Health inspection·September 14, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview, observation, and record review, the facility failed to perform proper technique with catheter care for Resident #24 and failed to utilize a urinary catheter anchor for 3 of 14 residents identified with urinary catheters, Residents #24, #19, and #55. The findings included: 1. The facility's policy titled Urinary Catheter Indication and Maintenance (Urethral and Supra-pubic), revised 6/9/17, has a section titled Maintenance/Care of Indwelling Urinary Catheters that has 6 steps. Step 5 states: Minimize the pull of catheter tubing by securing catheter to resident's body. 2. A procedure manual document from www.nursegroups.com, titled Indwelling Catheter Care, has numbered steps describing indwelling catheter care. Step 10 instructs: Perform perineal care with washcloths, soap, and warm water. Remember to clean front-to-back on female residents and under the foreskin of uncircumcised males. 3. On 09/13/23 at 9:35 AM, an observation was made of Staff A, a Certified Nursing Assistant (CNA), performing perineal care with catheter care on Resident #24. The CNA had all her equipment laid out on a barrier pad. The CNA washed her hands and put on gloves. The CNA filled a wash basin 1/2 full of warm water. The CNA repositioned the resident and removed his brief. The CNA used the warm water with disposable wash cloths and liquid soap to clean the tubing of the catheter from the urinary meatus outward. The CNA then used the same water and a clean disposable washcloth to provide perineal care. The CNA washed around the scrotum and the body of the penis up to the glans. The CNA then retracted the foreskin to wash the glans in a circular motion up to the meatus. The CNA took a disposable washcloth and wet it in the soapy water. The CNA squeezed the water over the penis. The CNA then used a dry towel to pat dry the resident's penis and scrotum. The CNA emptied the basin in the toilet, removed her gloves and put on new gloves. The CNA then refilled the basin with warm water, and washed the resident's buttocks from front to back. The CNA patted the resident dry and placed a new brief on the resident. The CNA did not place any device to secure the catheter tubing to the resident's body as documented in the catheter care policy. When asked about washing her hands between glove changes, Staff A admitted she did not wash her hands when she changed the water in the basin, and put on new gloves. 4. On 09/13/23 at 11:40 AM, after observing Resident #24 without an anchoring device for his catheter tubing, this surveyor used the facility matrix to determine all residents with an indwelling Page 1 of 4 106038 106038 09/14/2023 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter. These residents were observed for the presence of an anchoring device for their indwelling catheter tubing. There was a total of 3 residents out of 14, who had indwelling catheters, who did not have an anchoring device, Resident #24, #19, and #55. 5. On 09/13/23 at 11:59 AM, a meeting was conducted with the ADON and the Program Administrator of Clinical Services present. They were informed of the observations made of perineal care with an indwelling catheter. They agreed Staff A should have washed her hands between glove changes. They agreed Staff A should not have wrung out the washcloth above the groin because the water was dirty, and the technique did not ensure the groin had been rinsed clean properly. They agreed Staff A washed the perinium and Indwelling catheter in the incorrect order which could lead to a Catheter Acquired Urinary Tract Infection (CAUTI). The ADON and the Program Administrator of Clinical Services were also informed of the 3 residents who did not have an anchoring device for their indwelling catheter tubing. 106038 Page 2 of 4 106038 09/14/2023 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5 percent, as evidenced by three medication errors in 25 opportunities which resulted in a medication error rate of 12 percent, for 2 of 5 sampled residents (Resident #83 and #34). Residents Affected - Few The findings included: Review of the facility's policy titled Medication Administration, dated 12/31/21 revealed that The individual administering the medication must check the label to verify the . right dosage . of administration prior to giving the medication. 1) A medication administration observation was conducted on 09/13/23 at 8:46 AM with Staff B, Licensed Practical Nurse (LPN) for Resident #83. Staff B stated she had taken Resident #83's vital signs previously-Blood Pressure (BP) 142/79 and Heart Rate (HR) 76. Staff B then prepared the following medications: 1) Aspirin 81 milligram (mg) 1 tablet 2) Multivitamin with Minerals 1 tablet 3) Duloxetine 20mg 2 capsules 4) Lisinopril 5mg-Staff B discussed this medication and that based on the blood pressure parameters ordered by the physician, Resident #83 was due to receive the medication, however she failed to remove the medication from the medication cart. 5) Lithium Carbonate 300mg 1 tablet 6) Lorazepam 0.5 mg 1 tablet 7) Metformin 500mg 2 tablets 8) Simbrinza 1%-0.2% eye drops- 1 drop to each eye Staff B administered the above medications and then returned to her medication cart. The surveyor then asked Staff B to show her the package for the Lorazepam tablet that was given. Staff B retrieved the Lorazepam medication cards from the narcotic drawer and the surveyor confirmed that the medication cards contained 0.5mg tablets, but the zipper bag, medication order on the computer, and medication sticker in the narcotic book each documented 1mg tablets were ordered by the physician. Staff C, Nursing Program Specialist presented to the medication cart at this time to assist Staff B. The surveyor showed Staff C the observed error and she confirmed that this was not the correct dose of Lorazepam based on the physician order. Staff C then asked Staff D, Pharmacist to come to the medication cart for further advisement. Staff D also confirmed that these 0.5mg tablets were not the correct dose of Lorazepam based on the physician order. Staff D stated it was her covering pharmacist who dispensed this medication. At this time, the surveyor noted in the narcotic book that there had been 30 tablets dispensed on 09/07/23. It was noted during this observation, Staff B administered tablet #20 of the 30 that were dispensed. Staff D then told Staff B that she recommended giving a second 0.5mg Lorazepam tablet so Resident #83 received his full dosage and that she would contact the physician 106038 Page 3 of 4 106038 09/14/2023 Alexander "sandy" Nininger State Veterans Nursing 8401 W Cypress Dr Pembroke Pines, FL 33025

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to alert him of the error. Staff D further stated she would dispense new 1mg Lorazepam tablets. Staff D also stated she would put a one-time order into the computer for Lorazepam 0.5mg give 2 tablets so Staff B could properly sign off this administration. Following this interaction, the surveyor then alerted Staff B of the missed Lisinopril tablet during the medication administration. Staff B dispensed the missed Lisinopril and additional Lorazepam tablet and administered them to Resident #83 at 9:18 AM. 2) A medication administration observation was conducted on 09/13/23 at 9:22 AM with Staff E, Registered Nurse (RN) for Resident #34. Staff E stated she had taken Resident #34's vital signs previously-BP 133/78 and HR 72. Staff E then prepared the following medications: 1) Hydrochlorothiazide 12.5mg 1 cap given 2) Allopurinol 100mg 1 tab given 3) Aspirin 81mg 1 tab given 4) Citalopram 20mg 1 tab given 5) Methenamine Hippurate 1 gram 1 tab given 6) Amlodipine 2.5mg-Staff E discussed this medication and that there were no blood pressure parameters ordered by the physician, however she failed to remove the medication from the medication cart. Staff E administered the above medications and then returned to her medication cart. The surveyor then alerted Staff E to the missed Amlodipine tablet during the medication administration. Staff E dispensed the missed Amlodipine and administered it to Resident #34 at 9:32 AM. 106038 Page 4 of 4