Health inspection·October 9, 2020

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that the practice is safe. The resident will be assessed fro their cognitive, physical and visual ability to self-administer medications based on the attached form Self Administration of Medication Informed Consent and Assessment. If the interdisciplinary care team determines that the resident cannot safely self-administer medications, medications will be administered by the staff nurse. Review of the procedure guidelines for Administering nebulizer therapy (not dated, page 240 from unknown document) one page revealed: Nursing action 1. Auscultate breath sounds, monitor the heart rate before and after the treatment for patients using bronchodilators drugs. 4. Instruct the patient to exhale. 7. Observed expansion of chest to ascertain that patient is taking deep breaths. 8. Instruct the patient to breathe slowly and deeply until all the medication is nebulized. 9. On completion of the treatment, encourage the patient to cough after several deep breaths. Event ID: Facility ID: 106006 If continuation sheet Page 2 of 7 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 106006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldomero Lopez Memorial Veterans Nursing Home 6919 Parkway Blvd Land O Lakes, FL 34639 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 interview, the facility did not ensure that 1 (Resident #76) out of 5 residents reviewed for unnecessary medications had a diagnosis or indication for use listed for all medications on the active order list. Residents Affected - Few Findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to acute respiratory failure, pneumonia, and primary insomnia. Review of the resident's active orders revealed that the resident had an order for melatonin OTC (over the counter) 1 tablet 3mg PO (by mouth) QHS (every night at bedtime) dated 10/02/19. There was no diagnosis or indication for use listed for the medication. The resident also had an order for Siltussin DM DAS (dextromethorphan-guaifenesin) OTC liquid 10-100mg/5ml 10ml orally every 4 hours dated 12/09/19. There was no diagnosis or indication for use listed for the medication. On 10/09/20 at 1:16 PM in an interview with the Director of Nursing (DON), she said that there should be a diagnosis for each medication. When asked what melatonin was used for, she said it was used as a sleep aide. When asked what Siltussin DM was used for, she said it was for a cough. The DON acknowledged that there was no diagnosis or indication for use on either medication. She said that she didn't know why there wasn't a diagnosis or indication listed for either of the medications, but that there should be one. On 10/09/20 at 1:27 PM in an interview with Staff F, pharmacist, she said that she was not the normal pharmacist, so she could not speak to a specific resident, but that she could give her expectations as a pharmacist. She said that she would expect every medication to have at least one diagnosis related to use listed on the order, like insomnia for the melatonin or an indication of use, like cough for the Siltussin DM. On 10/09/20 at 1:29 PM, during a phone interview with Staff G, the facility's full-time pharmacist she said that all medications should have a diagnosis. She asked if the order list we had received from the facility had diagnoses printed with it. Staff F, who was present for the telephone interview, told Staff G that yes, the version we had did include diagnoses. Staff F also relayed to Staff G that there were no diagnoses or indication for use for either of the medications in question. Staff G said that it is her expectation that all medications have a diagnosis. Review of a facility policy Verbal and/or Telephone Physicians' Orders effective on 5/30/2009 revealed under the heading II. PROCEDURES . 4. The verbal or telephone order shall be documented by the professional who accepts the order and shall include: . e. Purpose or indication for a medication FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106006 If continuation sheet Page 3 of 7 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 106006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldomero Lopez Memorial Veterans Nursing Home 6919 Parkway Blvd Land O Lakes, FL 34639 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm 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** 2. Residents Affected - Few On 10/09/20 at 10:50 a.m., Resident #3 was observed sitting in the wheelchair next to the bed in his room. He was well groomed and dressed for the day. A review of the Resident Face Sheet for Resident #3 revealed that he was initially admitted into the facility on [DATE] with a primary diagnosis of Alzheimer's Disease. Other diagnoses included but were not limited to post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. A review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident was rarely/never understood. Section D indicated that the resident was rarely/never understood. The section related to feeling down, depressed, or hopeless was blank. Section N revealed that Resident #3 received an antidepressant for 7 days per week. A review of the Physician Order Reports for 08/01/20-08/31/20, 09/01/20-09/30/20, and 10/01/20-10/09/20 revealed that Resident #3 had the following orders: Memantine- 10 mg twice per day for dementia Sertraline- 50 mg once per day for depression There was no order for Behavior Monitoring found on the Physician Order Reports. A review of the Medications Administration History for 08/01/20-08/31/20, 09/01/20-09/30/20, and 10/01/20-10/09/20 did not reflect that Resident #3's behaviors were monitored. A review of the Treatment Administration History for 08/01/20-08/31/20, 09/01/20-09/30/20, and 10/01/20-10/09/20 did not reflect that Resident #3's behaviors were monitored. A review of the Resident Progress Notes for August, September, and October did not reflect daily documentation for non-verbal signs of anxiety, mood and behavior monitoring. The care plan for behavioral symptoms had a start date of 01/16/19. Interventions included but were not limited to monitor behavior episodes and attempt to determine underlying causes, document behavior and potential causes, and monitor for and document presence of mood and behaviors. The care plan for psychotropic drug use had a start date of 01/16/19. Interventions included but were not limited to monitor for non-verbal signs of anxiety and monitor Resident #3 frequently for mood and behaviors. On 10/09/20 at 10:24 a.m., the MDS Coordinator stated that behavior monitoring should be documented in progress notes. On 10/09/20 at 10:48 a.m., Staff A, Nursing Supervisor, reported that Resident #3 did not have any behaviors, but can be resistive to care often. Staff A reported that he was not combative or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106006 If continuation sheet Page 4 of 7 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 106006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldomero Lopez Memorial Veterans Nursing Home 6919 Parkway