Health inspection·January 13, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to maintain complete records of Notices of Medicare Non-coverage (NOMNC) and Advance Beneficiary Notices of Non-coverage (ABN) for two (Residents #16 and #415) of three sampled residents who were discharged from a Medicare A-covered stay with benefit days remaining in the last six months. Specifically, the records provided by the facility were without resident signatures to verify that the residents were made aware of the changes in coverage for services provided by the facility. Residents Affected - Few The findings include: A record review for three residents with remaining Medicare Part A days, revealed that two (Residents #16 and #415) of the three residents who resided in the facility had missing signatures on both their NOMNC and ABN forms. (Copies obtained) The signature areas were blank and there was no date on either form. There was no documented evidence to verify that Residents #16 and #415 were notified of coverage changes related to services provided by the facility. The two residents' ABN forms did not have an Options box selected, a signature or a date of contact on them. On the two NOMNC forms, the signature and date areas were blank. These forms did not indicate by what method the participants were contacted, if they had declined, planned to appeal or were not available to sign the forms. The Regional Business Office Manager (RBOM) was interviewed on 1/13/22 at 11:03 a.m. She was asked why the signatures were missing on the forms and she stated she was told they could fill out information in the Additional Information area and that was enough. She was asked to explain the information in the Additional Information area on the NOMNC form, because it did not indicate how the resident was contacted, whether they declined, etc. She stated, Yes, I understand. She was asked to provide additional information to confirm these forms were given to the residents, however, no additional information was provided prior to the survey exit on 1/13/22 at approximately 7:45 p.m. . Page 1 of 11 105980 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility observations and staff interviews, the facility failed to ensure that a safe, clean, comfortable and homelike environment was maintained in 17 (Rooms 301, 302, 303, 304, 305, 306, 309, 310, 312, 313, 101, 102, 106, 107, 202, 205, 206) of 65 resident rooms as well as the hallways in Units 1, 2 and 3, during four of four survey days. Specifically, the facility failed to ensure resident rooms, bathrooms, and common use areas were maintained to ensure a sanitary, orderly, and comfortable interior. The findings include: room [ROOM NUMBER]: On 1/10/22 at 12:02 PM, room [ROOM NUMBER] was observed with air conditioner (AC) filters that appeared blackened with debris. The AC vents and casing were also soiled with dry surface staining and with debris coming out of the front vents. Plumbing pipe covers for the sink in the residents' room were broken and on the floor. The bathroom had sticky floors, the paper towel dispenser was broken, and the raised toilet seat was soiled. Additional observations on 1/11/22 at 9:00 AM and on 1/12/22 at 9:30 AM, found that AC filters were changed, but the vents and casing of the AC unit remained soiled with debris, and the plumbing pipe covering remained on the floor under the sink. The paper towel dispenser remained broken and the toilet remained visibly soiled. Observations on 1/13/22 at 10:30 AM, revealed the trash can in the shared bathroom did not have a liner. room [ROOM NUMBER]: On 1/10/22 at 12:07 PM, room [ROOM NUMBER] was observed. The AC was soiled with debris on the casing and in the vents. The bathroom floor was sticky, the raised portable toilet seat and frame were soiled, and the toilet seat below was also soiled. The chalking around the toilet base was discolored and blackened, and the soap dispenser at the sink was empty. Additional observations on 1/11/22 at 10:55 AM, revealed the bathroom remained soiled, there was a ripped liner in the bathroom trash can, and there was no soap at the residents' sink. An additional observation on 1/13/22 at 9:18 AM, revealed the debris on the AC vents and casing were still present. room [ROOM NUMBER]: On 1/10/22 at 12:15 PM, room [ROOM NUMBER] was observed. The AC filters were covered in debris, the vents had debris in them, and the casing was soiled. The paper towel dispenser was broken and hanging open. The toilet was running without stopping. The trash can was unlined and a soiled towel was observed hanging over the side of it. Observations on 1/11/22 at 9:00 AM and on 1/13/22 at 10:30 AM, revealed that the AC air filter had been changed, but the vent was still heavily soiled with debris. The toilet was still continuously running. The trash can was unlined and remained soiled. The paper towel dispenser cover was in