Health inspection·August 31, 2023

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on record review, staff interviews, and resident interview the facility failed to ensure sufficient nurse staffing on all shifts resulting in 5 of 5 sampled residents not receiving physician ordered medications on the morning of 8/26/23. (Residents #1,# 2, #3, #4, and #5) The findings include: Review of the staff assignment sheet for 11:00 PM-7:00 AM shift beginning on 8/25/23 and ending on 8/26/23 revealed the south unit had only one nurse for the shift (Employee A, who is a licensed practical nurse (LPN)). The other nurse that was scheduled did not report to work for the assigned shift. An interview was conducted with the Administrator on 8/31/23 at 10:53 AM. The Administrator stated that, on the 8/25/23 11:00 PM-7:00 AM shift, the facility had 3 nurses scheduled to work, but one nurse was absent. The Director of Nursing (DON) nor himself were notified the nurse did not report for work until about 3:00 AM on 8/26/23. They attempted to find a nurse to come in but were not successful. He stated the DON had worked from 7 AM - 11 PM on 8/25/23 and had worked as on the floor for the 3:00 PM-11:00 PM shift on the south hall on 8/25/23. They were aware medications were not administered as ordered. The physician was notified, but no new orders were given. An additional interview was conducted with the Administrator on 8/31/23 at 12:24 PM. He stated that after the DON had worked 3:00 PM- 11:00 PM on medication cart 2 south unit on 8/25/23 that she then counted medications and gave cart 2 to Employee A (LPN). Employee A also counted medications and took over medication cart 1 on the south unit because the DON informed Employee A that the additional 11:00 PM 7:00 AM nurse was on the way to the facility. When asked why a nurse did not come to assist with the 6:00 AM medication pass on 8/26/23, he stated they were not able to find a nurse to assist. He stated the resident census was 60 on 8/25/23 on the south unit. An interview was conducted with Employee B, a Certified Nursing Assistant (CNA), on 8/31/23 at 2:55 PM. Employee B stated she worked the 11:00 PM - 7:00 AM shift beginning on 8/25/23 on the north hall. She stated there was only one nurse on the south hall that night. She did not realize there were only 2 nurses in the facility the night of 8/25/23 until after 2:30 AM on 8/26/23 when Employee A came and told her the 3rd scheduled nurse did not show for work. A telephone interview was conducted with the DON on 8/31/23 at 3:08 PM. The DON stated she was not aware medications were not administered on the south unit on 8/26/23 until a nurse texted her on 8/27/23. She stated she was relieved on 8/25/23 of her 3:00 PM-11:00 PM shift by Employee A (LPN) and was not aware the other scheduled nurse did not show until around 3:00 AM on 8/26/23 when the nurse Page 1 of 3 105975 105975 08/31/2023 Community Health and Rehabilitation Center 3611 Transmitter Road Panama City, FL 32404

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some called and left her a message. She stated she has been out of the facility since Tuesday (8/29/23) and had not yet addressed the medications that were not administered on 8/26/23. A telephone interview was conducted with Employee A (LPN) on 8/31/23 at 3:16 PM. The nurse stated she was the only nurse on the south unit for the 11:00 PM-7:00 AM shift beginning on 8/25/23 and ending on 8/26/23 and was responsible for 58-60 residents. The Director of Nursing (DON) reported that another nurse was coming in but was running late. The DON had worked the 3:00 PM- 11:00 PM shift on the south unit and asked her to take both medication carts 1 and 2 on the south unit. Employee A stated she attempted to inform the DON of the situation by texting the DON around 1:30 AM on 8/26/23, and then attempted to call around 2:00 AM on 8/26/23, but the call went to voicemail. She notified the nurse on the north unit, and they attempted to call the DON again, but the call still went to voicemail. The DON called back around 3:30 AM on 8/26/23 and stated she was under the assumption that a nurse was supposed to come in. Employee A stated none of the residents on south medication cart 2 had received morning medications, blood sugar checks, or insulin as ordered by the physician on the morning of 8/26/23. She could not administer medications to 60 residents, but she did check on the residents to ensure they were stable. No one came in to assist her on the shift and she did not know if the DON attempted to call anyone in. She reported to the 7:00 AM- 3:00 PM nurse that came in on 8/26/23 that the residents on south medication cart 2 had not received their morning medications. An interview was conducted with Resident #3 on 8/31/23 at 2:12 PM. She stated she had missed a few of the morning doses of her physician ordered insulin. A review of Resident #1's August 2023 medication administration record (MAR) revealed the resident had physician orders receive insulin glargine 32 units subcutaneous daily at 6 AM, hydralazine 25 mg one by mouth every 8 hours at 6 AM, 2 PM, and 10 PM, and blood glucose checks every morning at 6:30 AM. The MAR was blank for the 6 AM medications and the 6:30 AM blood glucose check on 8/26/23. A review of Resident #2's August 2023 MAR revealed the resident had physician orders to receive levothyroxine 175 mg by mouth daily at 6 AM. The MAR was blank for the 6 AM dose on 8/26/23. A review of Resident #3's August 2023 MAR revealed that the resident had physician orders to receive Novolog insulin 10 units subcutaneous before meals with a dose at 6:30 AM and a blood glucose check at 6:30 AM daily. The MAR was blank for the administration of the insulin and blood glucose check at 6:30 AM on 8/26/23. A review of Resident #4's August 2023 MAR revealed the resident had physician orders for insulin glargine 30 units subcutaneous daily at 6 AM, omeprazole 40 mg by mouth every morning at 6 AM, and a blood glucose check at 6:30 AM daily. The MAR was blank for the administration of the insulin, omeprazole, and blood glucose check at 6:30 AM on 8/26/23. A review of Resident #5's August 2023 MAR revealed the resident had physician orders for Zoloft 100 mg by mouth daily at 6 AM, pantoprazole sodium 40 mg by mouth twice daily with a dose scheduled for 6 AM, sucralfate 1 gram by mouth before meals and at bedtime with a dose scheduled for 6:30 AM, and a blood glucose check before meals and at bedtime with one scheduled for 6:30 AM daily. The MAR was blank for the 6 AM and 6:30 AM doses of medications and the 6:30 AM blood glucose check. Review of the facility assessment (updated 7/19/23) revealed on page 8 that the facility's overall staffing plan is based on an hours per patient day basis and utilizes both historical and current labor data, census, census mix, resident acuity, all resident care and support needs, and an analysis 105975 Page 2 of 3 105975 08/31/2023 Community Health and Rehabilitation Center 3611 Transmitter Road Panama City, FL 32404

F 0725 Level of Harm - Minimal harm or potential for actual harm of how well the facility met/is meeting all of the needs of the resident population. The facility is to meet this overall staffing plan on a constant basis and adjust as needed for changes in census, acuity, and resident care and support needs. Residents Affected - Some 105975 Page 3 of 3