Health inspection·May 12, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, and record review, the facility failed to ensure medications stored at the bedside were assessed for safe administration for one (Resident #336) of twenty-five sampled residents. Residents Affected - Few Findings Included: On 05/08/2023 at 09:41 a.m., Resident #336 was observed lying in his bed and was receptive to an interview. When he spoke, his speech was soft toned and garbled at times. His son was present and assisted with the interview. Resident #336 appeared comfortable and denied any discomfort when asked. On his over the bedside table an inhaler was present. Resident #336 stated, it's for my Parkinson's and confirmed he took it on his own as needed. On 05/09/2023 at 2:45 p.m., Resident #336 was lying in his bed with his eyes closed and appeared comfortable. His son was present at the time and confirmed his inhaler remained in his bedroom. Resident #336 remained with his eyes closed and stated softly I used it last night. Medical record review of Resident #336's admission Record form was reviewed and indicated he was geriatric in age and had resided at the facility for less than a month. His primary diagnosis was listed as Parkinson's disease. A review of Resident #336's physician orders included an order for Inbrija Inhaler Capsule 42 MG (Levodopa) 1 capsule inhale orally as need for Parkinson related to PARKINSON'S DISEASE dated 04/19/2023. A review of the Medication Administration Record (MAR) for May 2023 revealed Inbrija Inhaler was not administered in the month of May 2023. Further review of the medical record failed to reflect a physician order to self-administer Inbrija inhaler at the bedside. On 05/09/2023 at 3:04 p.m., an interview was conducted with Staff C, Licensed Practical Nurse. She confirmed she was caring for Resident #336. When asked about his Inbrija inhaler she stated, I think he has this one in his room. If he needs it right away, we can't get back there quick enough, so he takes it himself. Staff C stated, He does not tell me when he takes it. She confirmed she was unaware of the frequency Resident #336 was self-administering his inhaler. HOW TO USE INBRIJA: Use INBRIJA when Parkinson's symptoms start to return. Page 1 of 8 105866 105866 05/12/2023 Plaza West 912 American Eagle Blvd Sun City Center, FL 33573

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Use INBRIJA as needed when symptoms start to return in between doses of your carbidopa/levodopa medicine. Use it as prescribed when your Parkinson's symptoms start to return. Do not orally inhale more than 1 dose (2 capsules) for any OFF period. Do not take more than 5 doses (10 capsules) in a day. Do not stop taking your daily Parkinson's medicine. INBRIJA does not replace your regular carbidopa/levodopa medicine. Do not swallow or open INBRIJA capsules. Only use INBRIJA capsules with the INBRIJA inhaler. Do not use the INBRIJA inhaler for any other medicine. https://www.inbrija.com/how-to-use. On 05/09/2023 at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). She said if a resident wanted to take their own meds at bedside, they would let me know. When asked about Resident #336 she stated, I don't think so. The DON was shown the photographic evidence of the Inbrija inhalant on Resident #366's bedside table. She stated, The resident does not have a physician order to take meds at bedside. The DON said the facility had a process in place to determine if a resident could safely administer the medication. She confirmed the facility process was not followed. Review of the facility policy and procedure titled Self-Administration of Medications revision December 2016. Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific assessment, including (but not limited to) the resident's: a. ability to read and understand medication labels; b. comprehension of the purpose and proper dosage and administration time for his or her medications; c. ability to remove medications from a container and to ingest and swallow ( or otherwise administer) the medication; and d. ability to recognize risks and major adverse consequences of his or her medications. 8. Self-administered medications must be stored in a safe and secure place, which is no accessible by other residents. 9. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. 105866 Page 2 of 8 105866 05/12/2023 Plaza West 912 American Eagle Blvd Sun City Center, FL 33573

