Health inspection·February 2, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 4 of 5 medication carts and 1 of 2 medication rooms observed for medication storage. Photograph evidence obtained. Findings: On 1/30/2022 at 9:45 AM, an observation of the North Unit medication cart #1 with Staff C, Licensed Practical Nurse (LPN) revealed one bottle of eye drops labeled Latanoprost Solution 0.005% for Resident #89 with an opened date of 12/18/2021 and expired date of 1/29/2022 and one opened vial of insulin, Humulin R, with no residents name in the medication cart drawer. During an interview on 1/30/2022 at 9:45 AM with Staff C, LPN, she stated the eye drops showed an expired date and should have been discarded. The insulin vial of Humulin R should not be used for multiple residents and should have a label with residents name and order on the vial or it should not be in the medication cart drawer. On 1/30/2022 at 10:00 AM, an observation of the North Unit medication cart #2 revealed one opened vial of insulin, Humulin R, with no label with a residents name, one bottle of Fluticasone Propionate Suspension 50 MCG (micrograms) for Resident #36 with a label that read Fluticasone Propionate Suspension 50 MCG, one spray each nostril two times a day for nasal congestion with an opened date of 7/16/2021. Two Trulicity 0.75 milligrams (mg)/0.5 milliliters (ML) pens with a label that read Inject 0.75 mg subcutaneously one time a day every 7 days for Diabetes Mellitus before breakfast for Resident #77. One Trulicity injection pen read open date 7/2021. Dispose of after 14 days. The second Trulicity pen was in the medication cart drawer, for Resident #77, was observed unopened and the label read refrigerate until opened. During an interview on 1/30/2022 at 10:00 AM, Staff E, LPN stated, I cannot find the expiration date on Resident #36 Fluticasone Propionate nasal spray label but the open date reads 7/16/2021 and I know it expired way before 6 months. Staff E confirmed that Resident #77's Trulicity injection pen open date was 7/2021. The label read dispose of after 14 days and should not be left in the medication cart. The second Trulicity pen for Resident #77 was unopened and the label read to refrigerate until opened and should not be in the medication cart but in the refrigerator until it was ready for use for the resident. During an interview on 1/30/2022 at 10:15 AM, Staff B, Registered Nurse (RN) confirmed the eye Page 1 of 4 106084 106084 02/02/2022 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some drops were expired and should have been discarded. The insulin vial, Humulin R, should not be used for multiple residents and should be labeled with residents name and order on the vial or it should not be in the medication cart drawer. She stated, I cannot find the expiration date on Resident #36's Fluticasone Propionate nasal spray label but the open date reads 7/16/21 and I know it was opened 6 months ago. She confirmed that Resident #77's Trulicity injection pen read an open date 7/2021. Trulicity Label read dispose of after 14 days and should not be left in the medication cart. The second Trulicity pen for Resident #77 was unopened and the label read refrigerate until opened and should not be in the medication cart but in the refrigerator until it was ready for use for the resident. During an interview on 1/30/2022 at 11:30 AM the Director of Nursing (DON) confirmed she had been informed of all medication storage concerns. She stated, I expect all expired medications to be disposed of or returned to the pharmacy. I expect medications to be stored in their original packages according to the manufacturer's directions and labeled with the dates opened or expired. Record review of the facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles effective date 12/01/07, revised 10/31/16 reads Applicability: This policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. Procedure: 4. Facility should ensure that medications and biologicals that; (1) have an expired date on the label: (2) have been retained longer than recommended by manufacturer or supplier guidelines: or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. 