Health inspection·March 13, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 the accuracy of the Preadmission Screening and Resident Review (PASRR) for three (Residents #14, #26, and #83) out of thirty-two residents initially sampled to include review of their PASRR's. Residents Affected - Few Findings included: Review of Resident #14's admission Record revealed an admission date of 12/20/21. The record included diagnoses not limited to chronic Post-Traumatic Stress Disorder (PTSD), memory deficit following other cerebrovascular disease, unspecified anxiety disorder, and adjustment disorder with mixed anxiety and depressed mood. The record showed the diagnosis of PTSD had an onset date of 3/17/22, approximately 3 months after the resident was admitted to the facility. The Minimum Data Set (MDS) Significant Change in Status, 3/27/23, revealed the resident had an active diagnosis of PTSD. Review of Resident #14's PASRR completed at the facility on 12/22/21, two days after admission, showed the resident had Mental Illness (MI) or Suspected Mental Illness (SMI) diagnoses of anxiety and depressive disorder with the findings based on medications. The pre-screening evaluation did not show the resident was receiving or had previously received services for MI. The PASRR did not include the resident's diagnosis of adjustment disorder. The PASRR showed the resident's admission was not provisional and a Level II evaluation was not required due to no diagnosis or suspicion of a SMI or Intellectual Disability (ID). Review of the facility provided PASRR, dated 12/22/21, showed the facility failed to complete a PASRR after the diagnosis of PTSD was added to the resident's profile. During an interview on 3/12/24 at 11:35 a.m., the Director of Nursing (DON) reviewed Resident #14's PASRR and admission record stating the PASRR should have been redone to include the diagnosis of PTSD. Review of Resident #26's admission Record revealed an admission date of 6/8/17. The record included diagnoses not limited to Pseudobulbar Affect, unspecified anxiety disorder, and other specified depressive episodes. The record showed the above mentioned diagnoses had an onset date of 4/19/17. The Annual Minimum Data Set (MDS) assessment dated [DATE], included the diagnosis code of F48.2 - Pseudobulbar Affect (accessed at ICD10Data.com on 3/14/24). Review of Resident #26's PASRR, completed at the facility on 12/6/23, showed the resident had Mental Illness (MI) or Suspected Mental Illness (SMI) diagnoses of anxiety and depressive disorder with the findings based on documented history and medications. The pre-screening evaluation did not show Page 1 of 19 105881 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident was receiving or had previously received services for MI. The PASRR did not include the resident's diagnosis of Pseudobulbar Affect. The PASRR showed the resident's admission was not provisional and a Level II evaluation was not required due to no diagnosis or suspicion of a SMI or Intellectual Disability (ID). Review of the facility provided PASRR, dated 12/6/23, showed the facility failed to complete an accurate PASRR to include the diagnosis of Pseudobulbar Affect. During an interview on 3/12/24 at 11:30 a.m., the Director of Nursing (DON) reported being new at doing PASRR's. She said the ones she had changed were the ones we had done a Gradual Dose Reduction (GDR) on and a diagnosis had been added. She stated a SMI would be a primary diagnosis of dementia or schizophrenia. The DON reviewed Resident #26's and stated the Pseudobulbar Affect should have been added. Review of Resident #83's admission Record revealed an admission date of 12/2/21 and a readmission date of 2/29/24. The record included diagnoses not limited to unspecified persistent mood (affective) disorder, unspecified depression, unspecified anxiety disorder, unspecified schizoaffective disorder, unspecified mood disorder due to known physiological condition, unspecified not intractable epilepsy without status epilepticus, and unspecified severity unspecified dementia with psychotic disturbance. The record included a primary diagnosis (onset date 2/29/24) of brief psychotic disorder. Review of Resident #83's PASRR, completed at the facility on 3/6/24, showed the resident had Mental Illness (MI) or Suspected Mental Illness (SMI) diagnoses of anxiety, bipolar, psychotic, schizoaffective and mood disorders as well as brief psychosis. The evaluation did not show the resident had the related condition of Epilepsy or was receiving or had previously received services for MI. The PASRR showed the resident's admission was not provisional and a Level II evaluation was not required due to no diagnosis or suspicion of a SMI or Intellectual Disability (ID). The evaluation revealed the resident had not exhibited actions or behaviors that may make them a danger to themselves or other, the resident did not have psychiatric treatment more intensive than outpatient care (e.g. partial hospitalization or inpatient hospitalization), and did not have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis was a SMI or ID. An interview was conducted with the Nursing Home Administrator (NHA) on 3/13/24 at 8:43 a.m. The NHA reviewed an incident on 2/1/24 involving Resident #83. The NHA reported the resident was found on the floor facing the door, after being just seen by the nurse. She stated Resident #83 had a history of throwing self out of chair, was working with therapy to become more mobile, would scoot self in bed, and had behaviors from being calm to inconsolable yelling out. The resident had complained of (c/o) pain to right knee which an x-ray