place but was broken. Rooms 304/305/306/309: On 1/10/22 at 1:00 PM, it was observed in rooms 304, 305, 306 and 309, that the AC unit filters were blackened with debris. Additional observations on 1/11/22 at 10:55 AM, found that each of the AC filters had been changed, but a large amount of debris remained on the vents. room [ROOM NUMBER]: On 1/10/22 at 1:11 PM in room [ROOM NUMBER], the resident's privacy curtain was observed to be stained and soiled. room [ROOM NUMBER]: On 1/10/22 at 1:15 PM, room [ROOM NUMBER] was observed with an enteral feeding pump and IV (intravenous) pole that were soiled with dried liquid debris. The AC vents were soiled with dried liquid debris. The sink in the residents' room did not have soap or hand sanitizer available. Numerous observations throughout the day on 1/11/22 found no changes in the findings. Numerous 105980 Page 2 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observations throughout the day on 1/13/22, revealed that the enteral feeding pump had been cleaned but the IV pump remained soiled with dried liquid. The soap dispenser remained empty. room [ROOM NUMBER]/313: On 1/10/22 at 1:45 PM, rooms [ROOM NUMBERS] were observed with dried liquid on the residents' floors, dried debris was observed on the residents' room walls, the AC filters and vents were darkened with debris, and the toilets were soiled. room [ROOM NUMBER]/102/106: On 1/13/22 at 12:00 PM, resident room AC vents were observed stained with debris hanging from the vents. room [ROOM NUMBER]: On 1/11/22 at 10:40 AM, the resident's closet door appeared to be broken. An additional observation on 1/13/22 at 3:33 PM, revealed no change to the broken door. room [ROOM NUMBER]: On 1/13/22 at 11:35 AM, the bathroom toilet seat was soiled with darkened material and the ceiling vent in the bathroom was covered in debris. room [ROOM NUMBER]: On 1/13/22 at 11:40 AM, the IV pole in the resident's room was visibly soiled with dried liquid. A heavily soiled air filter was also noted. room [ROOM NUMBER]: On 1/13/22 at 11:50 AM, room [ROOM NUMBER]'s AC casing was soiled, and six pills were found in the vents (5 white tablets, 1 pink tablet). Common Areas: Observations on 1/10/22 at 10:00 AM, on 1/11/22 at 2:00 PM, and on 1/13/22 at 3:45 PM, revealed that hallway handrails on Units 1,2, and 3 had large amounts of darkened dirt and debris between the handrails and the wall. A housekeeping observation was made on 1/11/22, which revealed only superficial exterior cleaning of the handrails on the 300 hallway. An interview was conducted on 1/13/2022 at 11:15 AM with Housekeeper L. He stated there were three housekeepers on the day shift, and they cleaned the resident rooms daily and as needed. He further stated they made sure to clean the bathrooms, toilets, dressers, and bedside tables. They filled the soap dispensers and paper towels, emptied the trash, replaced the can liners, and mopped the floors. An interview was conducted on 1/13/22 at 2:45 PM with Activities Staff H regarding the policy/procedure for alerting the housekeeping/maintenance department when repairs were needed in a resident's room. She stated she completed a form and placed it in the slot or under the door for Maintenance. An interview was conducted on 1/13/22 at 3:15 PM with Care Aide I regarding the policy/procedure for reporting a need for repairs in a resident's room. She stated she would tell the charge nurse or a housekeeper, and they would complete a form to request housekeeping or maintenance services. An interview was conducted Housekeeping/Maintenance Director M and the Nursing Home Administrator (NHA) on 1/13/22 at 4:00 PM, while conducting a facility tour. The Housekeeping/Maintenance Director stated he recently began his employement with the facility and the facility had a system installed in the building so he could improve the tracking and responses for repair requests. The NHA confirmed this. The identified resident rooms and common areas were visited and the areas of concern were identified. The NHA and Housekeeping/Maintenance Director M stated they would speak with the employees in his department to reeducate them on proper housekeeping and maintenance processes. 105980 Page 3 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0584 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 105980 Page 4 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0692 Provide enough food/fluids to maintain a resident's health. 