Health inspection·January 3, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure pain was managed effectively for three residents (#4, #5, and #3) out of three residents sampled for pain management. Residents Affected - Some Findings included: An observation was conducted on 1/3/24 at 9:36 a.m. of Staff D, Registered Nurse (RN) preparing and administering medication for Resident #4. Resident #4 was observed sitting in a chair at her bedside. The nurse did not ask the resident about pain level or characteristics of the pain. Staff D, RN administered Percocet 5-325 mg (milligram) x 1 tablet at 9:36 a.m., 1 hour and 36 minutes passed the 8:00 a.m. ordered time. Review of admission Record showed Resident #4 was admitted on [DATE] with diagnoses including hypertensive heart disease, arthritis, chronic pain, acquired absence of other left toes, peripheral vascular disease, and chronic kidney disease. Review of Resident #4's Order Summary Report for January 2024 showed the following: - Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) *Controlled Drug* Give 1 tablet by mouth three times a day for moderate to severe pain hold for sedation. Start date of 02/12/2023 and scheduled at 8:00-1600-2200 for administration. An interview was conducted on 1/3/24 at 12:02 p.m. with Resident #4. The resident said she had pain every day, especially in the right shoulder from a previous fracture. Resident #4 said occasionally her pain medication is late. The resident said it was late that morning and her pain level had reached an 8 out of 10 on the pain scale. Resident #4 stated, I got through it, what else am I going to do? Review of Resident #4's Weights and Vitals Summary showed 0 was documented for pain everyday twice a day from 10/01/23 through the morning of 1/03/24. Review of Resident #4's Medication Administration Audit Report, over a 14-day period from 12/20/23 to 1/3/24, revealed Resident #4 was administered her pain medication, Percocet, over an hour passed the scheduled dose 7 times. Review of Resident #4's significant change Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns, the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. Page 1 of 9 105881 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #4's medical records showed a care plan in place for Chronic Pain related to arthritis, dated 1/26/22. Interventions included administering analgesia as per orders, and monitor for effectiveness. An observation was conducted on 1/3/24 at 9:56 a.m. of Staff A, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #5. Staff A, LPN administered Baclofen 10 mg x 1 tablet, Gabapentin 300 mg x 1 tablet, and Oxycodone 10-325 mg x 1 tablet at 9:56 a.m., 1 hour and 56 minutes passed the 8:00 a.m. ordered time. The resident was observed lying in his bed with the head of the bed elevated. The nurse did not ask the resident about pain level or characteristics of the pain. Review of admission Record showed Resident #5 was re-admitted on [DATE] with diagnoses including encephalopathy, paraplegia, cervical disc disorder, muscle weakness, and chronic pain syndrome. Review of Resident #5's Order Summary Report for January 2024 showed the following: -Oxycodone HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 10 mg (Oxycodone HCl) Give 1 tablet by mouth two times a day for chronic pain. Start date 11/20/2023. Scheduled to Administer at 0800 and 2000. -Oxycodone-Acetaminophen Oral Tablet 10-325 mg (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 4 hours for pain. Start date 11/20/2023. Scheduled to administer at 0000, 0400, 0800, 1200, 1600 and 2000. -Baclofen Oral Tablet 10 mg (Baclofen) Give 1 tablet by mouth three times a day for Muscle Spasms 11/18/23. Start date 11/18/2023. Scheduled to administer at 0800, 1600, and 2200. -Gabapentin Oral Capsule 300 mg (Gabapentin). Give 1 capsule by mouth two times a day for Neuropathy. Start date 11/18/23. Scheduled to administer at 0800 and 2000. An interview was conducted on 1/3/24 at 1:08 p.m. with Resident #5. Resident #5 said his pain level had reached a 6 or 7 out of 10 this morning by the time he got his medication. The resident said when he gets his pain medication regularly it keeps his pain under control. Resident #5 stated he was having more muscle spasms in his legs than normal. The resident confirmed he took Oxycodone and Gabapentin for his pain and Baclofen to help with muscle spasms. Review of Resident #5's Medication Administration Audit Report over a 14-day period, from 12/20/23 to 1/3/24, showed Resident #5 was administered his prescribed medications of Oxycodone, Gabapentin, and Baclofen over an hour passed the scheduled administration time a total of 61 times. (all three medications combined). Resident #5's Medication Administration Audit Report showed on 1/3/24 he was administered the 8:00 a.m. dose of Oxycodone 10-325 mg at 10:05 a.m., the 10:00 a.m. dose of Oxycodone Extended Release 10 105881 Page 2 of 9 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mg at 11:10 a.m. and the 12:00 p.m. dose of Oxycodone 10-325 mg at 11:14 a.m. All three doses given within 1 hour and 9 minutes of each other instead of the Oxycodone 10-325 mg being spaced four hours apart as ordered with the Extended Release given in the middle. Review of Resident #5's Quarterly MDS, dated [DATE], Section C-Cognitive Patterns, showed the resident had a BIMS score of 15, indicating he was cognitively intact. Review of Resident #4's medical records showed a care plan in place for Chronic Pain related to arthritis, dated 6/14/23. Interventions included: administering analgesia as per orders, monitor for effectiveness