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 ensure the medication error rate was not 5
percent or greater. The medication error rate was 11.11 percent. Three medication errors were identified
while observing a total of 27 opportunities, affecting 2 of 6 sampled residents observed (Residents #45 and
#58).
Residents Affected - Few
The findings included:
1) A medication pass observation for Resident #45 was made on 06/02/22 beginning at 8:28 AM with Staff
A, a Registered Nurse (RN). The RN obtained eleven medications, to include nine pills, a patch, and an eye
drop. The RN also poured a nutritional supplement. The medication prepared by the RN was as follows:
a) Amlodipine 10 mg (milligrams) - one tablet
b) Calcium 600 mg - one tablet
c) Vitamin B12, 250 mcg (micrograms) - one tablet
d) Bisacodyl 5 mg - two tablet
e) Ferrous Sulfate 325 mg - one tablet
f) Lidocaine Patch 5%
g) Miralax 17 gm (grams) - powder mixed in water
h) Morphine Sulfate ER (extended release) 60 mg - one tablet
i) Ocuvite - one tablet
j) Systane Lubricant eye drops
k) Vitamin D3, 50 mcg/2000 IU (international units) - one tablet
l) ProHeal 30 ml (milliliters) - liquid nutritional supplement
When asked if that was all that was due for this medication pass for Resident #45, the RN stated it
(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:
105838
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
105838
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Edward J Healey Rehabilitation and Nursing Center
5101 West Blue Heron Blvd
Riviera Beach, FL 33418
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)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
was. The RN was asked to count the number of pills she had obtained for administration to Resident #45,
as a way to verify the surveyor's documentation . The RN counted out nine pills, informing the surveyor she
had poured out two of the Bisacodyl for administration.
Staff A, the RN, administered the above medications and supplement to Resident #45.
Residents Affected - Few
During reconciliation of the medications with the physician orders, the record documented the order for
Oxybutynin Chloride ER 10 mg daily. Review of the corresponding Medication Administration Record (MAR)
revealed Staff A had signed out the medication as administered.
During an interview on 06/02/22 at 11:34 AM, when asked about the Oxybutynin that was ordered for daily
administration, the RN stated, It was in there. The surveyor reviewed with Staff A the medications pulled
from the medication cart for Resident #45, confirming the nine pills. The RN again stated she thought the
Oxybutynin was in the medications that she had obtained from the cart, but agreed it could not have been.
Staff A agreed with the medication error.
2) On 06/01/22 at 9:25 AM, an observation of medication administration was conducted with staff B on
Resident # 58. Staff B administered 1 tablet of Multivitamin with mineral without a physician order, and Staff
B omitted the Vitamin D3 1000 unit that was ordered to be administered at 9 AM. Staff B had administered
the following medications to Resident #58: Multivitamin with Mineral 1 tablet by mouth; Baclofen 10 mg 1
tablet by mouth; and Aspirin 81 mg 1 tablet by mouth, for a total of 3 pills which was confirmed with Staff B
before the administration. After the medication administration, the medications were reconciled and
compared against the orders and the scheduled medications. It was revealed that there was no order for
Multivitamin with Mineral that Staff B had administered, and the Vitamin D3 1000 unit, that was scheduled
to be administered, was omitted. Once the surveyor questioned Staff B about these meds, Staff B,
acknowledged the errors, she removed the Vitamin D3 1000 unit out of the medication cart and
administered it to Resident #58.
Record review revealed Resident #58 was admitted to the facility on [DATE], the quarterly Minimum Data
Set (MDS) assessment reference date 03/23/22 documented a brief interview for mental status (BIMS)
score of 15, indicating the resident was cognitively intact.
On 06/02/22 at 3:01 PM, an interview was held with the Director of Nursing (DON), she voiced she was
made aware of the medication error by the attending nurse and the nurse was in-serviced.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105838
If continuation sheet
Page 2 of 2