found to be negative of acute findings. The NHA reported it had been hard to find a regimen: a plan of care and medications for the resident, had pending genetic testing for administration of medications. The next day the resident c/o pain in leg and an x-ray showed a comminuted fracture of the distal tibia. The NHA reported the hospital reported it was noncomminuted spiral fracture of the distal tibia. The interview continued as the NHA reported on incidents leading to the resident being [NAME] Act on 2/25/24. She reported the resident had increased behaviors that day, was threatening to throw self out of chair and window, several attempts had been made to calm the resident which would last about 10 minutes, then the resident did throw self from chair, complaining of pain to left hip and legs. The resident attempted to take off right leg soft cast and to crawl out of bed. The Attending physician and Psychology Nurse Practitioner (NP) was notified, the NP completed and signed a Certificate of Professional Involuntary Examination, on 2/25/24 at 105881 Page 2 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11:00 a.m. due to there was a substantial likelihood that without care or treatment the person will cause serious bodily harm to self and others, cannot be redirected. The NHA stated following the hospitalization psychology and psychiatry follow weekly. She stated the resident was sent to a certain local hospital due to the fact they have a geriatric psych wing. During an interview on 3/12/24 at 11:40 a.m., the Director of Nursing (DON) reviewed Resident #83's PASRR, stating the epilepsy and dementia should have been added and a Level II should have been done. Review of the policy - Pre-admission Screening and Resident Review (PASRR), undated, revealed The purpose of the PASRR is to ensure individuals who are being considered for placement in a nursing facility are evaluated for serious mental illness and/or intellectual disability and are offered the most integrated setting appropriate for their long term care needs (including determining whether a Nursing Facility is appropriate). All persons, regardless of payer or age, needing admission to a Nursing Facility must first be screened for possible mental illness or the presence of an intellectual disability (ID) or both (level 1). If a mental illness (MI) or intellectual disability (ID) appears to exist, the person must be referred for further evaluation (Level II) before Nursing Facility admission. There are two elements of PASRR: Level I determines whether an individual referred for admission into a nursing facility has or is suspected of having an SMI and/or ID diagnosis. Level II is an individualized, in-depth evaluation of an individual, including confirming or ruling out the suspected diagnosis and determining the need for Nursing Facility services. If a Nursing Facility is the most integrated setting appropriate to meet that individual's long -term care needs, the Level II PASRR must also evaluate what specialized services if any are needed for the individual. The Level I PASRR screen must be done prior to admission for all persons seeking admission to the facility. Note: a Level I PASRR screen does not have to be completed when a resident has been discharged to the hospital and is returning to the nursing facility after being in a hospital for 90 days or less and there is no significant change triggering a new PASRR or when the resident is accepted or transferred to another nursing facility. A copy of the most recent PASRR should be sent with the resident (if our facility is transferring a resident to another facility) or requested from the transferring facility (if our facility is receiving a resident from another facility). The Level II PASRR must be done prior to admission for all persons seeking admission except when the following exemption applies for a provisional admission: 105881 Page 3 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0645 Level of Harm - Minimal harm or potential for actual harm individuals who are discharged from a hospital into a Nursing Facility after receiving acute inpatient care, and require Nursing Facility services, for which they received the inpatient hospital care, may be admitted to the Nursing Facility if a physician certifies on the AHCA-5000-3008 form before admission that the individual is likely to require less than 30 days of Residents Affected - Few Nursing Facility services. Should the individual require a stay in the Nursing Facility longer than 30 days, in advance of the expiration of 40 days, the facility must notify KEPRO on or before the 25th day of the stay to request a Level II PASRR. A Resident Review (RR) - Evaluation Request, is the reevaluation of an individual, and the reassessment of appropriateness of continued placement and recommended specialized services, as applicable, following a significant change in the resident's physical or mental condition or if there is a new onset of mental illness or intellectual disability/developmental disability diagnosed. Resident Reviews (RR) are triggered when: a) An individual undergoes a significant change in condition and that change has a material impact on their functioning as it relates to their MI/ID status. The notion of significant change is defined by responses to the Minimum Data Set (MDS). b) Referral for Level II Resident Review Evaluations is Required for Individuals Previously Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances: Note: this is not an exhaustive list: A resident who demonstrates increased behavioral, psychiatric, or mood related symptoms. A resident with behavioral, psychiatric, or mood related symptoms that have not responded to ongoing treatment. A resident who experiences an improved medical condition - such that the resident's plan of care or placement recommendations may require modifications. A resident whose significant change is physical, but with behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living. 