Health inspection·May 27, 2021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility policy, the facility failed to ensure proper labeling and storage of drugs and biologicals for two (Resident #77 and Resident #66) of eight residents observed for medication administration, in three of three medication carts observed, and in one of two medication storage rooms observed. Findings included: A medication cart inspection was conducted on 05/26/21 at 10:56 a.m. with Staff F, Licensed Practical Nurse (LPN) on the 200 unit of the facility. A container of glucose monitoring test strips was observed in the top drawer of the medication cart. The glucose monitoring test strips did not have a date labeled on them to indicate when they were opened. Staff F, LPN was not able to state whether or not the glucose monitoring test strips should have been dated upon opening and stated that she would not normally put a date on the bottle. Two small brown bottles of Nitroglycerin 0.4 milligram (mg) tablets was observed in the medication cart. One of the small brown bottles of Nitroglycerin 0.4 mg tablets was stored inside of the manufacturer's box, but did not have a lid. The bottle also did not have a date labeled on it to indicate when it was opened. Staff F, LPN was not able to state why the Nitroglycerin tablet bottle did not have a lid and stated that it may have come that way from the pharmacy. A second bottle of Nitroglycerin 0.4 mg tablets was observed to be stored inside of the manufacturer's box with a yellow label that read Date Opened. No date was documented on the label to indicate when the bottle was opened. Staff F, LPN was not able to state why the bottle of Nitroglycerin 0.4 mg tablets did not have a documented date of when it was opened. Staff F, LPN addressed that if a medication came from the pharmacy with a Date Opened label on it, then it should be dated with the date that it was opened by the nurse. During the inspection of the medication cart, 4 loose medication pills were observed throughout the medication cart. Staff F, LPN stated that the medication cart should not have loose medications in it and that the 11:00 p.m. to 7:00 a.m. shift nurse would normally inspect the medication carts to ensure that medications were properly labeled and that there were not any loose medications in the medication carts. An inspection of a medication storage room was conducted on 05/27/21 at 7:50 a.m. with Staff C, Assistant Director of Nursing (ADON) on the 300 unit of the facility. An observation was made during the inspection of a small yellow bin, just inside of the entrance to the medication storage room, which contained several medication cards, boxes, and plastic storage sleeves full of medications inside of it. Located on the left side of the sink in the medication storage room was a large red plastic container, which was filled with various medications and was not able to be properly closed. One large brown paper bag full of medications sat on top of the large red bin and a large brown paper bag Page 1 of 5 106030 106030 05/27/2021 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few full of medications was also sitting next to the large red bin on the counter of the medication storage room. A two tiered black storage bin was also observed to be full of various medications on the counter next to the brown paper bags and large red bin full of medications. The right side of the sink in the medication storage room contained another large brown paper bag full of various medications and two clear plastic bins full of medications next to it. Staff C, ADON stated that education needed to be conducted with the nursing staff related to proper procedures for returning medications to the pharmacy. Medications should be returned to the pharmacy using the large red bins and should be taken down when the pharmacy delivery came on the 11:00 p.m. to 7:00 a.m. shift. Staff C, ADON stated that the facility was having some staffing issues on the 11:00 p.m. to 7:00 a.m. shift and that the agency nurses may not have been aware of the proper procedure for returning medications to the pharmacy. The 11:00 p.m. to 7:00 a.m. nurse should also be conducting audits of the medication carts to ensure that there were no expired medications, medications were properly labeled, and to ensure that there were no loose medications in the medication carts. An interview was conducted on 05/27/21 at 8:05 a.m. with the facility's Director of Nursing (DON). The DON stated that the pharmacy would make a delivery on the 3:00 p.m. to 11:00 p.m. shift and that the nursing staff should be returning any medications to the pharmacy during that pharmacy run. The DON stated that the nursing staff may be forgetting to take the red bin down to return to the pharmacy when they pick up new medications that were delivered. The DON also addressed that the medication storage room should not contain a large number of medications to