 of 6