105881 Page 4 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A resident who indicates a preference (may be communicated verbally or through other forms of communication, including behavior) to leave the facility. A resident whose condition or treatment is or will significantly different than described in the resident's most recent PASRR Level II evaluation and determination. (Note that a referral for a possible new Level II PASRR evaluation is required whenever such a disparity is discovered, whether or not associated with a SCSA.) c) Referral for Level II Resident Review Evaluations is Also Required for Individuals Who May Not Have Previously Been Identified by PASRR to Have Mental Illness, Intellectual disability/Developmental Disability, or a Related Condition in the Following Circumstances: Note: this is not an exhaustive list: A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where dementia is not the primary diagnosis). A resident whose intellectual disability as defined under 42 CFR 483.100, or related condition as defined under 42 CFR 435.1010 was not previously identified and evaluated through PASRR. A resident transferred, admitted , or readmitted to a Nursing Facility following an inpatient psychiatric stay. 105881 Page 5 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to allow one (Resident #94) of three residents sampled for care planning, to participate in developing and revising their care plan related the side rails. Findings included: On 3/10/24 at 11:53 a.m., Resident #94 was observed lying in bed, bilateral legs were offloaded on pillows, and she was alert and oriented. The resident reported to having asked for side rails however the state made a ruling (against them) because of being to restricted. The resident stated her legs did not work and with side rails she could use upper her arms to roll side to side and sit up. She said she have begged and begged and they won't do it. The resident stated she did not not know about quarterly care plan meetings. The observation showed Resident #94 did not have any side or adaptive rails on either side of bed. Review of Resident #94's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status score of 15 out of 15, which indicated intact cognition. Review of Resident #94's admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral([NAME]), unspecified malignant neoplasm of cervix uteri, secondary malignant neoplasm of bone, and unspecified spinal stenosis site. Review of Resident #94's clinical record showed one Care Plan progress note, dated 2/9/24, showing Quarterly Care Plan conference held by Interdisciplinary Team (IDT) for [resident name]. Plan of care and medication reviewed. No changes made. Will proceed with current Plan of Care (POC). The note did not show the resident or representative had been involved with the meeting. The record did not include a care plan signature log of who attended the care plan meeting(s) of the resident. Review of Resident #94's care plan revealed the following focuses and interventions were included: - Resident has the capacity to make health care decisions and has the following Advance Directives on file: Do Not Resuscitate (and) Health Care Surrogate. - Resident is independent for meeting emotional, intellectual, physical, and social needs. - Resident has an Activities of Daily Living (ADL)self-care performance deficit related to (r/t) Activity Intolerance, Disease Process, Impaired balance, Limited Mobility. The interventions included: Side Rails/Enablers for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use, initiated 7/30/23 and revised on 8/10/23. An intervention showed the resident required one person limited assistance for bed mobility. - Resident has potential for pressure ulcer development r/t impaired mobility. The interventions included to educate resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. 105881 Page 6 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the MDS Coordinator on 3/12/24 at 11:50 a.m. The coordinator stated the care plan meetings were held in the resident rooms and were held upon admission and quarterly. The staff member reported the clinical record should have a downloaded signature page (of meeting attendees) and a Care Plan progress note. The process was to schedule the meeting, an invitation was sent to the family, and one was placed in the resident's room. The coordinator reviewed the care plan and stated Resident #94's side rail intervention should have been revised. She said the process was to go through each intervention and during the quarterly assessment the facility looked for changes and revised as needed. The MDS Coordinator reviewed the record downloads and progress notes and confirmed there were no signature logs and no other care plan progress notes. A continued interview was conducted with the MDS Coordinator on 3/12/24 at 12:32 p.m. The coordinator stated there were no admission care plan meetings for Resident #94 and no further information. She confirmed the note on 2/9/24 did not specify whether the resident attended the meeting or not and there was no documentation of quarterly meetings. The policy - Person Centered Care Planning, revised 12/2016, revealed When admitted , each resident will have physician orders, dietary needs, medications, treatments, and