Health inspection·May 12, 2022

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review and interviews, the facility failed to monitor behaviors for one (Resident #6) of five residents selected for unnecessary medications review, from a total of 23 residents in the sample. Residents Affected - Few The findings include: An observation and interview was conducted with Resident #6 in her room on 5/10/22 at 3:36 p.m. The resident was sitting in her wheelchair at bedside smiling and talking. She did not remember which medications she took. A medical record review revealed an admission date of 12/27/18 and a diagnosis of anxiety disorder. Active physician's orders revealed an order dated 4/22/22 for lorazepam (Ativan, sedative) 0.5 mg (milligrams) to be administered daily. The active care plan included the following Focus Areas: Behavior Problem - manipulative due to ineffective coping skills. Intervention: Monitor behavior and side effects of psychotropic medication. Uses antianxiety medication. Intervention: Monitor behaviors and administer medications as ordered. A review of the May 2022 Medication Administration Record (MAR) revealed no documentation of behaviors, medication side effects, or nonpharmacological interventions for Lorazepam. (Photographic Evidence Obtained) There was no documentation in the medical record to verify that behaviors, medication side effects, or nonpharmacological interventions were being monitored/provided. An interview was conducted with Licensed Practical Nurse (LPN) B on 5/12/22 at 10:59 a.m. She stated resident behaviors were monitored and documented on the Medication Administration Record (MAR). An interview was conducted with LPN A on 5/12/22 at 11:04 a.m. He stated resident behaviors were documented on the MAR daily. He confirmed there was no behavior monitoring documented for Resident #6. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/12/22 at 12:10 p.m. She confirmed behavior monitoring for Resident #6 was not documented and should have been on the MAR. The ADON stated she would initiate that now. (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 4 Event ID: 105826 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 105826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion at Jacksonville, The 1771 Edgewood Ave W Jacksonville, FL 32218 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)