Blvd Land O Lakes, FL 34639 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anything. She reported that behaviors would be monitored if a resident was taking psychotropic medications. If a resident was monitored for behaviors, it would pop up on the Medication Administration Record (MAR) and it should be documented every shift. If they are not on a psychotropic, then behaviors would be documented in the progress notes. Staff A reported that she was not sure what medications Resident #3 was ordered. At 10:54 a.m., she looked up the resident's orders. She stated that he had an order for sertraline, but not an antipsychotic. Staff A stated that Resident #3 does not like to particularly be changed, but he was not combative. The policy Psychotropic Medication Clinical Guidelines revised on 10/06/17 revealed the following: Standard Psychotropic Drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to drugs in the following categories: Antipsychotics Antianxiety Antidepressants Hypnotics Nursing 1. Daily monitoring of the resident for presence of target behaviors and any adverse effects of the medication (charting behaviors/adverse effects when present) 2. Review the use of the psychotropic medication with the interdisciplinary team on a quarterly basis to include presence of target behaviors and/or adverse effects of the medication. Pharmacist 1. Monitors psychotropic drug use in the facility to ensure appropriate use/monitoring of medications. Based on interview and record review, the facility did not ensure 1. that 2 (Resident's #76 and #3) out of 5 residents reviewed for unnecessary medications were being monitored for behaviors related to the use of psychotropic medications; and 2. that a care plan related to monitoring the effectiveness of psychotropic medications was implemented for 2 (Resident #76 and #3) out of 5 residents reviewed for unnecessary medications. Findings included: 1. On 10/09/20 at 1:16 PM in an interview with the Director of Nursing (DON), she said that behaviors for psychotropic medications are documented on the eMAR (electronic medication administration record). She said that behaviors should be monitored for psychotropic medication every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106006 If continuation sheet Page 5 of 7 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 106006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldomero Lopez Memorial Veterans Nursing Home 6919 Parkway Blvd Land O Lakes, FL 34639 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few When she was asked if anti-depressants were considered psychotropic medication, she said I don't think so. When asked if nurses should be monitoring behaviors for residents who are taking anti-depressants, she said we only monitor anti-psychotics every shift. With residents who are taking anti-depressants, we go by the PHQ-9 tool (section D of the Minimum Data Set (MDS) assessment) done by our Social Services (SS) Department quarterly. SS monitors all residents quarterly with the PHQ-9 tool, and nurses document in the notes if the resident has any behaviors. She was asked to clarify what the PHQ-9 was and told us that the PHQ-9 is a tool to determine if there is any indication of depression for all residents. On 10/09/20 at 1:27 PM Staff F, pharmacist said that she was not the facility's full-time regular pharmacist, but that she was in the facility covering the regular pharmacist's vacation. She said that she could give her expectations as a pharmacist, but not about a resident specific. She said that she would expect to see behaviors monitored, even if there were no behaviors that should be documented. She believes that the monitoring should be done when the nurse gives the medication, not every shift. On10/09/20 at 1:29 PM, during the interview with Staff F, the facility's regular pharmacist Staff G, by request of the DON, called to answer surveyor questions. Staff G said that behaviors should be monitored every shift, and that there are questions on each eMAR about behaviors. She said the nursing staff should be monitoring residents if they are having behaviors and documenting how many times the residents are having those behaviors. If a resident has no behaviors, that should be documented as well. Behavior monitoring is part of a standard nursing order set that should go along with all psychotropic medication ordered. If the resident gets an order for a psychotropic, they should be adding the order set that includes behavior monitoring and side-effect monitoring. When asked if nurses should be monitoring residents on anti-depressants every shift for behaviors, Staff G said that if they are on the anti-depressant, we are only monitoring side effects. Those behaviors don't change shift to shift, so we use the PHQOV or PHQ-9 (filled out) by social services every quarter. Resident #76 was initially admitted to the facility on [DATE] for a diagnosis of acute respiratory failure with hypoxia. Other diagnoses included, but not limited to, eczema of face, cognitive communication deficit, unspecified convulsions, primary insomnia and chronic pain syndrome. Review of the Resident #76's most recent quarterly MDS dated [DATE] the resident was assessed to have a BIMS (brief interview for mental status) of 14, indicating the resident had intact cognitive responses. The resident was assessed to feel tired or have little energy 7-11 days during a 14-day assessment period, and to refuse or reject care 4-6 days of a 7-day assessment period. The resident was assessed to receive an antidepressant daily. The resident had orders that included, but were not limited to: Carbamazepine 200mg tablet oral every 12 hours for seizure disorder dated 5/23/2019 Citalopram 20mg one tablet orally at bedtime for depression dated 5/17/2019 Trazodone 100mg one tab orally at bedtime for depression dated 5/17/2019 Anti-depressant medication side effect monitoring dated 6/1/2020 Review of the residents eMAR revealed that the resident had been given citalopram and trazodone, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106006 If continuation sheet Page 6 of 7 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 106006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baldomero Lopez Memorial Veterans Nursing Home 6919 Parkway Blvd Land O Lakes, FL 34639 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few both for depression, daily for the past 3 months and was being monitored for side effects only every shift and not for the effectiveness of the medication. Part of the resident's care plan included to be at risk for complications and side effects from daily administration of psychotropic medications. One of the approaches to this problem area included monitor for effectiveness. Another approach was Monitor resident frequently for mood or behaviors. Review of the residents eMAR (electronic medication administration record) revealed that the resident was not being monitored for effectiveness or behaviors, only side effects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106006 If continuation sheet Page 7 of 7