preliminary discharge plans reviewed by the IDT and we'll have an interim care plan developed within 24 hours of admission, along with input from the resident and or representative. This assures that the resident's immediate needs are met and his/her preferences are considered. This plan will be implemented and updated as needed until the staff can conduct a comprehensive assessment and develop a complete interdisciplinary plan of care. - The facility's IDT, in coordination with the resident, the resident's family or representative, develops and maintains this care plan in an effort to attain and/or maintain the highest level of function the resident may be expected to reach. - The facility's IDT will be made of up of a registered nurse and certified nursing assistant responsible for the care of the resident, along with a food and nutrition staff member, Social Service Director, Activity staff member, MDS nurse, the attending physician, and other appropriate staff or professionals in disciplines as determined by the residents needs or as requested by the resident. - The Social Service Director or designee will notify the resident of his/her right to participate in his/her treatment and care planning process. The facility will support the resident in this right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings, and the right to request revisions to the person centered plan of care. - The Social Service Director or designee will schedule any upcoming care plan meeting with the resident and his/her family or representative. Social Service Director will be responsible for notifying all parties of the upcoming care plan meeting and maintaining records of the method of notification (mail, telephone, e-mail, etc.), and whether the resident or family or representative declined to participate. Every effort will be made to schedule the care plan meeting at a date and time convenient for the resident and/or representative. - An explanation will be included in the resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the of the resident's care plan. At the care plan meeting, the resident, and the resident's family or representative are encouraged to participate in the development of goals and approaches most suited to that resident. The care 105881 Page 7 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0657 Level of Harm - Minimal harm or potential for actual harm plan should be built on the resident's strengths, preferences, choices, incorporating identified problems, and risk factors. - Care plans are to be revised as changes in the resident's condition warrant or when there is a change in resident's preference or choice of treatment. Residents Affected - Few 105881 Page 8 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 obtain a physician order prior to administering oxygen for one (Resident #273) of two residents reviewed for oxygen. Residents Affected - Few Findings included: During an observation on 03/10/24 at 12:10 p.m., Resident # 273's oxygen concentrator was set at 5 liter per minute (lpm). Photographic evidence obtained. During an interview on 03/10/24 at 12:10 p.m., Resident #273 stated that he usually did not wear oxygen however he had been wearing it since admission from the hospital. Review of the admission Record showed Resident #273 was re-admitted to the facility on [DATE] with diagnoses included but not limited to Rhabdomyolysis, Chronic Obstructive Pulmonary Disease (COPD) and other Asthma. Review of the Order Summary Report on 03/10/24 at 12:12 p.m., showed no current order for oxygen. A review of Resident #273's care plan showed, a focus of The resident has COPD, Asthma. The goal showed, The resident will display optimal breathing patterns daily through review date. The interventions included but not limited to Oxygen Settings: O2 [oxygen] via nasal cannula per MD orders. During an interview on 03/11/24 at 3:05 p.m., the Director of Nursing (DON) stated typically a resident came into the facility with an order for oxygen. The DON stated in this case Resident #273 came back to the facility via ambulance with oxygen being administered at 5 lpm. The DON stated Resident #273 was re-admitted to the facility on [DATE] and the nurse should have immediately addressed Resident #273's oxygen administration and lack of physician order for oxygen administration during re-admission. The DON stated, it was the facility's policy that oxygen should not be administered without a physician order. The DON stated she was told by staff they watched a state surveyor looking at Resident #273's oxygen concentrator on 03/10/24 and then also reviewed his oxygen administration and realized there was no current order. A review of the facility's policy Oxygen Administration not dated showed, .7. Turn on oxygen. Start the flow rate of oxygen at the prescribed rate. 105881 Page 9 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not ensure staffing posting information was up-to-date and current. Residents Affected - Few Findings included: Upon entering the facility on 03/10/24 at 9:15 a.m., an observation was made of a posting titled, Daily work Hours by Provider Position, date range 03/08/24 to 03/08/24. The review showed the staff posting was not updated on 03/09/24 and 03/10/24. On 03/10/24 at 11:12 a.m., the staffing posting was still not updated. On 03/13/24 at 12:28 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Staffing Coordinator. The NHA stated the staff posting was supposed to be updated daily. The Staffing Coordinator stated it was her responsibility to update the posting. She stated she worked Monday through Friday. She said, On the weekends I print the sheet out for the days I will be out until Monday. I adjust the numbers as needed when I return. The receptionist changes the posting to the updated one. The NHA stated they should have had it up to date. A review of an undated facility policy titled, Nurse Staffing Information showed: 1. Data requirements the facility must post the following information on a daily basis: i. Facility name. ii. Current date. iii. