Health inspection·September 28, 2023

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 interviews and record review, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 (Resident #86) of 4 residents with diagnoses of mental illness, and failed to refer the resident Residents Affected - Few to the appropriate state designated authority for a comprehensive evaluation within the specified time frame. The findings included: Review of the facility policy for PASSR (Preadmission Screening and Resident Review) reviewed April 2022 revealed, It is the policy of the center to follow the Federal and State regulations with regards to pre-screening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/20/21 revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, and depression. The list of diagnoses noted Bipolar Disorder and Major Depressive Disorder, recurrent were present on admission. The care plan initiated on 12/20/21 noted Resident #86 had behaviors related to Bipolar Disorder, Major Depressive Disorder and Anxiety Disorder. On 9/26/23, review of Resident #86's medical record revealed a PASRR Level I dated 11/21/21. The Level I PASRR did not list the resident's diagnoses of Bipolar disorder or Depression. The Level I PASRR noted Resident #86's admission to the facility was a hospital discharge exemption with the condition, a PASRR Level II evaluation must be completed no later than the 40th day of admission. There was no PASRR Level II evaluation in the medical record. On 9/25/23 at 11:16 a.m., Resident #86 said he sees the psychiatrist and the psychologist at the center because of, going stir crazy in bed, change of life three years ago, spinal fusion and stroke that left him bed ridden. On 9/27/23 at 11:24 a.m., the Director of Nursing (DON) confirmed a PASRR Level II evaluation was never completed for Resident #86 as required. The DON confirmed Resident #86 has been a resident in the facility since 12/6/21 and the PASRR Level II was overdue. Page 1 of 3 105982 105982 09/28/2023 Sun Harbor Healthcare 18480 Cochran Blvd Port Charlotte, FL 33948

F 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review, and interview, the facility failed to appropriately address the consultant pharmacist's recommendations for 1 (Resident #48) of 5 residents reviewed for unnecessary medications. Residents Affected - Few The findings included: Review of Resident #48's medical record revealed an order for Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth every 6 hours for chronic pain. Do not exceed 3000 mg in 24 hours, start date 1/18/2023 at 2:00 p.m. Review of the record revealed a separate order for Percocet Oral Tablet 7.5-325 mg (Oxycodone 7.5 mg with Acetaminophen 325 mg), give 1 tablet by mouth every 6 hours as needed for moderate to severe pain, hold for sedation and altered mental status (AMS), start date 3/21/2023 at 5:15 p.m. Review of the medical record revealed on 5/8/23 the consultant pharmacist documented Resident #48 was currently receiving Oxycodone/Acetaminophen as needed which was used daily along with standing order for Acetaminophen 650 mg every 6 hours. Please evaluate current pain management and consider switching to Oxycodone twice daily and PRN (as needed) to reduce risk of exceeding Acetaminophen maximum daily dose, if appropriate. The Medical Director disagreed with the recommendation on 5/9/23, with the reason, ordered by pain management. Review of the orders for Resident #48 revealed no change or modifications in the orders for Acetaminophen and the Oxycodone/Acetaminophen (Percocet) for Resident #48 after the pharmacist made the recommendation. The clinical record lacked documentation the pain management physician was notified of the consultant pharmacist's recommendations. On 9/28/23 at 12:43 p.m., the Medical Director said he was not sure he was notified of the recommendation because all pain medication orders are addressed by the pain management physician. He said if he was notified, he would have deferred to the pain management physician. He said the risk of complications is greater in the elderly with the higher amounts of Acetaminophen. He said the order should have been fixed. On 9/28/23 at 1:58 p.m., The Director of Nursing (DON) said she is responsible for notifying the physician of the pharmacy recommendations. She said she thought she took care of the recommendation dated 5/8/23 and confirmed she signed the form implying it was done. The DON confirmed the orders for Acetaminophen and Percocet had not been changed since the recommendation of 5/8/23, and the daily Acetaminophen dose had exceeded 3000 mg on numerous days. The DON did not have documentation verifying the pain management physician was notified of the recommendation. On 9/28/23 at 3:17 p.m., during a telephone interview the consultant pharmacist said the Acetaminophen irregularity was identified 5/8/23. The facility was giving over 3000 mg of Acetaminophen almost daily to Resident #48. 105982 Page 2 of 3 105982 09/28/2023 Sun Harbor Healthcare 18480 Cochran Blvd Port Charlotte, FL 33948

F 0756 Level of Harm - Minimal harm or potential for actual harm On 9/28/23 at 4:04 p.m., during a telephone interview, the pain management physician said he could not recall if he was notified or not of the pharmacy recommendation on 5/8/23. He said he spoke to the DON earlier in the day, and the Acetaminophen dose will be adjusted. Residents Affected - Few 105982 Page 3 of 3