Health inspection·November 17, 2021

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to ensure medications were administered according to physician orders for 1 of 6 sampled residents, of a total sample of 49 residents, (#70). Findings: Resident #70 was admitted to the facility on [DATE] with diagnoses including dementia, and depression. Review of the physician orders revealed an order dated 10/23/21 that read, Lorazepam tablet 0.5 mg [milligram], give one tablet by mouth every 4 hours as needed (PRN) for agitation related to anxiety for 14 days. Review of the Medication Administration Record (MAR) reflected the above order with a start date of 10/23/21 and a stop date of 11/03/21. The MAR had an X in all boxes for all dates after 11/03/21, to indicate that Lorazepam 0.5 mg should not be administered. Review of resident 70's Controlled Medication Utilization Record for Lorazepam 0.5 mg revealed nurses signed for removal of the medication on 5 occasions after the stop date of 11/03/21. Nurses documented removal of Lorazepam 0.5 mg one dose on 11/04/21, 3 doses on 11/15/21, and 1 dose on 11/16/21. There was no associated documentation on the MAR for administration of Lorazepam 0.5 mg. on these days. On 11/17/21 at 12:20 PM, Licensed Practical Nurse B acknowledged Lorazepam 0.5 mg was signed out on dates after the stop date of 11/03/21. She stated the medication should not have been given without obtaining a new order. On 11/17/21 at 12:35 PM, the Unit Manager explained the PRN or as needed Lorazepam order indicated the medication should have been administered for only 14 days and acknowledged the stop date of 11/3/21. She stated nurse leaders usually reviewed PRN orders for stop dates and could not explain why the medication was given after the stop date. The policy and procedure for Medication Pass Guidelines revised 4/25/17, read Medications are administered in accordance with written orders of the attending physician . Record the name, dose, route and time of the medication on the Medication Administration Record. Initial the record after the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105987 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hunters Creek Nursing and Rehab Center 14155 Town Loop Blvd Orlando, FL 32837 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)