Health inspection·August 11, 2023

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy and procedure review, and interviews with facility staff, agency nursing staff, and the key management staff the facility failed to ensure the nursing staff received adequate orientation and training to ensure competency in completing the admission/readmission process in a timely manner for one resident (#1) out of three residents reviewed for re-admission. The facility failed to ensure nursing staff received adequate orientation and training to ensure competency in completing the medication reconciliation. The facility nursing staff failed to reconcile the medication by not entering the physician orders into the facility's system to ensure nursing staff administered medication according to the physician orders for three residents (#1, #11, and #19) out of three residents reviewed for re-admission to the facility. Resident #1 returned to the facility on 7/28/23 from the hospital. Upon return, the facility did not implement admission procedures. The resident was not entered into the facility census and the physician ordered medication was not entered in the computer. Resident #1 did not receive her medication from 7/28/23 at 2:07 p.m. until she transferred out and arrived at the Emergency Department (ED) on 7/30/23 at 11:55 a.m. Resident #11 was also re-admitted to the facility on [DATE] after being in the hospital for two days for a scheduled procedure. Upon return to the facility at 1:15 p.m. on 7/28/23, the resident did not receive her medication for the rest of the day. Resident #11 was not administered her physician ordered antidepressants, antianxiety medication, other the counter medication, or medication she takes to treat her Parkinson's disease until 7/30/23. Resident #19's August Medication Administration Record (MAR) showed the resident had missed multiple doses of seizure and pain medication on 7/29/23 and 7/30/23 when her orders were not entered correctly upon re-admission to the facility on 7/29/23. Resident #19's primary care physician said missing regularly scheduled medications put the resident at higher risk for increased seizures and lowered the threshold for breakthrough seizures. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1, #11, and #19 and resulted in the determination of Immediate Jeopardy on 07/28/23. The findings of Immediate Jeopardy were determined to be removed on 8/11/23 and the severity and scope was reduced to a D. Findings included: 1. An interview was conducted on 8/9/23 at 12:52 p.m. with the Director of Nursing (DON). The DON Page 1 of 10 106103 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated they had not done education on charting on a resident if the resident is not in the computer system or if the system is down. She said if she was a floor nurse, she would have probably questioned Resident #1 not being in the system or not having medications. The DON said at the time of the incident (7/28/23 to 7/30/23) paper charting options were not available to staff. Review of the Public Health Information Audit Log for Resident #1 showed Resident #1 was not re-entered into the facility census until 7/29/23 at 10:06 p.m. by Staff G, Licensed Practical Nurse (LPN) [agency staff]. From the time of re-admission on [DATE] at 2:07 p.m. until 7/29/23 at 10:06 p.m., Resident #1 did not show up in the facility computer charting system as being in the building. Review of the Medical Certification for Medicaid Long-term Care Services and Patient Transfer form hospital on 7/28/23 at 1:00 p.m. She had a diagnosis of urinary tract infection (UTI) and altered mental status (AMS) and was listed as being on Enhanced Contact Isolation Precautions. The Discharge Medications were listed as the following unchanged scheduled medications: -Apixaban 5 milligram (mg) tablet. Twice a day. Next dose was due on 7/28/23 at 9:00 p.m. -Aspirin 81 mg tablet. Once a day. Next dose was due on 7/29/23 at 9:00 a.m. -Bumetanide (Bumex) 2 mg. Once a day. Next dose was due on 7/29/23 at 9:00 a.m. -Carbidopa-levodopa (Sinemet 25 mg-100 mg oral tablet.) 1 tablet four times a day. Next dose due not listed. -Cranberry (Azo-Cranberry oral tablet.) 450 mg by mouth once a day. Next dose was due on 7/29/23 at 9:00 a.m. - Divalproex Sodium (Depakote) 500 mg delayed release tablet. 1 tablet twice a day. Next dose due not listed. -Docusate (Colace 100 mg oral capsule) 1 capsule every 12 hours. Next does due on 7/28/23 at 9:00 p.m. -Escitalopram (Lexapro 20 mg oral tablet.) 1 tablet once a day. Next dose due on 7/29/23 at 9:00 a.m. -Levothyroxine 125 microgram (mcg) oral tablet. 1 tablet once a day. Next dose due on 7/29/23 at 9:00 a.m. -Magnesium hydroxide (Milk of Magnesia 8% oral suspension.) 30 milliliters (ml) once a day as needed for constipation. Next dose due on 7/28/23 at 9:00 p.m. -Multivitamin with minerals. 1 tablet once a day. Next dose due on 7/29/23 at 9:00 a.m. 106103 Page 2 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 -Omeprazole 20 mg delayed release capsule. 1 capsule once a day. Next dose due on 7/29/23 9:00 a.m. Level of Harm - Immediate jeopardy to resident health or safety -Potassium chloride 10 milliequivalents (mEq) extended-release oral tablet. 1 tablet three times a day. Next Residents Affected - Few -Risperidone (Risperdal 0.5 mg oral tablet.) 