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 maintain acceptable parameters of nutritional status by failing to follow orders for one (Resident #100) of two residents triggered for weight loss from a total sample of 46 residents. Residents Affected - Few The findings include: A record review for Resident #100 revealed she was admitted on [DATE] with diagnoses including respiratory failure with hypercapina, anxiety disorder, anemia, seizures, major depressive disorder, personality and behavioral disorder, adult failure to thrive, pain, delusional disorders, hypertension, edema, and overactive bladder. A review of the quarterly minimum data set (MDS) assessment, dated 12/23/21, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. The resident's mobility needs were documented is extensive assistance of one person. A review of the Physician's Order Sheets for January 2022, revealed current orders for Buspirone for anxiety, Remeron 15 mg (milligrams) for appetite, Sertraline for depression and Tramadol for pain as needed. The resident's orders for nutritional supplements included Magic Cup two times a day (started on 12/13/21), Mighty Shakes three times a day (started 10/18/21), and Resource 2.0 (nutritional supplement) three times a day (started 10/18/21). The resident's weight was recorded monthly. Her weight on 08/01/2021 was recorded at 101 pounds. On 01/01/2022, her weight was recorded at 88 pounds, which was a 12.87 % weight loss in five months. The resident's Care Plan, initiated on 1/6/2022, revealed a potential nutritional problem due to a diagnosis and history of edema, which may cause fluctuating weights. She required a modified consistency of mechanical soft diet and left 25% or more food uneaten at most meals. She had a weight below Body Mass Index range with interventions that included administration of medications, monitor/record/report to doctor as needed signs symptoms of malnutrition and serve diet as ordered. A review of the Registered Dietitian's (RD) Nutrition Note, dated 12/13/2021, reported a 4.6% weight loss x 1 week, and her intake of the mechanical soft diet was 0-25% of most meals. The RD note dated 1/11/2022, reported a weight loss of 8.49% x 3 months, and that was below ideal body weight. The note indicated the resident's intake of her mechanical soft, thin liquids diet was 0-50% and she received Resource 2.0, 120 ml 3 times a day. A review of the Nursing Notes indicated the resident consumed 82% of her Resource 2.0, 120 ml (milliliters) three times a day. The RD recommended Magic Cup two times a day, which provided 580 kcal/18 g (grams) protein. An interview was conducted with Licensed Practical Nurse (LPN) B on 1/13/2022 at 11:40 AM. She stated she handled the tube feedings and the nutrition supplements like Resource. She stated the kitchen put the shakes and frozen Magic Cup on the meal trays. Yes, we have protocols for weight loss. We would notify the family, the doctor, and the Registered Dietitian. We give supplements to prevent weight loss like Resource, Magic Cup and shakes. 105980 Page 5 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LPN Q was interviewed on 01/13/2022 at 11:49 AM. She reported that she would defer to the RD and the resident's doctor if the resident was losing weight. I think the resident gets Resource three times a day. She does need to be encouraged to eat. An interview was conducted with the Certified Dietary Manger (CDM) on 01/13/2022 at 3:29 PM. She stated she entered the weekly weight loss list in the computer for the RD, so she would be prompted to see residents with weight loss, and then the RD would reassess those residents. The CDM was asked if all residents' diet sheets were current. She stated, I won't say that. A review of the Tray Slip form was done for the date of 1/13/22. The Tray Slip revealed that Resident #100 had a Mighty Shake on her Tray Slip only two times, but her orders were to have a Mighty Shake three times. She also had an order for Magic Cup two times a day. It was missing from the Tray Slip completely. (Copy obtained) During an interview with the CDM on 01/13/2022 at 5:23 PM, she stated, If a resident is supposed to get Mighty Shake on her tray three times a day, it should be on her Tray Slip. An interview was conducted with the RD at 5:40 PM on 1/13/2022. She reported that if a resident had a weight loss, she would reevaluate the resident and would put new supplement orders, etc., in the computer, then give them to the CDM. The CDM would put them in the kitchen computer system. The orders would then print on the Tray Slip for meal service staff to place the item(s) on the meal tray. The CDM was responsible for putting any new orders in the kitchen computer system. The RD reported she did not have access to this system and was unable to add the orders herself. Certified Nursing Assistant (CNA) S was interviewed on 01/13/2022 at 6:00 PM. She reported that dietary staff put nutritional supplements on meal trays before leaving the kitchen. CNA S stated she could not remember whether Resident #100 received any nutritional supplements. An interview was conducted with LPN T on 01/13/2022 at 6:05 PM. She reported that she had been working in the facility for three years and dietary staff put Magic Cup and Mighty Shake supplements on meal trays at each meal service. She stated the nurses were responsible for administering the medical nutritional supplements (i.e Resource 2.0). An interview was conducted with CNA U on 01/13/2022 at 6:10 PM. She reported that Resident #100 received Mighty Shake on her tray, but I have not seen any Magic Cup. The facility's policy addressing resident weight loss was requested but was not received over the course of the survey. . 105980 Page 6 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