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that appropriated care and services related to the use of oxygen was provided to 1 of 25 (#187) sampled residents. Residents Affected - Few Findings included: Resident #187 was observed on 5/8/23 at 10:55 a.m., in bed with oxygen being delivered at 4 liters per minute (lpm). The admission Record for Resident #187 revealed the resident was admitted on [DATE] with diagnoses that included but not limited to cellulitis of right lower limb, acute bilateral embolism and thrombosis of unspecified deep veins of lower extremity, and hypokalemia. A review of a Change in Condition evaluation, dated 5/6/23, revealed Resident #187 was short of breath, with an oxygen saturation of 84% on room air was gasping for breath, and was placed on 2 lpm of Oxygen (O2). The Change in Condition indicated the provider instructed staff to continue to monitor. A progress note, dated 5/7/23 at 11:58 a.m., indicated Resident #187 was alert and oriented x4, appeared to be less anxious, and was receiving 2 lpm of continuous oxygen via nasal cannula (nc). A progress note, dated 5/8/23 at 3:29 a.m., indicated the resident was alert and oriented x2, normal respiratory, short of breath/trouble breathing when lying flat, and using oxygen. A progress note, dated 5/8/23 at 12:15 p.m., indicated Resident #187 had a pulse of 108, respirations of 22, had a sudden change in level of consciousness, and was noted to be lethargic with altered mental status. The physician was made aware and orders were received to send to emergency room for evaluation and treatment. A review of the Order Summary Report, did not include an order for oxygen. The physician progress note, dated 5/8/23, indicated Resident #187 was found to be lethargic, not answering and was on 4 lpm of oxygen at the time of the visit. The note indicated the physician was informed that the resident had been like that all weekend and morning. On 5/12/23 at 9:05 a.m., Staff G, Registered Nurse/Unit Manager (RN/UM), stated oxygen could be placed (on resident) if it was an emergency and if the oxygen (level) was low. Staff G stated respiratory came in every Thursday and put orders into the computer. If the resident had shortness of breath any day other than Thursday, the staff nurse called (physician) and got an order for oxygen. On 5/12/23 at 9:40 a.m., the Director of Nursing stated nurses were allowed to place oxygen on a resident then get an order from the physician. The DON confirmed there was no order for oxygen and an order should have been obtained after the application of oxygen on 5/6/23. 105866 Page 3 of 8 105866 05/12/2023 Plaza West 912 American Eagle Blvd Sun City Center, FL 33573

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure recommendations reported by the consultant pharmacist regarding irregularities in the resident's drug regimen were acted upon for one (Resident #12) of five residents reviewed for unnecessary medications. Findings included: A review of Resident #12's medical record revealed he was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) dated 3/24/23 with a score of 15, which indicated intact cognition. The record indicated the resident had diagnoses that included Essential Hypertension. A review of the resident's physician orders revealed he had a current order dated 1/5/23, to check blood pressure every 8 hours. refer to Clonidine HCI Tablet 0.1 MG order, if sbp [systolic blood pressure] is greater than 160 administer medication every shift for elevated b/p [blood pressure]. A review of the March 2023 Medication Administration Record revealed the resident had systolic blood pressure (SBP) readings greater then 160 on at least 10 occasions and was not administered the Clonidine HCI 0.1 tablet. A review of the April 2023 Medication Administration Record revealed the resident had systolic blood pressure (SBP) readings greater then 160 on at least 11 occasions and was not administered the Clonidine HCI 0.1 tablet. A review of the May 2023 Medication Administration Record, from 5/1/23 to 5/10/23, revealed the resident had systolic blood pressure (SBP) readings greater then 160 on at least 2 occasions and was not administered the Clonidine HCI 0.1 tablet. A review of the Consultant Pharmacy Review dated 3/14/23 revealed the following: PRN order for Clonidine is to be given as needed for SBP> 160. This is not always happening. Recommendation: Please remind staff to administer medications as ordered by the prescriber. A review of the record revealed there was no documentation that would indicate the physician had been made aware of this recommendation. A review of the Consultant Pharmacy Review dated 4/11/23 revealed the following: PRN order for Clonidine is to be given as needed for SBP> 160. This is not always happening. Recommendation: Please remind staff to administer medications as ordered by the prescriber. A review of the record revealed there was no documentation that would indicate the physician had been made aware of this recommendation. A review of the care plan dated 3/16/22, revealed the resident, is on diuretic therapy r/t: 105866 Page 4 of 8 105866 05/12/2023 Plaza West 912 American Eagle Blvd Sun City Center, FL 33573