1 tablet once a day. Next dose due on 7/28/23 at 9:00 p.m. dose due at 7/28/23 9:00 p.m. Review of admission Record showed Resident #1 was originally admitted to the facility on [DATE] and had a re-admission date of 7/28/23 with diagnoses to include anxiety disorder, bipolar disorder, Parkinson's disease, chest pain, schizophrenia, venous insufficiency, acute embolism and thrombosis of deep veins of left lower extremities, and depression. Review of progress notes showed Resident #1 was sent to the hospital for evaluation for increased confusion on 7/25/23. The Emergency Medical Services (EMS) Patient Care Report showed the resident returned to the facility on 7/28/23 at 2:07 p.m. with Staff L, Licensed Practical Nurse (LPN) [agency staff] signing as accepting the resident at 2:16 p.m. Review of the July 2023 MAR showed Resident #1 did not receive any of the ordered medications from the time of her re-admission on [DATE] at 2:07 p.m. until 7/30/23 when the resident was sent to the Emergency Department for acute care at 10:30 a.m. The first documentation following Resident #1's re-admission to the facility was a progress note on 7/30/23 at 2:43 p.m. The progress note written by Staff F, Registered Nurse (RN) showed the following: Seizure activity noted for 15 minutes. Resident sent to ER [Emergency room] to be evaluated and Tx [treated.] Per MD's [medical doctor] orders. POA [Power of attorney] and MD notified. An interview was conducted on 8/8/23 at 11:48 a.m. with the Director of Nursing (DON). The DON said Staff H, Licensed Practical Nurse/Unit Manager (LPN/UM) was assigned to Resident #1 when the resident came back to the facility on 7/28/23, but Staff H, LPN/UM was doing treatments on other residents and didn't do any assessments. The DON said Staff H, LPN/UM gave report to Staff J, LPN telling her she needed to do the admission. The DON said Staff J, LPN said she told Staff H, LPN/UM she didn't know how to use the facility's charting system and would need assistance. The DON said, Long story short, the admission wasn't completed as far as medications being entered into the computer. The DON said she thinks Staff H, LPN/UM had A really busy day. She had a fall that day and I forgot what the other things that were happening. I think it was a COVID testing day; maybe just super busy and she was doing treatments. The DON said Staff H, LPN/UM never actually made it into Resident #1's room. She said the next day, 7/29/23, Resident #1's medications were still not entered into the computer and the resident wasn't even entered into the facility census until Saturday night, 7/29/23, at 10:22 p.m. During a follow-up interview with the DON on 8/8/23 at 2:12 p.m., she stated she would consider it unusual for staff to provide care and not document. An interview was conducted on 8/9/23 at 11:17 a.m. with the DON. The DON was asked how agency nurses were educated on doing a resident admission prior to this incident, she said, It is nursing 101. All nurses know how to do an assessment. When asked if there had been information or training about doing an admission prior to this incident she said, No, not that I know of, no. 106103 Page 3 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An interview was conducted on 8/8/23 at 3:05 p.m. with Staff H, LPN/Unit Manager (UM.) Staff H, LPN/UM confirmed she was working on 7/28/23 as the Unit Manager and was assigned to a medication cart including the room Resident #1 was re-admitted too. Staff H, LPN/UM said typically if a resident comes in the facility after 2:30 p.m. the nurse coming on for the 3:00 p.m. to 11:00 p.m. shift would do their admission. She said when Resident #1 came into the facility, she was in another resident's room doing treatments. She said when she came back to the nurses' station around 2:35 p.m. the other nurse on duty (Staff L, LPN/agency staff) informed her Resident #1 had returned. Staff H, LPN/UM said she saw the resident was in her room with her private sitter and the resident looked comfortable and fine. She said she continued with a few more treatments she had to complete for other residents. Staff H, LPN/UM said the evening nurse (Staff J, LPN/agency staff) came on for her 3:00 p.m. to 11:00 p.m. shift and she gave her report and let her know Resident #1 had returned and her admission needed to be done. She said that nurse should have been the one to do the assessment and put physician orders in the computer. Staff H, LPN/UM said she was basing which nurse was responsible for the admission on the time she was told the resident had arrived which was close to 2:40 p.m. She said the nurse that took over from her was an agency nurse (Staff J, LPN) who had been to the facility a few times in the previous month or so. Staff H, LPN/UM said she previously showed Staff J, LPN how to enter orders and do a medication pass in the facility's electronic charting system. Staff H, LPN/UM said on 7/28/23 Staff J, LPN didn't ask her for any help or instructions. She said she told Staff J, LPN that she had to finish some treatments then she would be in her office doing her charting if she needed anything. Staff H, LPN/UM said she was in her office until 8:30 p.m. and if Staff J, LPN would have asked her for help she would have assisted. Staff H, LPN/UM said she had been very busy during her shift. They had a call out (staff member not able to work their shift) and she had to work a floor assignment. She said she had