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. A. Registered Nurses. B. Licensed practical nurse or licensed nurses. C. 105881 Page 10 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0732 Certified Nursing Assistants, Personal Care Assistants or other Direct care staff. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105881 Page 11 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 medications for two (Residents #78 and #83) of eleven residents observed during the administration of medications and reviewed for the appropriateness of medications had received medications within the parameters set by the physician. Residents Affected - Few Findings included: 1. On 3/12/24 at 8:37 a.m., an observation was conducted of the administration of medications for Resident #78 with Staff D, Licensed Practical Nurse (LPN)/Unit Manager (UM). The staff member was observed dispensing the following medications placing them into a single medication cups: - Iron 325 milligram (mg) over-the-counter (otc) tablet - Vitamin C 500 mg otc tablet - Multi Vitamin otc tablet - Gabapentin 300 mg capsule - Baclofen 10 mg tablet - Escitalopram 10 mg tablet - Amlodipine 5 mg tablet - Oxycodone 10 mg tablet Staff D poured 30 milliliters of liquid protein into another medication cup and dispensed a 25 mg tablet of Metoprolol Tartrate into separate cup saying the blood pressure previously taken was 127/74, and said the blood pressure would be retaken. The staff member entered the resident room and obtained a manually-taken blood pressure of 118/78. Staff B administered the oral tablets in the one cup and liquid protein. The staff member informed this writer and resident of holding Metoprolol due to blood pressure. Staff B returned to the medication cart and reported the resident's Amlodipine should have been held also, confirming the administration of Amlodipine, the staff member said I'm so sorry. Review of the March Medication Administration Record (MAR) for Resident #78 included the following orders: - Amlodipine Oral Tablet 5 mg - Give 1 tablet by mouth one time a day for hypertension (HTN). Hold is systolic blood pressure (BP) less than (<) 120. - Metoprolol Tartrate Oral Tablet 25 mg - Give 1 tablet by mouth two times a day for HTN. Hold for SBP less than 120. Review of the MAR documentation for Amlodipine showed the resident received the medication outside of the physician ordered parameters on 3/2: 110/60, 3/3: 119/69, 3/4: 117/65, 3/7: 111/68, 3/8: 105881 Page 12 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 118/70, 3/11: 108/60, 3/12: 118/78, and 3/13/24: 113/66. The review showed the resident had been administered Amlodipine outside the parameters 8 out of 13 opportunities. Review of the MAR documentation for Metoprolol Tartrate showed the resident received the medication outside of physician ordered parameters on 3/2: 110/60, 3/3: 119/69, 3/4: 117/65, 3/7: 111/68, 3/8: 118/70, 3/11: 108/60, and 3/13/24: 113/66. The review showed the resident had been administered Metoprolol outside the parameters 7 out of twenty-five opportunities. 2. Review of Resident #83's admission Record revealed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to Brief Psychotic Disorder, unspecified Persistent Mood (Affective) Disorder, unspecified anxiety disorder, unspecified depression, unspecified schizoaffective disorder, and unspecified severity dementia with psychotic disturbance. Review of Resident #83's February MAR showed a physician order, Clonidine oral tablet 0.1 mg - Give 1 tablet by mouth two times a day for lowering blood pressure (BP) to reduce anxiety. Hold for systolic blood pressure (SBP) less than < 90 and diastolic blood pressure (DBP) < 40. Review of Resident #83's February MAR showed NA instead of documented blood pressure during the administration of Clonidine on 3/17, 3/18 and 3/23/24. The resident received Clonidine without verifying blood pressures were within parameters three out of 18 opportunities. Review of the March Medication Administration Record (MAR) for Resident #83 revealed the physician had ordered Clonidine 0.1 milligram (mg) daily for anxiety, Hold for systolic blood pressure (SBP) less than < 110 and diastolic blood pressure (DBP) < 60. Review of the March MAR revealed the documentation for Clonidine from 3/2 - 3/13/24, the blood pressure (bp) spaces were X'd out and not allowing for documentation of the blood pressure at the time of administration. The MAR did instruct staff to obtain vital signs every shift (6 a.m. - 6 p.m. and 6 p.m. and 6 a.m.) the observation did not identify when the blood pressures were taken during the 12 hour shift. The documentation of vital signs showed the resident would have received Clonidine outside the physician order parameters 3 out of 13 opportunities. An interview was conducted with the Director of Nursing (DON) on 3/13/24 at 10:24 a.m. The DON stated staff should be obtaining blood pressures prior to administration of Clonidine, should always get a blood pressure when giving Clonidine. The staff member reviewed Resident #83's March MAR and BP summary then confirmed the Clonidine should have been held. The DON confirmed no other blood pressures had been obtained at the time of documentation. She reviewed the February MAR and not applicable (documented in space for blood pressure) and stated what does that mean, confirming blood pressures had not been taken and should have been. The policy - Oral Medications, undated, revealed The purpose of this procedure is to provide guidelines for the administration of oral medication. The procedure instructed staff to Verify the physician's medication order for resident's name, drug name, dose, time, and route of administration. Perform preadministration assessment (e.g. pulse rate or blood pressure) , if necessary. 