Inspection·July 29, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent medication administration error rate of 5% or greater for 2 of 4 residents sampled for medication administration, (#37,#16). There were 2 medication errors in 27 opportunities for a medication error rate of 7.41%. Residents Affected - Few Findings: 1. Review of resident #37's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included osteoarthritis and fracture of the right femur. On 7/26/23 at 9:20 AM, Licensed Practical Nurse (LPN) A prepared to administer resident #37's nine scheduled morning medications and placed a total of 9 pills into a small plastic cup. LPN A then approached resident #37 with the cup of 9 pills and the resident declined to take the Acetaminophen 325 milligrams (mg) tablet stating that she was not in pain. LPN A then went out to the medication cart and with a spoon took out the single Acetaminophen 325 mg tablet and then returned to resident #37's room and administered the remaining medications by mouth to the resident. A review of resident #37's medical record post medication administration revealed an order for Acetaminophen oral tablet 325 mg give 2 tablets by mouth four times a day for hip and back pain. On 7/26/23 at 11:42 AM, a follow up interview was conducted with LPN A. The LPN read in the MAR (medication administration record) for resident #37 an order for routine Acetaminophen 325 mg 2 tablets. The nurse acknowledged medication error as she only brought one tablet to administer with the resident's routine morning medications. LPN A explained, she usually read the orders twice to avoid making errors but didn't today. 2. Resident #16 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). On 7/26/23 at 9:35 AM, medication administration was observed for resident #16 and LPN B. LPN B was observed preparing the morning medications for resident #16 by placing pills in small plastic cup and taking a boxed inhaler out of the medication cart. The inhaler box label read, Breo Ellipta 100/25 mcg [micrograms]. The LPN proceeded to administer the medications to resident #16. A record review post medication administration for resident #16 revealed an order dated 1/5/23 that read, Breo Ellipta Aerosol Powder Breath Activated 200-25 mcg/inh (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day at 9 AM for COPD. (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 2 Event ID: 105797 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 105797 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guardian Care Nursing & Rehabilitation Center 350 South John Young Parkway Orlando, FL 32805 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)