Health inspection·August 6, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on staff interviews, record review and facility policy review the facility failed to report an incident of possible neglect to the State Survey Agency related to a medication error for a critical medication for 1 (Resident #1) of 3 residents reviewed. The findings included: The facility's policy and procedure for Coumadin Management with a creation date of 10/2022 noted, It is the policy that residents on Coumadin therapy will be monitored to assist in maintaining recommended laboratory parameters as established by the attending physician . Prior to and with each medication administration, the nurse will: a. Review the Medication Administration Record [MAR] to ensure consistency in medication dose orders, b. Document the most recent lab result (PT/INR), c. The physician has been notified of laboratory results, and d. Document the next laboratory draw date is identified. Licensed staff receiving laboratory results are required to update the MAR, notify the physician of results, and adjust dosage orders as necessary. Changes in dosage require the entire medication order to be discontinued and a new order be written . Review of the clinical record for Resident #1 revealed an admission date of 7/12/24. Diagnoses included heart failure and a cardiac pacemaker. The physician's orders included to administer Coumadin (blood thinner) 4 milligrams (mg) once a day at bedtime, and PT (Prothrombin)/ INR (International Normalized Ratio) blood test (measures how long it takes for blood to clot). (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: 105995 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 105995 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109 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)