105881 Page 13 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, record review, and interview, the facility failed to ensure medications with shortened shelf life once opened were dated in three (100, 200/500, and 600) out of six medication carts, failed to ensure two medications in pre-filled syringes were not stored mixed together in one (600) out of six medication carts and one (300/400) out of three medication rooms, and expired medications had been removed from two (300 and 600) out of six medication carts. The facility failed to ensure medications were not left unattended and inaccessible to unauthorized staff, residents, and visitors for three (Residents #98, #74, and #314) of 45 sampled residents. Findings included: An observation was made during medication administration on 3/11/24 at 11:53 a.m. with Staff B, RN. The staff member reported a resident required 4 units of insulin. Staff B removed an opened bottle of Humalog from the cart which was labeled with an open date of 1/15/24. The staff member turned the vial around and reported the expiration date was 10/6/2026 (manufacturer's printed date). Staff B reported not knowing when the insulin expired, going to the medication room and removing a vial of Admelog for the resident. According to humalog.com/u100, reviewed on 3/14/24 at 8:07 p.m.,Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. The review of the website on humalog.com revealed 28 days after the open date of 1/15/24 was 2/12/24, 28 days prior to the observation. An observation was conducted on 3/11/24 at 11:53 a.m. with Staff B, RN of the 300/400 medication unit. The observation revealed a drawer with multiple prefilled syringes of Normal Saline and Heparin. The syringes were not separated and were stored lying intermixed within the drawer. The staff member stated they were going back to the pharmacy. On 3/13/24 at 11:45 a.m., an observation was made with Staff C, Registered Nurse (RN) of the 100-hall medication cart. The observation revealed the following: - an opened Latanoprost Ophthalmic solution bottle, not dated with open date. The bottle had a pharmacy label attached to it and the box holding the bottle had a label attached to it with a space for Date Opened which was blank. The bag holding the box and bottle had a sticker instructing Throw Away Any Drug Left After 6 Weeks. - an opened Bottle of Timolol Maleate Ophthalmic solution, undated. The attached pharmacy tag had a space for Date Opened: which was blank. The box containing the bottle also had a label attached with no date. - an opened Humalog insulin vial, undated with open date. the pharmacy tag Date Opened: was blank. The sticker on bag containing the vial and box read Throw Away Any Medication That Remains 28 Days After First Use. 105881 Page 14 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - an opened Humalog insulin vial, undated with open date. The pharmacy tag attached to vial was not dated and the box with a tag Date Opened: was not dated. - an open vial of Semglee insulin, undated, pharmacy tag with a space for Date Opened was blank. - an open vial of Insulin Aspart, with an undated attached pharmacy tag. A sticker attached to the bag holding the vial read Throw Away Any Medicine That Remains 28 Days After First Use. - an open vial of Lantus insulin with an undated attached pharmacy tag and also a pharmacy tag on the box Date Opened was blank. The bag containing the box and vial was dated 2/13 and a sticker instructed staff to Throw Away Any Medicine That Remains 28 Days After First Use. A review of the monthly calendars revealed 28 days from 2/13 was 3/12, the day before the observation. - an opened Insulin Glargine prefilled insulin pen was undated. The sticker attached to the bag containing the pen read Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 2/24. -an opened Insulin Glargine prefilled insulin pen was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 3/4. - an opened Insulin Glargine prefilled insulin pen was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated either 2/14 or 2/24. - an opened Insulin Glargine prefilled insulin pen was dated either 2/21/24 or 2/4/24. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 2/23. - an opened Admelog insulin pen with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened prefilled Insulin Glargine pen with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened Admelog insulin pen with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 3/11. - An opened Advair diskus was observed lying on the bottom of the drawer. The nearby Advair box was opened and lying on its side. An observation and review was conducted on 3/13/24 at 12:06 p.m. with Staff B, RN of the 200/500 medication cart. The observation revealed the following: - An opened prefilled Insulin Glargine with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After 105881 Page 15 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0761 First Use. Level of Harm - Minimal harm or potential for actual harm - An opened Admelog prefilled insulin pen was undated, the