Health inspection·October 30, 2020

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed administered and two errors were identified for one (Resident #356) of four residents observed. These errors constituted a medication error rate of 7.41 percent. Residents Affected - Few Findings included: An observation of medication administration on 10/29/2020 at 9:15 a.m., resulted in Staff D (LPN), not giving Resident #356 two (2) medications of Fluticasone Suspension 50 MCG/ACT and Ivabradine HCL Tablet Give 5 mg. During the observation Staff D (LPN) indicated she was running late on medication administration, and did not say or provide further information when asked, as to why her medications were late. On 10/29/2020 at 11:21 a.m., a record review was conducted of Resident #356's medications that were administered at 09:00 a.m. During the record review it was observed that Staff D (LPN) did not give Resident #356 his physician ordered medications of Fluticasone Suspension 50 MCG/ACT and Ivabradine HCL Tablet Give 5 mg. (Photographic Evidence Obtained.) An immediate interview was conducted with Staff E, Unit Manager (UM), who was informed of the observations and asked if Staff D (LPN) had reported to her that the medications were late. Staff E (UM) revealed that she had not told her about the medications not being given to Resident #356. The Regional Corporate Nurse revealed that both medications were given at 11:40 a.m., by Staff D (LPN). She further indicated that both medications were located, the Fluticasone Suspension 50 MCG/ACT was in another medication cart. The medication Ivabradine HCL Tablet Give 5 mg was found in Staff D's (LPN) medication cart, under the brand name of Corlander, that Staff D (LPN) did not recognize, so she did not give it to Resident #356 during the morning medication administration at 09:00 a.m. Record review of active physician orders for the Resident #356 included Fluticasone Propionate Suspension 50 MCG/ACT 2 sprays in each nostril, one time a day, to be given at 9:00 a.m. for Allergy Symptoms/Nasal Congestion, and Ivabradine HCL Tablet Give 5mg by mouth every morning to be given at 09:00 a.m. and at 9:00 p.m. for diagnosis of Congestive Heart Failure (CHF.) A further record review for Resident #356 indicated he was admitted on [DATE] with multiple diagnoses that included Pneumonia, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Hypertensive Chronic Kidney Disease and Left Non-Dominant side, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. Review care plan dated revised on 10/28/2020 denotes under Focus area reads At risk for cardiac complications related t diagnosis of Page 1 of 3 106093 106093 10/30/2020 Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hypertension, A-Flutter and history of Cerebrovascular Accident (CVA), and under Interventions reads to administer cardiac medications as ordered. An interview was conducted with the Director of Nursing (DON) on 10/29/2020 at 11:50 a.m. The DON was notified of the medication administration observations made of Staff D (LPN) for Resident #356. The DON stated, For Medications that are late, the staff has to make the MD aware of it, and find out potential outcomes, getting physician orders if there are any. At 2:46 p.m. an interview, was conducted with the Pharmacy Consultant. The Pharmacy Consultant informed the surveyor that the facility notified him of Staff D (LPN) not administering both medications in a timely manner to Resident #356. He indicated that it was unfortunate the nurse did not recognize the name of the one medication, and stated I will have to get our clinical nurse to educate the nurses in the facility and make sure the nurses are taking responsibility for the medications. A facility provided policy titled, Miscellaneous Special Situations, IF11 Unavailable Medications, revision date April 2018, Page 80, 88 and 90 reads under Policy and Procedure, The facility must make every effort to ensure that medications are available to meet the needs of each resident. B. Nursing Staff shall: Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. Administration-12. Medications are administered within 60 minutes of scheduled time. 106093 Page 2 of 3 106093 10/30/2020 Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews and record review, the facility did not ensure the kitchen and cooking equipment were maintained in a clean and sanitary manner related to the dishwashing machine not reaching the required hot water temperature which had the potential to negatively impact 75 of the 77 residents in the facility. Findings included: On 10/27/20 at 9:45 AM, a tour of the kitchen was conducted with the Dining Manager and the Registered Dietician (RD). On 10/27/20 at 10:00 AM, Staff B, Dishwasher, was observed running the last load of breakfast dishes on the dishwashing machine. Staff B was requested to run the cycle again. The temperature gauge was noted rising to 122 degrees. The Dining Manager confirmed that the temperature of 122 degrees on a wash cycle was below the minimum requirement of 155 degrees. (photographic evidence obtained). During the observation, the Dining Manager intervened and stated the washer was working okay this morning. The temperature log was reviewed. A reading of 157 degrees for the wash and 185 for the rinse were documented for the date 10/27/20 on the breakfast wash column. The Dining Manager proceeded to run the machine a second time and the temperature gauge stopped at 122 degrees for the wash cycle and 160 for the rinse cycle. The Dining Manager reported that he would call and get it fixed right away. He stated, We will use disposables for serving meals until the dishwasher is fixed. At 10/27/20 at 10:10 AM, an observation was made of a posting on the wall by the dishwasher reading; the wash temperatures should be at a minimum of 155 degrees, and the rinse temperatures should be at a minimum of 180 degrees. An interview was conducted with the RD on 10/27/20 at 10:15 AM. She acknowledged the dishwasher temperature concern and stated that the vendor would be out by the end of the day. On 10/29/20 at 9:00 AM, an interview was conducted with the Nursing Home Administrator (NHA) who brought the invoice to show the dishwasher had been repaired. She reported that they found the root cause of the temperature issue and that it was addressed. 106093 Page 3 of 3