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 record reviews, observations, and staff interviews, the facility failed to ensure residents who required respiratory services, received such services, consistent with professional standards of practice, for two (Residents #46 and #25) of two residents reviewed for oxygen administration, from a total of 46 residents in the sample. Specifically, the facility failed to ensure both residents were receiving oxygen as ordered by their physicians. Residents Affected - Few The findings include: 1. A review of Resident #46's medical record revealed an admission date of 2/17/21. His diagnoses included chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. A review of the quarterly minimum data set (MDS) assessment, dated 11/10/21, revealed the resident was documented as having shortness of breath or trouble breathing when sitting, at rest, or when lying flat. He was also documented as receiving oxygen. A physician's order, dated 3/9/21, instructed staff to provide the resident oxygen at a flow rate of 2 liters per minute via nasal cannula, continuously, every shift, for COPD. A physician's order, dated 12/9/21, instructed staff to change the oxygen tubing every night shift, every Sunday. An observation of Resident #46 on 1/10/22 at 11:18 AM, revealed the resident resting in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. (Photographic evidence obtained) An observation of Resident #46 on 1/11/22 at 9:24 AM, revealed the resident resting in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The oxygen tubing was dated 1/1/22, and based on the physician's order, it should have been changed by 1/9/22. An observation of Resident #46 on 1/12/22 at 10:29 AM, revealed the resident in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The oxygen tubing was still dated 1/1/22, but the humidification receptacle was dated 1/10/22 at 6:00 AM. (Photographic evidence obtained) An observation of Resident #46 on 1/12/22 at 3:15 PM, revealed the resident in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The oxygen tubing was still dated 1/1/22. (Photographic evidence obtained) An observation of Resident #46 on 1/13/22 at 9:45 AM, revealed the resident in bed with his oxygen being administered via nasal cannula. The oxygen concentrator's flow rate was set between 3.5 liters and 4 liters per minute. The resident's oxygen tubing was undated. (Photographic evidence obtained) A review of the electronic medication administration record (eMAR) for January 2022, revealed it included oxygen, 2 liters via nasal cannula, continuously, every shift, related to chronic-obstructive pulmonary disease. 105980 Page 7 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0695 Level of Harm - Minimal harm or potential for actual harm During a 1/12/22 interview with Certified Nursing Assistant (CNA) D at 2:58 PM, she stated oxygen management was solely the responsibility of the nurses. Her tasks were to report low levels of oxygen saturation, below 90%, and to report to the nurse when that occurred. She was also to report difficulty breathing and make sure the cannula is on their face. Communication of vital signs was made through a paper log which was handed to the nurse once it was completed. Residents Affected - Few During a 1/13/22 interview with CNA C at 9:49 AM, she stated her responsibility was to obtain oxygen saturation levels during vital signs rounding, and to report back to the nurse if difficulty breathing was noted. The nurse would then reassess the resident's breathing effort and obtain further oxygen levels. CNA C further stated, Oxygen is a medication, so it's the nurse's responsibility to monitor that. She stated she would ask the nurse to review and verify the resident's oxygen administration order. During a 1/13/22 interview with Licensed Practical Nurse (LPN) B at 9:58 AM, she stated an overview of oxygen levels and orders was the nurses' responsibility, and the oxygen flow rate to be administered was indicated in the MAR. The CNA was responsible for checking oxygen levels during vital signs rounding and reporting back to the nurse if the resident was short of breath or having breathing difficulty. LPN B opened Resident #46's January 2022 MAR, and confirmed that her oxygen order was for 2 liters per minute via nasal cannula. During a 1/13/22 interview with the Director of Nursing (DON) at 2:33 PM, she stated oxygen administration, implemented by nursing, must be performed correctly, per the physician's order. She further stated oxygen tubing was replaced every seven days, usually on the 11-7 shift, and should be dated. 