pharmacy sticker instructed to Throw Away Any Medicine That Remains 28 Days After First Use. Residents Affected - Some - An opened prefilled Insulin Glargine pen was undated, the attached pharmacy tag, Date Opened: was blank. The pharmacy sticker instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened Insulin Aspart vial was dated 3/11/24. The pharmacy label attached to the plastic bag containing the vial was dated 3/11/24 and a pink sticker attached to the bag was dated 3/9. An observation and review was conducted on 3/13/24 at 12:56 p.m., with Staff A, RN of the 600 medication cart. The observation revealed the following: - Two opened bottles, one of Latanoprost and one of Brinzolamide, were rolled up in plastic bags together in the top drawer of the cart. The bottles were undated. The pharmacy label was dated 12/16. The Latanoprost label instructed to throw away left over drug after 6 weeks. - An opened bottle of Dorzolamide and Timolol Ophthalmic solution was observed with a pharmacy tag labeled Date Opened which was blank with no date. - An opened bottle of Brimonidine Ophthalmic solution was observed with an attached pharmacy tag reading Date Opened which was blank without a date. - An opened bottle of Latanoprost Ophthalmic solution was observed with an attached pharmacy tag labeled with a blank Date Opened. The sticker attached to bag instructed user to discard after 6 weeks. - An opened bottle of Latanoprost Ophthalmic solution was observed with an undated pharmacy tag, the box containing the bottle had an undated pharmacy tag. The bag containing the box and bottle was labeled with a sticker instructing users to Throw Away Any Drug Left After 6 weeks. - An opened bottle of Dorzolamide/Timolol was undated. - An opened bottle of Brimonidine was undated and the box containing the bottle had an attached pharmacy tag with a space to label date opened which was blank. - An opened prefilled Insulin Glargine pen with an attached pharmacy label allowing to document Date Opened which was blank. The bag containing the pen was labeled Throw Away Any Medicine That Remains 28 Days After First Use. - An opened prefilled Admelog insulin pen without a pharmacy label was undated. The pharmacy label attached to the bag containing the pen instructed Throw Away Any Medicine That Remains 28 Days After First Use. - An opened Insulin Glargine vial was observed with a pharmacy tag allowing to document Date Opened. The pharmacy sticker attached to the bag containing the vial instructed Throw Away Any Medicine That Remains 28 Days After First Use. The bag was labeled 2/27. 105881 Page 16 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - An opened Insulin Glargine pre-filled pen with an attached pharmacy tag, Date Opened was undated. The bag containing the pen was labeled with Throw Away Any Medicine That Remains 28 Days After First Use. The sticker attached to the bag was dated 2/27. - An opened Insulin Glargine pre-filled pen with an attached pharmacy tag, Date Opened was undated. The bag containing the pen was labeled with Throw Away Any Medicine That Remains 28 Days After First Use. The sticker attached to the bag was dated 3/12. - An opened Insulin Glargine pre-filled pen was observed with a partially removed pharmacy tag and was undated. The pharmacy label attached to the bag containing the pen was dated 3/8/24. The pink sticker, Date Opened was undated and another sticker instructed Throw Away Any Medicine That Remains 28 Days After First Use. A date of 3/8/24 was handwritten on the pharmacy label. - An opened vial of Novolog was observed with an undated pharmacy tag. The sticker attached to the pharmacy bag instructed Throw Away Any Medicine That Remains 28 Days After First Use. - An opened vial of Insulin Lispro was observed with an undated pharmacy tag. The bag containing the vial and box instructed Throw Away Any Medicine That Remains 28 Days After First Use. - An opened vial of Insulin Glargine was observed with an undated attached pharmacy tag. The bag was labeled to Throw Away Any Medicine That Remains 28 Days After First Use. The bag containing the vial was dated 2/13/24, which showed the insulin was to be discarded on 3/12/24, the day before the observation. - A box was observed in a drawer containing both prefilled syringes of 10 milliliter (mL) normal saline and 50 units in 5 mL Heparin. - In the bottom drawer of the cart was a container of MicroKill disinfecting wipes and a bottle of a chemical drug disposal system, stored along with liquid oral medications. According to medlineplus.gov, reviewed on 3/14/24, revealed Latanoprost, Once opened, the bottle can be kept at room temperature for either 6 weeks (Xalatan) or 30 days (iyuzeh). On 3/10/24 at 2:03 p.m., Resident #98 was observed lying in bed with a nebulizer machine on the bedside dresser. The observation revealed a vial of Ipratropim Bromide and Albuterol was lying next to the machine. Immediately following the observation, Staff B observed the vial and stated no the medication should not be at bedside. Staff F, Licensed Practical Nurse (LPN) stated no it should not be at the bedside and admitted to administering the resident a treatment this morning, 3/10/24. On 3/11/24 at 3:25 p.m., the Director of Nursing reviewed the photo of the vial and stated no resident in the facility was allowed to self-administer medications. She confirmed the vial should not be left at bedside. The DON reviewed Resident #98's medication and confirmed the resident was not ordered the duo of Ipratropium and Albuterol. She stated she was not going to answer it should be the correct medication. Review of Resident #98's March