be returned to pharmacy and stated this never happens. A medication cart inspection was conducted on 05/27/21 at 10:45 a.m. with Staff A, Registered Nurse (RN) on the facility's 300 unit. During the inspection, a total of 5 loose medications were observed throughout the drawers of the medication cart. Staff A, RN stated that she did not routinely check the medication cart for the presence of loose medications but stated that there should not be any loose medications in the medication cart. An observation was made of the medication Arnuity Ellipta via inhaler with a white label reading Expires 42 Days After Date Opened. No date was documented on the label, but hand written documentation on the box revealed that the medication was opened on 03/28/2021. Staff A, RN addressed that the inhaler was considered expired since it had been over 42 days since it was opened. An observation was made on 05/27/21 at 11:07 a.m. of a medication cart on the 300 unit of the facility. The medication cart was observed to be unlocked. No staff members were observed in the immediate area of the medication cart and the medication cart was able to be inspected without staff being present. Shortly after beginning the medication cart inspection, Staff D, LPN returned to the medication cart. Staff D, LPN addressed that she should have locked the medication cart before stepping away from it. During the inspection of the medication cart, 2 loose pills were observed in the top drawer of the medication cart. Staff D, LPN stated that the medication cart should not have loose medications in the drawers, but she did not check for loose medications when she took responsibility of the medication cart. Staff D, LPN stated that she just hoped that the previous nurse checked for any issues with the medication cart because she was an agency nurse. Staff D, LPN also stated that she checked the expiration date of the medications as she gave the medications. A container of glucose monitoring test strips were observed in the top drawer of the medication cart. The glucose monitoring test strips did not have a date labeled on them to indicate when they were opened. An observation was made of a package of Restasis 0.4 milliliter (ml) single use eye drop vials. A yellow label on the package read Date Opened. No date was documented on the yellow label to indicate when the package was opened. A bottle of Latanoprost 0.005% eye drops were observed inside of a brown plastic bag in the medication cart. The bag and vial of eye drops both had a white label that read 106030 Page 2 of 5 106030 05/27/2021 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Expires 42 days from date opened. No date was documented on the bag or the vial to indicate when the vial was opened. A Combivent Respimat inhaler was observed in the manufacturer's box inside of the medication cart. A white label was observed on the box which read Expires 90 Days From Date Opened. No date was documented on the label to indicate when the inhaler was opened. Staff D, LPN stated that medications that have a label to document the date that it was opened should have a date documented on the label by the nurse. Staff D, LPN was not able to state why the medications were not dated properly. A follow up interview was conducted on 05/27/21 at 1:25 p.m. with the facility's DON. The DON stated that the cart audits that were supposed to be conducted on the 11:00 p.m. to 7:00 a.m. shift were not being followed properly and that the 11:00 p.m. to 7:00 a.m. shift should be checking for expiration dates of medications and the cleanliness of the medication cart. The DON also stated that nurse's should not walk away from the medication carts without first locking the cart. Photographic evidence was obtained. 2. On 05/24/2021 at 12:00 p.m., Resident #66 was observed in her bed asleep. On the left side of her bed, three medications were located on top of the bedside table. A closer look revealed a Breo Ellipta 200-25 MCG Inhaler, a clear medication cup with a white round tablet in it, and Fluticasone Prop 50 MCG Spray. The Resident was observed to wake up, and then looked at the clear medication cup containing the white round pill and stated Hi! what is that? (Pointing to the medication cup with the white round pill in it) I don't know, I don't know what it is A further interview was attempted with Resident #66, but she was unable to answer any questions related to the medications. Photographic Evidence Obtained. On 05/24/2021 at 12:02 p.m., an interview was conducted with Resident #66's nurse, Staff A, Registered Nurse, (RN) who was sitting at the nurse's station typing on the computer. Staff A was asked about the three medications observed on Resident #66's bedside table, and if the resident had an active physician order to administer the medication by herself. Staff A got up and indicated that she did not leave medications in the room and ran down to Resident #66's room. Staff A