F 0756 hypertension with interventions that included Administer medication as ordered Level of Harm - Minimal harm or potential for actual harm A review of the care plan dated 12/7/22, revealed the resident, has hypertension with interventions that included Give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic hypertension and increased heart rate (Tachycardia) and effectiveness. Residents Affected - Few An interview on 5/10/23 at 2:07 p.m., with the Consultant Pharmacist revealed his expectation was that recommendations were addressed by the next visit. He reported that related to the recommendation for the blood pressure for Resident #12 and the use of Clonidine, the facility should follow the physicians order. He said during the April Quality assurance review, he let the Director of Nursing (DON) know there was a problem with parameters. An interview on 05/10/23 at 2:39 p.m., with the DON revealed her expectation was for the facility to follow the physician orders. She said she had trained staff on following the physician orders and the parameters. A review of the facility policy titled Administering Medications with a revised date of December 2012 revealed the following: 3. Medications must be administered in accordance with the orders, including any required time frame. 105866 Page 5 of 8 105866 05/12/2023 Plaza West 912 American Eagle Blvd Sun City Center, FL 33573

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed and five errors were identified for three (Residents #73, #50, and #86) of four residents observed. These errors constituted a 16.13% medication error rate. Residents Affected - Some Findings included: 1. On 5/8/23 at 11:13 a.m., an observation was conducted with Staff D, Registered Nurse (RN) of blood glucose monitoring and the administration of insulin for Resident #73. Staff D obtained a blood glucose level of 233. The staff member returned to the medication cart and removed the resident's pen of Insulin Lispro. The pen was dialed to eight (8) units, the staff member returned to the resident's room, and injected 8 units into the back of the residents' left arm. Following the administration of Resident #73's Insulin Lispro, Staff D confirmed she did not prime insulin pens. She said she was told by one person something like 2 units then at another time was told she did not have to prime insulin pens. During an interview, on 5/12/23, the Director of Nursing provided a quick reference guide which was attached to the medication carts that instructed nurses Prime (Air Shot) insulin pens with each administration with 2 units or Manufacturer's recommendations. Hold the pen with the needle up, tap to move any air bubbles to the top. The manufacturers' literature, located at https://www.lillyinsulinlispro.com, instructed users of an Insulin Lispro Kwikpen to Prime before each injection: - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. - If you do not prime before each injection, you may get too much or too little insulin. The literature identified: - Step 6: to prime your pen, turn the Dose Knob to select 2 units, - Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. - Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops. and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the needle. 2. On 5/10/23 at 8:19 a.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #50. Staff E dispensed the following medications: - Metoprolol Tartrate 100 milligram (mg) tablet - Hydralazine 25 mg tablet 105866 Page 6 of 8 105866 05/12/2023 Plaza West 912 American Eagle Blvd Sun City Center, FL 33573