Medication Administration Record revealed the resident had a order for Budesonide Inhalation Suspension 0.5 milligram (mg)/2 milliliter (mL) (Budesonide Inhalation) - 1 105881 Page 17 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0761 Level of Harm - Minimal harm or potential for actual harm vial inhale orally two times a day for shortness of breath (sob) and Albuterol Sulfate (2.5 mg/3 mL) 0.083% nebulization solution - 1 vial inhale orally via nebulizer three times a day for chronic obstructive pulmonary disease (COPD)/SOB. (Photographic Evidence Obtained) Residents Affected - Some On 03/10/24 at 12:02 p.m. an inhaler labeled Trelegy Ellipta was observed at Resident #314's bedside table. Resident #314 stated she inhaled it once daily as needed for shortness of breath (SOB). She stated she kept it on her person. She stated she had taken it that morning and the day before. During this time, an observation was also made of a small white round tablet on the floor to the right side of the resident's bed. On 03/10/24 at 9:56 a.m., an interview was conducted with Staff E, Registered Nurse (RN). She stated there was no one self-administrating medications on this hall. She stated the resident should not keep the inhaler on her, it should be locked in the med cart. She stated the tablet was Furosemide/Lasix. Staff E said, it should not be on floor, I watched her take her meds this morning. It might be from yesterday. Resident #314's family member said, No, it was not here yesterday afternoon. On 03/10/24 at 10:19 a.m. a follow -up interview was conducted with Staff E, RN. She stated she reviewed the resident's record and confirmed the tablet was Lasix. She stated she would let the doctor know and ask if she would have to administer another dose. She stated the resident shook quite a bit. She said, She may have dropped it. The expectation is to watch the residents take their meds. Staff E, RN stated the resident did not have orders for the inhaler. She stated the resident should have turned it in. She stated she did not see it on the bedside table. She stated she would contact the doctor to get administration orders. Review of Resident #314's record showed progress note indicating on 3/10/24 Pt (patient) educated about keeping medication in room. MD (Medical Doctor) notified. New orders for Trelegy Ellipta once daily. Review of Resident #314's physician orders confirmed the resident was prescribed Furosemide Oral Tablet 20 MG, Give 1 tablet by mouth one time a day for Edema. The review did not show this resident was prescribed Trelegy Ellipta inhaler. The review showed an order for Fluticasone-salmeterol 100-50 MCG/ACT, give 1 inhalation by mouth two times a day for SOB. On 3/11/24 Note Text: Lasix pill found on resident's floor on 3/10 and inhaler located at bedside. Pill discarded and inhaler removed. Message sent to MD to notify that resident may have inadvertently missed a dose of Lasix. Awaiting return call. On 3/12/24: Note Text: Message sent to MD, again, to attempt to notify of Lasix pill found on floor on 3/10 and inhaler at bedside. Awaiting return call for any orders that may be indicated. Also, sent message to Medical Director to notify. Awaiting return call. On 03/11/24 at 3:13 p.m. an interview was conducted with the Director of Nursing (DON). She stated they did not have any one on self-administration of medications at the facility. She stated the expectation was for nurses to stay with the resident and verify meds had been received. She said, If a medication is found on the floor, the nurse is to confirm or verify what the medication was and then call the doctor for further follow -up. She stated upon admission, the nurse should confirm if the resident had any medications on them and obtain orders to administer. The DON stated the nurse should 105881 Page 18 of 19 105881 03/13/2024 Hawthorne Center for Rehabilitation and Healing Of 851 West Lumsden Rd Brandon, FL 33511

F 0761 have notified the doctor and followed any new orders. Level of Harm - Minimal harm or potential for actual harm During a tour of Resident #74's room on 03/10/24 at 12:58 p.m., an observation was made of a tube of zinc oxide at the bedside and a white tablet on the floor to the left side of the resident's bed. The resident stated she did not know why a tablet was on the floor. Residents Affected - Some On 03/10/24 at 1:03 p.m., an interview was conducted with Staff E, RN. She stated the resident shook when she took her medication, she probably dropped it herself. She stated the resident liked her medications spoon fed to her without applesauce or yogurt. She stated she would check to see what the tablet was. On 03/10/24 at 1:50 p.m., Staff E, RN stated the treatment nurse must have left the cream at bedside. She stated it should be kept in the treatment cart. She stated the tablet on the floor was Trazodone, probably from the night before. She restated all mediations should be locked in the medication cart per facility protocol. Review of Resident #74's physician orders revealed the resident was not prescribed Trazodone medication. On 03/11/24 at 03:19 p.m., a follow-up interview was conducted with the DON. She stated all prescribed medications should be secured and administered by the nurse as ordered. She stated residents should be supervised during medication administration. Review of an undated facility policy titled, Medication Storage showed medication will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health Guidelines. Under procedure: With the exception of emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by policy. Surveyor: [NAME], [NAME] 105881 Page 19 of 19