2. A review of Resident #25's medical record revealed and admission date of 4/19/18. Her diagnoses included asthma and COPD. A review of the quarterly MDS, dated [DATE], revealed the resident was receiving oxygen. A review of the Physician's Order Sheets for January 2022, revealed a current order for oxygen, 2 liters per minute continuously, checked every shift, and oxygen tubing to be changed every Sunday. A review of Resident #25's Care Plan for Oxygen, initiated on 10/29/21, revealed she was receiving oxygen therapy due to ineffective gas exchange and chronic obstructive pulmonary disease. The interventions included: Change delivery method if resident eats, monitor for signs and symptoms of respiratory distress and report them to the doctor as needed. Oxygen settings via nasal cannula per physician's orders. An observation of Resident #25 in her room on 1/11/22 at 2:09 PM, revealed that her oxygen flow rate was set at 4 liters per minute, and the oxygen tubing was dated 1/3/2022. Based on the facility's protocol, the oxygen tubing should have been changed by 1/9/22. An observation of Resident #25 in her room on 1/12/22 at 3:00 PM, revealed that her oxygen flow rate was still set at 4 liters per minute. (Photographic evidence obtained) An observatin of Resident #25 in her room on 1/13/22 at 11:20 AM, revealed that her oxygen flow rate was now set at 2 liters per miute, however the oxygen tubing was still dated 1/3/2022. The facility policy on Oxygen Administration, last revised 10/2020, revealed the following: 105980 Page 8 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Documentation of oxygen administration per policy and procedure include the recording of the rate of oxygen flow, route and rationale, the frequency and duration of the treatment. According to the National Center for Biotechnology Information (NCBI) at https://www.ncbi.nlm.nih.gov/books/NBK430743/ (Accessed 2/4/22 at 1:56 p.m.): Oxygen is vital to sustain life. However, breathing oxygen at higher than normal partial pressure leads to hyperoxia and can cause oxygen toxicity or oxygen poisoning. The clinical settings in which oxygen toxicity occurs is predominantly divided into two groups; one in which the patient is exposed to very high concentrations of oxygen for a short duration, and the second where the patient is exposed to lower concentrations of oxygen but for a longer duration. These two cases can result in acute and chronic oxygen toxicity, respectively. The acute toxicity manifests generally with central nervous system (CNS) effects, while chronic toxicity has mainly pulmonary effects. Severe cases of oxygen toxicity can lead to cell damage and death. Those at particular risk for oxygen toxicity include patients exposed to prolonged high levels of oxygen. Extended exposure to above-normal oxygen partial pressures, or shorter exposures to very high partial pressures, can cause oxidative damage to cell membranes leading to the collapse of the alveoli in the lungs. Pulmonary effects can present as early as within 24 hours of breathing pure oxygen. Symptoms include pleuritic chest pain, substernal heaviness, coughing, and dyspnea secondary to tracheobronchitis and absorptive atelectasis which can lead to pulmonary edema. Pulmonary symptoms typically abate 4 hours after cessation of exposure in the majority of patients. CNS effects manifest with a multitude of potential symptoms. Early symptoms and signs are quite variable, but twitching of perioral and small muscles of the hand is a fairly consistent feature. If exposure to oxygen pressures is sustained tinnitus, dysphoria, nausea, and generalized convulsions can develop. . 105980 Page 9 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure residents were free from significant medication errors for one (Resident #410) of six residents reviewed for medication administration, from a total of 46 residents in the sample. Specifically, the facility failed to ensure antibiotics were administered for a newly admitted resident with diagnoses of UTI (urinary tract infection) and Cellulitis. Residents Affected - Few The findings include: A review of Resident #410's medical record revealed she was admitted to the facility on [DATE]. Her primary diagnoses were urinary tract infection (UTI), and cellulitis. Additional diagnoses included severe onychomycosis bilaterally to lower extremities, with infection to the right lower extremity, cutaneous abscess to right lower limb, hyperlipidemia, diabetes mellitus 2, hypothyroidism, anxiety, congestive heart failure, depression, and chronic obstructive pulmonary disease. The resident's Baseline Care Plan, initiated on 1/3/22, documented that the resident was receiving antibiotic