Health inspection·September 15, 2022

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, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on three errors out of 31 opportunities for error, resulting in an error rate of 9.68%. This involved three (Residents #31 and #6 & #13) of five residents observed during medication administration, from a total sample of 18 residents. Residents Affected - Few The findings include: During a medication administration observation for Resident #31 on 09/14/22 at 9:37 a.m., Licensed Practical Nurse (LPN) A obtained Amlodipine 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the resident's blood pressure (BP) was less than 120/80. LPN A popped the medications into the medication cup, performed hand hygiene and went into Resident #31's room. Before administering the medication, the nurse was asked for the resident's blood pressure. she stated it was 125/62 millimeters of mercury (mmHg). She was asked to verify the resident's blood pressure again before administering the medication. She again stated, The blood pressure is 125/62 mmHg and proceeded to administer the medication. (Copy of the medication administration record (MAR) obtained) During another observation on 09/14/22 at 9:48 a.m., LPN A was observed preparing medication for Resident #6. She obtained Aspirin 81 mg, Ativan 1 mg, Buspirone 15 mg, Ferrous sulfate 325 mg, and lisinopril 40 mg. All of the medications were popped into a medication cup. LPN A also obtained four ounces of Ensure (nutritional supplement), then proceeded into Resident #6's room. After performing hand hygiene, LPN A assisted the resident in taking the medication by pouring all of the pills into the resident's mouth. She then gave the resident the Ensure. After Resident #6 was finished drinking the Ensure, LPN A performed hand hygiene before administering eye drops. While she was performing hand hygiene, Resident#6 was observed taking a pill out of her mouth and dropping it on the floor. LPN A was made aware of the resident's behavior, and she picked the pill up from the floor. She then asked Resident #6 if she had additional pills in her mouth, and the resident spit out two additional pills. LPN A stated the medications spit out were Buspirone, Aspirin and ferrous sulfate. (Photographic evidence obtained) LPN A discarded the medication and notified the Director of Nursing (DON). The DON arrived and could be heard explaining to LPN A her next steps to take. In an interview on 09/14/22 at 9:49 a.m., LPN A was asked to review the physician's orders, which revealed the orders for Amlodipine 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the if the resident's blood pressure (BP) was less then 120/80. When asked if the medication should have been administered, she stated she went by the top number (systolic 120) and not the bottom number (diastolic - 62). She stated she was not sure what the facility's policy said about that. When asked about Resident #6's behavior of pocketing her medication, LPN A confirmed that she should have checked the resident's mouth to ensure she had swallowed (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 4 Event ID: 106096 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 106096 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pavilion for Health Care, The 3465 Caroline Blvd Penney Farms, FL 32079 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)