confirmed the presence of the medications left out and then asked Resident #66 to take the white round pill, handing her a Styrofoam cup filled with water. Staff A, then stated, I left the meds here. The resident across the hall's alarm on his chair went off and I forgot the medications were in the room, it's my fault I forgot them. I know I am not supposed to leave it in a resident room. She was observed to take the other two medications off the table and leave the room. Record review for Resident #66 indicated she was admitted on [DATE] with multiple diagnoses that included cognitive communication deficit, Muscular Dystrophy, Schizoaffective disorder, bipolar type, and generalized Anxiety Disorder and Dementia. A review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that Resident #66's Brief Interview for Mental Status (BIMS) score was 0, which indicated severe cognitive impairment. On 05/24/2021 at 12:30 p.m., an observation was conducted of Resident #77 sitting in a recliner chair in his room. The resident appeared to be sleeping as his eyes were closed. Observation of Triamcinolone 0.1% Ointment medication was on a shelf near the resident's closet. A record review for Resident # 77 indicated he was admitted on [DATE] with multiple diagnoses that included Cognitive Communication Deficit and Dementia with Behavioral Disturbance. A review of physician orders revealed Triamcinolone 0.1% Ointment daily at 9:00 a.m. and then as needed (PRN) in the evening for Rash. Record review of Minimum Data Set (MDS) dated [DATE], identified in Section C, 106030 Page 3 of 5 106030 05/27/2021 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident #77's Brief Interview for Mental Status (BIMS) score was 3, which indicated severe cognitive impairment. An interview was conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 05/26/2021 at 10:32 a.m. During the interview, the DON and NHA were informed of the observations made of Resident #66 and Resident #77 and were shown two photographs of medications left out in both resident rooms. The DON revealed that Staff A (RN), informed him of the white round pill she left on the bedside table. The DON indicated that the nurses should store all medications properly and stay in the resident's room during administration. The NHA stated, The nurses should follow the facility policy and they should not leave medications at bedside, in a resident room. On 05/27/2021 at 12:39 p.m., a telephone interview related to the observations was attempted with the Pharmacy Consultant, without success. A facility provided policy titled, Medication Storage, with Revision Date 07/2020, Page 01 of Page 02, was reviewed and read under Policy Heading It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure the proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms, under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 106030 Page 4 of 5 106030 05/27/2021 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy review, the facility failed to follow their policy to appropriately store and maintain food in for a safe and sanitary manner in one of four refrigerators and one freezer. Residents Affected - Few Findings included: During the initial kitchen tour on 05/29/2021 at 9:30 a.m., an observation of the freezer revealed two large white plastic buckets of cornbread batter on the floor of the freezer. The Certified Dietary Manager (CDM) confirmed the presence on the floor, and indicated they need to be stored on a shelf. The CDM further indicated that they were moved there due to inventory process and placed each bucket on the bottom shelf. Observation of the walk-in refrigerator included on the side second shelf, a cardboard box that contained two moldy lemons. On the first shelf at the back of the refrigerator, a large bottle was seen without a cover, that contained garlic. The CDM, confirmed the presence of both moldy lemons, and asked an unidentified kitchen staff to remove the bottle of garlic, that she quickly threw away into a nearby garbage receptacle. (Photographic Evidence Obtained) A review of the facility's policy Westminster Communities of Florida Dining Services Standards and Guidelines, titled Food and Supplies Storage, Revised 9/2011, Pages 01-02 of Page 03, included under Guidelines reads: 4. All foods stored in walk-in refrigerators and freezers will be stored on shelves, on racks, dollies, or other surfaces that facilitate thorough cleaning. All food items shall be stored a minimum of 6 from the floor. 5. Food shall be rotated as delivered and used in a First In, First Out Method. 6. Prepared or opned foods stored in the refrigerator until served, shall be covered. Such food stored in a refrigerator must be placed in a storage container and tightly sealed with a tight fitting lid marked with the name o the item, and date of expiration (5 days after preparation or opening), or wrapped tightly with foil or plastic wrap and labeled. 106030 Page 5 of 5