2. On 1/30/2022 at 9:30 AM, an observation of the South Unit medication room revealed the refrigerator door was not locked. The lock was hanging open on the refrigerator door, the lock was not closed in a locked position and secured. During an interview on 1/30/2022 at 9:30 AM Staff A, LPN confirmed the lock was opened and not locked and the lock was hanging on the refrigerator. She stated that the refrigerator is supposed to be locked at all times. During an interview on 1/30/2022 at 9:30 AM Staff B, RN, Weekend Supervisor, stated that the refrigerator was to be locked at all times. All nurses are responsible to complete this task. During an interview on 1/30/2022 at 1:32 PM the DON stated that the medication refrigerator is to be locked at all times. On 1/30/22 at 9:45 AM an observation of the South Unit medication cart #1 revealed the following medications opened and not dated when opened: 1) Geni-Kot, 2) Iron tablets, 3) Senna Plus, and four (4) single individual plastic tubes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution not labeled for a specified resident. During an interview on 1/30/2022 at 9:45 AM, Staff A, LPN verified the medications were opened and not dated and stated that all medications are to be labeled with the open date when they are opened. Ipratropium Bromide and Albuterol Sulfate Inhalation Solution should be labeled with a resident 106084 Page 2 of 4 106084 02/02/2022 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0761 identifier. Level of Harm - Minimal harm or potential for actual harm On 1/30/2022 at 10:15 AM an observation of South Unit medication cart #2 revealed one bottle of opened insulin, Humulin 70/30, vial with an expired date of 1/19/2022 and labeled for Resident #92 and multiple medications opened with no open date placed on the bottle as follow: 1. Multivitamin, 2. Acidophilus with Pectin, 3. Loratadine 10 mg, 4. Melatonin 5 mg, 5. Omeprazole 20 mg, 6. Iron 325 mg, 7. Aspirin 81 mg, 8. Laxative Geni-Kot, and 9. Gamotidine 10 mg. Residents Affected - Some During an interview on 1/30/2022 at 10:15 AM, Staff D, LPN verified that Humulin Insulin 70/30 vial labeled for Resident #92 expired on 1/19/2022 and should have been wasted (discarded). She verified the following: 1. Multivitamin, 2. Acidophilus with Pectin, 3. Loratadine 10 mg, 4. Melatonin 5 mg, 5. Omeprazole 20 mg, 6. Iron 325 mg, 7. Aspirin 81 mg, 8. Laxative Geni-Kot, and 9. Gamotidine 10 mg. should have be dated when open and should be written on the bottle. During an interview on 1/30/2022 at 10:15 AM Staff B, RN, Weekend Supervisor, stated that all nurses are responsible for checking medication carts for expired medications and disposing of them. All medications are labeled with the open date when a nurse opens the vial. The Humulin 70/30 expired 1/19/2022 and should have been disposed of by expiration date. During an interview on 1/30/22 at 1:32 PM the DON stated that all medication carts are to be checked by the nurses daily and expired medication are to be thrown away. New medication when opened are to have the opened date written on the vial. 106084 Page 3 of 4 106084 02/02/2022 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, accordance with accepted professional standards and practices, for each resident that are complete and accurately documented for 1 (Resident #4) of 3 residents sampled for catheter care. Findings: Resident #4 was re-admitted to the facility on [DATE]. Review of the Minimum Data Set Quarterly Assessment for Resident #4 dated 1/20/2022, Section H0100 reads Appliances. Indwelling catheter. Review of the physician orders for Resident #4 contained no orders for a Foley catheter, for catheter care, or for changing of the catheter bag. Review of the Medication Administration Record and Treatment Administration Record for Resident #4 follow re-admission revealed no documentation related to care of the indwelling catheter. Review of the Resident Centered Comprehensive Care Plan for Resident #4 read Focus: Resident has a urinary elimination condition/concern or is at risk for complications related to Obstructive Uropathy. Goal: The resident will maintain optimal status and quality of life without complications. Interventions included empty catheter bag every shift and PRN (pro re nata-as needed) and change catheter 18 French/20 Cubic Centimeter indwelling catheter per MD (Medical Doctor)/urologist order. Review of the Point of Care Response History for Resident #4 for catheter care from 1/15/22 - 2/1/22 revealed catheter care was not documented on 1/17/22, 1/18/22, 1/20/22, 1/24/22, and 1/27/22. During an interview on 2/01/2022 at 2:00 PM the Director of Nursing confirmed Resident #4 currently had an indwelling catheter and his medical record did not contain orders for the indwelling catheter, catheter care, or changing of the catheter bag since Resident #4 returned from the hospital on 1/14/2022. She stated catheter care was being provided by the staff and that Resident #4 was sent to the emergency room today due to blood colored drainage which continued after flushing of the catheter by the Registered Nurse on duty. 106084 Page 4 of 4