treatment. Interventions included the administration of the antibiotic as ordered by the physician. The Nursing admission Assessment, dated 1/1/22, documented that the resident was as alert and oriented to person, place, time, and situation. She was admitted with an active infection requiring antibiotic therapy. A review of the physician's orders revealed an order dated 1/1/22, for Ceftriaxone (antibiotic used to treat bacterial infections), 2 grams IV (intravenously) twice a day for Cellulitis (bacterial skin infection), continue to complete a 4-week course with a stop date of 1/23/22. A second physician's order, dated 1/1/22, was written for Metronidazole (antibiotic used to treat a wide variety of infections) tablet, 500 mg (milligrams), to be given by mouth two times a day for Cellulitis, complete a 4-week course with a stop date of 1/23/22. A review of the resident's January 2022 medication administration record (MAR), revealed that the resident was not administered Ceftriaxone 2 grams IV on 1/1/22 at 5:00 PM, on 1/2/22 at 9:00 AM, on 1/3/22 at 5:00 PM, on 1/4/22 at 9:00 AM, or on 1/6/22 at 5:00 PM. The record also showed missed doses on 1/10/22 at 5:00 PM and on 1/11/22 at 9:00 AM, secondary to a clogged IV administration site, as per nursing documentation. Further review of the MAR revealed that the resident was not administered Metronidazole tablet 500 mg by mouth on 1/1/22 at 9:00 AM, on 1/2/22 at 5:00 PM, or on 1/6/22 at 5:00 PM. A review of the Nursing Progress Notes, revealed that on 1/2/22 was documented, awaiting pharmacy delivery of Ceftriaxone 2 grams. A progress note dated 1/3/22, documented that Ceftriaxone 2 grams was on order. A 1/10/22 progress note written at 9:07 PM, documented that line was bad, and on 1/11/22 at 11:30 AM, a progress note documented the IV port possible compromise. IV access team notified, and MD notified. A review of the Physician's Progress Notes revealed an admission Note dated 1/6/22. It documented that the resident was to continue IV antibiotics Ceftriaxone (Rocephin) and Flagyl (Metronidazole) until 1/23/22 for Cellulitis of the right lower limb. The progress note did not indicate that the physician was aware that the resident had missed five doses of Ceftriaxone and two doses of 105980 Page 10 of 11 105980 01/13/2022 Lakeside Center for Rehabilitation and Healing 11411 Armsdale Road Jacksonville, FL 32218

F 0760 Metronidazole prior to this visit. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Licensed Practical Nurse (LPN) L at 2:30 PM on 1/13/22. She stated when a resident was admitted , the nurses went through all of the resident's paperwork and information received upon admission. Upon admission, the nurse contacted the pharmacy and put the medical information in the admitting resident's medical record. Depending upon the time of admission, the facility usually received the resident's medications on the next run, and if they did not come in, the nurse called the pharmacy, or had the medication sent STAT (immediately). LPN L added that the facility had a back-up system and staff could access the medication in the system if necessary. Residents Affected - Few An interview was conducted with LPN K at 3:00 PM on 1/13/22. She stated the medications usually arrived on time, but if they did not arrive, she would check the back-up box for the medication, then call the pharmacy and document that in the resident's medical record. If a medication was unavailable, she would contact the physician to see whether he/she wanted to give new orders or instructions. An interview was conducted with the Director of Nursing (DON) at 2:00 PM on 1/13/22. She stated the admitting nurse reviewed all of the admission paperwork, and sent the medication list to the pharmacy for delivery on the next scheduled run. If the medications were not received, it was her expectation that the nurse would call the pharmacy to follow up. She further stated the facility had a back-up automated medication dispensing system for medication and antibiotics, so if it was needed, the nurse could pull medication from that system or they could call to have medications sent STAT from the pharmacy. She said if medication was not received and the resident missed a dose, there should be documentation in the progress notes indicating why the medication was not given, and that the physician had been notified. Usually, the physician would extend the dosing to the quantity needed so the resident received the correct number of doses. She said she would review the resident's chart and the physician would be notified. She further stated there should be no holes in the documentation of Resident #410's MAR. The facility policy on Antibiotic Orders, implemented on 1/27/21 without revision, revealed the following: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all of the above drug and dosing elements. . 105980 Page 11 of 11