Health inspection·November 17, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews the facility failed to ensure staff consistently implemented individualized interventions to meet the needs and prevent avoidable accidents for 1 (Resident #41) of 4 sampled residents reviewed for falls. The findings included: Review of the clinical record revealed Resident #41 was readmitted on [DATE] with diagnoses including diabetes and hypothyroidism. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 8/22/22 noted the required extensive physical assistance of two persons for bed mobility and transfer. Review of the progress notes revealed on 8/26/22 at 6:15 a.m., the resident rolled out of bed during care and landed in supine position (face down) on the right side of the bed. The investigation report dated 8/26/22 noted the resident rolled onto the side facing away from the aide. The resident attempted to assist and rolled out of bed. The aide was changing the resident by herself. The Certified Nursing Assistants (CNAs) [NAME] (Document that provides a summary and overview of the resident's care) for the most recent admission of 9/15/22 specified in bold letters the resident required extensive assist of two for bed mobility. Review of the CNA documentation from 11/2/22 through 11/14/22 revealed 17 times Resident #41 was toileted with one-person physical assist. On 11/15/22 at 7:50 a.m., CNA Staff C was observed providing incontinent care and changing the resident's brief in the bed by herself. On 11/16/22 at 12:27 p.m., CNA Staff C said she knew there should be two persons to move him. She said she received the training but sometimes it is difficult to get some help. She also said she has asked another CNA or a Licensed Practical Nurse (LPN) for help. On 11/17/22 at 7:55 a.m., Licensed Practical Nurse (LPN) Staff F said, there should always be two persons assisting with a resident who required extensive assistance of two persons. The LPN said they received education on it. Page 1 of 3 105842 105842 11/17/2022 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, resident and staff interviews, the facility failed to maintain proper medication storage for 1 (Resident #82) of 1 resident observed with unsecured, unlabeled medication at the bedside. The facility failed to properly label opened medication in 1 ([NAME] medication cart) of 3 medication carts reviewed. The findings included: Review of facility policy titled, Storage and Expiration Dating of Drugs, Biological, syringes and Needles, revised 08/2018 which stated, The Nursing Center should ensure that drugs and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/ freezers of sufficient size to prevent crowding .The Nursing Center should ensure that all drugs and biologicals, including treatment items, are securely stored in a locked cabinet/ cart or locked medication room, inaccessible by residents and visitors .Once any drug or biological package is opened the Nursing Center should follow manufacturer guidelines with respect to expiration dates for opened medications. Nursing staff should record the date opened on the medication container. Nursing Center personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. Review of facility policy titled, Medication and Treatment Administration Guidelines, revised 03/2018 which stated, Medications and biologicals are securely stored in a locked cabinet, cart or medication room, accessible to only licensed nursing staff and pharmacist or authorized pharmacy staff and maintained under a lock system when not actively utilized and attended to by nursing staff for medication administration, receipting or disposal. 1. Review of facility policy titled, General Dose Preparation and Medication Administration, revised 08/2018 which stated, Medication Administration .Observe the resident's consumption of the medication(s). On 11/14/22 at 9:30 a.m., observed Resident #82 with medicine cup containing seven pills at her bedside. Resident #82 said she needed ice water to take her pills. Resident #82 said the pills included medication for high blood pressure, baby aspirin, zinc and vitamin C. Photographic evidence obtained On 11/14/22 at 10:03 a.m., Registered Nurse (RN), Staff A verified he left the pills with Resident #82. He stated, I thought she took them while I was in there . That was my error. I was rushing and the therapist was helping her get back to bed. 2. On 11/16/22 at 10:13 a.m., reviewed [NAME] 500 hall medication cart with Licensed Practical Nurse (LPN), Staff B. An opened medication (Breztri aerosphere inhaler) for Resident #36 was observed in the cart. The medication was not labeled with the date opened. Photographic evidence obtained 105842 Page 2 of 3 105842 11/17/2022 Crescent Health and Rehabilitation Center 5401 Sawyer Rd Sarasota, FL 34233

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LPN, Staff B, stated, I will need to throw this away. It should be dated when opened. I don't know how long it has been opened. I will reorder it now. Review of the manufacturer's insert for Breztri aerosphere (a medication used to help treat lung disease) noted; Throw away Breztri aerosphere 3 months after you open the foil pouch (for the 120-inhalation canister), or 3 weeks after you open the foil pouch (for the 28 inhalation canister) or when the dose indicator reaches zero 0, whichever comes first. On 11/16/22 at 12:44 p.m., in an interview, the Director of Nursing (DON) said medications should not be left at the resident's bedside. 105842 Page 3 of 3