and monitor/record pain characteristics PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. The resident also had a care plan in place for paraplegia related to spinal issues, dated 6/14/23. Interventions included: give medications as ordered and pain management as needed. An interview was conducted on 1/3/24 at 2:03 p.m. with Staff A, LPN. Staff A, LPN confirmed Resident #5's medications were due at 8:00 a.m. When discussing the observation of medication administration was at 9:56 a.m. he nodded and said, They were late. Staff A, LPN confirmed the medications should have been given between 7:00 a.m. and 9:00 a.m. Staff A, LPN did not give a reason as to why they were late. An interview was conducted on 1/3/24 at 2:21 p.m. with Resident #3. Resident #3 stated he was at the facility for two weeks after having his toe amputated and would not receive his pain medication on time. He stated the pain medication would control his pain, If I got it in a reasonable amount of time. Resident #3 said a couple of times he was in a significant amount of pain for a while and at that point it didn't do any good to take another pill. He said it could take 4-6 hours to get the pain level back down. Resident #3 said one time he didn't get his pain medication for three hours and he was at The tip of the edge on that one. He said his pain was 9 out of 10 on the pain scale for a long time. Review of admission Record showed Resident #3 was admitted on [DATE] and was discharged on 12/11/23 with diagnoses including osteomyelitis, acquired absence of left toe, gout, and rheumatoid arthritis. Review of Resident #3's Medicare 5 Day MDS, dated [DATE], Section C-Cognitive Patterns, showed the resident had a BIMS score of 15, indicating he was cognitively intact. Review of Resident #3's Order Summary Report for January 2024 showed the following: - Oxycodone-Acetaminophen Oral Tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Start Date 11/20/23. Discontinued 12/1/23. - Oxycodone-Acetaminophen Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. Start Date 12/1/23. - Oxycodone ER Oral Capsule ER 12 Hour Abuse-Deterrent 9 mg. Give 1 capsule by mouth two times a day for Pain for 30 Days. Start Date 12/1/23. Scheduled administration at 0800 and 2000. - Ibuprofen Oral Tablet 600 mg. Give 1 tablet by mouth every 8 hours as needed for pain. Start Date 105881 Page 3 of 9 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0697 11/30/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's medical record showed a care plan in place for risk for pain. Interventions included administering analgesia as per orders, and monitor for effectiveness. Residents Affected - Some Review of Resident #3's Medication Administration Audit Report over a 11-day period, from 11/30/23 to 12/11/23 showed Resident #3 was administered his pain medication, Oxycodone, over an hour passed the scheduled dose 5 times. An interview was conducted on 1/3/24 at 12:15 p.m. with the Director of Nursing (DON). The DON stated medications should be administered in a two-hour window, one hour before the scheduled time until one hour after the scheduled time. She said the facility recently educated all the nursing staff on the Five Rights of Medication-right patient, right drug, right time, right dose, and right route. A follow-up interview was conducted on 1/3/24 at 2:25 p.m. with the DON. The DON reiterated the nurses have one hour before and one hour after the scheduled time to give medication. She said the morning medications should have been given between 7:00 a.m. and 9:00 a.m. The DON said they did not have a staffing issue, the nurses' resident load was not too heavy, and they should have plenty of time to pass the medication on time. The DON was unaware there was an issue with residents not receiving medications on time. Review of a facility policy titled, Pain Management-Overview, undated, showed the following: The facility will strive to improve resident comfort and quality of life and to minimize pain as much as possible. The overall goal of the Pain Management Program will be to: -Identify residents with the potential for pain. -Recognize the onset or presence of pain. -Address and/or treat the underlying cause of the pain, to the extent possible. -Develop and implement approaches to manage pain. -Monitor for effectiveness or adverse consequences related to approaches. -Modify the approaches as indicated. Review of a facility policy titled, NURSING- Medications, Oral, undated, showed the following: Purpose The purpose of this procedure is to provide guidelines for the administration of oral medication. Procedure 2. Verify the physician's medication order for resident's name, drug name, dose, time, and route of 105881 Page 4 of 9 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0697 administration. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Some 105881 Page 5 of 9 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