F 0759 - Amlodipine 5 mg tablet Level of Harm - Minimal harm or potential for actual harm - Cetirizine hydrochloride (HCl) 10 mg tablet - Calcium 600 mg tablet Residents Affected - Some - Aspirin 81 mg chewable tablet - Vitamin D 25 microgram (mcg) 1000 international units (IU) -2 tablets - Furosemide 80 mg tablet - Potassium Chloride Extended Release 20 milliequivalent (meq) tablet - Vitamin B complex with folic acid & Vitamin C tablet - Dorzolamide eye drops - Combigan 0.2%-0.5% eye drops Staff E watched Resident #50 take the oral medications and explained the procedure for eye drops. On 5/10/23 at 8:32 a.m., Staff E applied one drop of into the resident's right eye and at 8:35 a.m. applied one drop of Dorzolamide into the resident's right eye, a period of 3 minutes in between the different eye drops. A review of Resident #50's physician order included on the May 2023 Medication Administration Record (MAR), identified an order for Cetirizine hydrochloride (HCl) 5 mg - Give 1 tablet by mouth one time a day for allergy symptoms, started on 6/7/22 and discontinued at 3:15 p.m. on 5/10/23. During an interview on 5/10/23 at 2:15 p.m., the Consultant Pharmacist stated different eye drops should be given 5 minutes in between so that the drops did not wash the other one out. During an interview on 5/10/23 at 1:33 p.m., Staff E confirmed the administration of 10 mg Cetirizine to Resident #50. During the interview with the staff member, the Consultant Pharmacist was reviewing the medication cart and confirmed that 5 mg of Cetirizine was not available in the medication cart. According to the website, medline.gov (https://medlineplus.gov/druginfo/meds/a697049.html) before using dorzolamide eye drops, If you are using another topical eye medication, instill it at least 10 minutes before or after you instill dorzolamide eye drops. A review of clevelandclinic.org, (https://my.clevelandclinic.org/health/drugs/19263-dorzolamide-timolol-eye-solution) instructed users, If you use other eye medications, they should be used at least 10 minutes before or after this medication. The facility policy - Instillation of Eye drops, revised January 2014, identified the purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections, and dry eyes. The guidelines indicated When administering two or more different eye drops allow three to five minutes between each application. 105866 Page 7 of 8 105866 05/12/2023 Plaza West 912 American Eagle Blvd Sun City Center, FL 33573

F 0759 Level of Harm - Minimal harm or potential for actual harm The facility policy - Administering Oral Medications, revised October 2010) indicated The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The procedure described in step 6 that staff Check the label on the medication and confirm the medication name and dose with the MAR. Step 8 of the procedure instructed staff to Check the medication dose. Re-check to confirm the proper dose. Residents Affected - Some On 5/12/23 the Director of Nursing stated that the placards at each of the medication carts and the policy indicated that different eye drops should administered 3-5 minutes in between so she stood with that and said staff need to follow (physician) orders. 3. On 5/10/23 at 8:45 a.m., an observation of medication administration with Staff F, Licensed Practical Nurse (LPN), was conducted with Resident #86. Staff F dispensed the following medications: - Vemlidy 25 mg tablets - Spironolactone 50 mg tablet - Carvedilol 25 mg tablet - Pyridium 100 mg tablet - Vitamin B12 1000 mcg tablet - Loratadine 10 mg tablet - Flaxseed oil 1000 mg - 4 large brown capsules - Brimondine 0.2% eye drops On 5/10/23 at 8:51 a.m., Staff F administered oral medications to Resident #86 then the eye drops into both eyes. A review of the physician orders included with Resident #86's May Medication Administration Record (MAR) indicated Staff F had documented 4 tablets of Omega 3 Fatty Acids had been administered for the scheduled 9:00 a.m. dose on 5/10/23. The MAR indicated that the resident had received one tablet of Flaxseed Oil twice a daily, scheduled for 9:00 a.m. and 5:00 p.m. on 5/4 through the 9:00 a.m. dose on 5/8/23, then the order was discontinued. The MAR indicated the resident received one capsule of Flaxseed in the evening of 5/9/23 and the medication had not been administered at 5:00 p.m. on 5/10/23. On 5/10/23 at 8:51 a.m., the Consultant Pharmacist confirmed Flaxseed oil was not the same as Omega 3, Flaxseed comes from a plant. The policy - Administering Medications, revised December 2012, indicated that Medications must be administered in accordance with the orders, including any required time frame. The policy identified The individual administering medications must check the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 105866 Page 8 of 8