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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 106093 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 106093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe at Lutz Rehabilitation Center (the) 19091 N Dale Mabry Hwy Lutz, FL 33548 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)