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 observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for three residents (#4, #5, #6) out of four sampled residents who were administered medications. This resulted in 19 errors from 20 medication administration opportunities for a medication error rate of 95%. Residents Affected - Some Findings Included: An observation was conducted on 1/3/24 at 9:36 a.m. of Staff D, Registered Nurse (RN) preparing and administering medication for Resident #4. Staff D, RN prepared the following medications: -Amlodipine 5 mg x 1 tablet -Docusate sodium 100 mg x 1 tablet -Iron 325 mg x 1 tablet -Furosemide 720mg x 1 tablet -Percocet 5-325 mg x 1 tablet -Vitamin B-12 1000 mg x 1 tablet -Folic acid 1 mg x 1 tablet -Vitamin C 500 mg x 1 tablet Review of physician orders showed the Vitamin C order did not have a dose listed and all the prepared medications were due at 8:00 a.m. The medications were observed to be administered at 9:36 a.m., 1 hour and 36 minutes passed the ordered time. Review of admission records showed Resident #4 was admitted on [DATE] with diagnoses including hypertensive heart disease, arthritis, chronic pain, acquired absence of other left toes, peripheral vascular disease, and chronic kidney disease. An observation was conducted on 1/3/24 at 9:56 a.m. of Staff A, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #5. Staff A, LPN prepared the following medications: -Amlodipine 5 mg x 1 tablet -Ascorbic Acid 500 mg x 1 tablet -Baclofen 10 mg x 1 tablet -Escitalopram Oxalate 10 mg x 1 tablet 105881 Page 6 of 9 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0759 -Gabapentin 300 mg x 1 tablet Level of Harm - Minimal harm or potential for actual harm -Iron 325 mg x 1 tablet -Metoprolol 25 mg x 1 tablet Residents Affected - Some -Multivitamin x 1 tablet -Liquid Protein 30 ml -Oxycodone 10-325 mg x 1 tablet Review of Resident #5's physician orders showed all the prepared medications were due at 8:00 a.m. The medications were observed to be administered at 9:56 a.m., 1 hour and 56 minutes passed the ordered time. Review of admission records showed Resident #5 was re-admitted on [DATE] with diagnoses including encephalopathy, paraplegia, cervical disc disorder, anxiety, depression, muscle weakness, and chronic pain syndrome. An interview was conducted on 1/3/24 at 2:03 p.m. with Staff A, LPN. Staff A, LPN confirmed Resident #5's medications were due at 8:00 a.m. When discussing the observation of medication administration was at 9:56 a.m. he nodded and said, They were late. Staff A, LPN confirmed the medications should have been given between 7:00 a.m. and 9:00 a.m. Staff A, LPN did not give a reason they were late. An observation was conducted on 1/3/24 at 11:44 a.m. of Staff C, LPN completing a blood sugar check for Resident #6. The resident had a blood sugar level of 433. Staff C, LPN said she needed to administer 10 units of insulin and call the doctor. Staff C, LPN was observed taking out Resident #6's insulin pen, turning the dial to 10 units, and administering the insulin. Staff C, LPN did not prime the insulin pen prior to turning the dial to 10 units and administering the insulin. The insulin pen Staff C, LPN used to administer insulin to Resident #6 was an Admelog SoloStar (insulin Lispro injection). (Photographic evidence obtained.) Review of admission records showed Resident #6 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and type II diabetes mellitus. Review of Resident #6's orders showed the following insulin order dated 12/26/23: -Admelog SoloStar 100 UNIT/ML Solution pen-injector. Inject subcutaneously before meals and at bedtime for DM Inject as per sliding scale: if 0 - 149 = 0 units; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 400 = 10 units; 401+ = 10 units. For blood sugar greater than 400 give 10 units and call physician. An interview was conducted on 1/3/24 at 11:58 a.m. with Staff C, LPN. When asked about priming an insulin pen, Staff C, LPN looked very confused and said she has never done that and didn't know what it meant. Staff C, LPN said she did not know about priming insulin pens and had not been educated on it. Staff C, LPN said she had worked in the facility for one year. 105881 Page 7 of 9 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted on 1/3/24 at 12:15 p.m. with the Director of Nursing (DON). The DON stated medications should be administered in a two-hour window, one hour before the scheduled time until one hour after the scheduled time. She said the facility recently educated all the nursing staff on the Five Rights of Medication--right patient, right drug, right time, right dose, and right route. The DON stated insulin pens should be primed prior to dialing the pen to the ordered dose and administering the insulin. She stated, I'd have to look for a policy outlining the proper method for priming insulin pens. During a follow-up interview with the DON on 1/3/24 at 2:25 p.m. the DON stated they had no policy on the use of insulin pens and there had been no previous education to the nurses on the use of insulin pens. Review of the Admelog SoloStar instructions provided by the facility showed the following: Step 1: Check your pen . Step 2: Attache a new needle . Step 3: Do a safety test. Always do a safety test before each injection to: -Check your pen and the needle to make sure they are working properly. -Make sure that you get the correct insulin dose. 3A. Select 2 units by turning the dose selector until the dose pointer is at the 2 mark. 3B. press the inject button all the way in. -When insulin comes out of the needle tip, your pin is working correctly. Step 4: Select the dose . Step 5: Inject your dose . Review of a facility policy titled NURSING- Medications, Oral, undated, showed the following: Purpose The purpose of this procedure is to provide guidelines for the administration of oral medication. Procedure 1. Sanitize hands thoroughly before beginning the procedure. 2. 105881 Page 8 of 9 105881 01/03/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0759 Level of Harm - Minimal harm or potential for actual harm Verify the physician's medication order for resident's name, drug name, dose, time, and route of administration. . Residents Affected - Some 105881 Page 9 of 9