a resident fall and multiple residents test positive for COVID and she was getting orders for all of those residents. Staff H, LPN/UM said she asked the Director of Nursing (DON) and the first floor UM (Staff P, LPN/UM) for help. She said that morning the DON had come up and asked her if she needed help passing medication and I told her that I didn't need help with medications. She said she was also informed she was getting three admissions that day. Staff H, LPN/UM said the first floor UM said that she would help her with orders if Staff H, LPN/UM got three admissions. Staff H, LPN/UM said when the first admission arrived, she messaged the first floor UM and got no response. Staff H, LPN/UM said the DON texted her after 4:00 p.m. Staff H, LPN/UM read a text message from the DON that stated, I am sorry you are having a bad day. I don't know what you expect . If you needed help [Staff P, LPN/UM] or myself would have gladly helped. I thought you would be off the cart by 3:00 . I am sorry if this makes you mad. Staff H, LPN/UM said she told the DON she didn't need help with medications, but the DON and Staff P, LPN/UM knew what all was going on her unit. She said they were both texting her saying she had medications in the red (meaning they are late) and admission audits needed to completed from previous days. Staff H, LPN/UM said she shouldn't have to call and say, Can someone help again. We are supposed to be a team. She said she told the DON she wasn't still on the medication cart at 3:00 p.m. but had several dressing changes to do, still had to enter orders for the COVID positive residents, do the incident report for the fall, and there were two residents sending themselves to the hospital. She let her know the other 7:00 a.m.-3:00 p.m. nurse was an agency nurse and asking for her help and her relieving nurse was agency and she was a little late and not that familiar with the facility's charting system and she wasn't sure what was going to get done with the admission. Staff H, LPN/UM said she told the DON she had to work on these several things and then she had to go because she had been there since 6:45 p.m. Staff H, LPN/UM 106103 Page 4 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few said she texted the DON, I don't know how I'm being angry if I'm simply saying I have a lot on my plate to complete and can't take on something else right now. That's also a sign to help a friend or a teammate is it not? I put a question mark I said this could go on and on, but I don't want to keep going on about it because I need to get my stuff done to get out of here, so she (DON) responded OK. Staff H, LPN/UM said she knew the agency nurse relieving her wasn't fully aware of the admission process and all the assessments they do to complete a full admission. She said she let the agency nurse know she would be in her office finishing her work if she needed help. Staff H, LPN/UM said she was at work until 8:30 p.m. and she was never asked for help. She said she even called the weekend supervisor (Staff D, LPN) on Saturday morning at 8:15 a.m. She said she asked Staff D, LPN to check and make sure the assessments were completed and look at the admission to make sure it was completed due to the 3:00 p.m. -11:00 p.m. nurse being agency. She said Staff D, LPN told her she would look at it. Staff H, LPN/UM said she would have expected the agency nurse that got report from her to put the orders in and she thought Staff D, LPN would review it. Staff H, LPN/UM said she had worked at the facility about four weeks and had not really gotten an orientation and had no training on the admission process. An interview was conducted on 8/9/23 at 2:30 p.m. with Staff J, LPN/agency staff. Staff J, LPN said 7/28/23 from 3:00 p.m. to 11:00 p.m. was her first time caring for Resident #1. Staff J, LPN said she knew there were orders for the resident, but she was never trained on admissions in the electronic medical record system the facility uses. She stated Staff H, LPN/UM told her she was going to complete the orders later that night. Staff J, LPN said she did take care of the resident and made sure she was repositioned, had dinner, and asked if she was in pain. She said she was seen and taken care of, but she did not give her any medications. Staff J, LPN said she did not inform anyone about the problem because Staff H, LPN/UM, that took care of the resident the previous shift, said she was going to take care of it and there was no one else in the building. She also said she did not do an admission assessment as the resident had arrived on the previous shift. Staff J, LPN said she put in a late entry progress note when she came to the facility on 8/1/23. An interview was conducted on 8/9/23 at 12:43 p.m. with Staff K, Certified Nursing Assistant (CNA)[agency staff]. Staff K, CNA confirmed he cared for Resident #1 on 7/28/23 3:00 p.m. to 11:00 p.m. He said the resident was in the bed when his shift started, she was responsive, good-natured, and communicated. He said he provided incontinence care, and she did get a food tray. He said he is an agency CNA and did not have a password to get into the computer system until later in the day. He said he documented on paper but didn't know where that went. He said it was just a piece of paper he was writing on. He said he did not notify anyone he couldn't document on Resident #1. He said a staff CNA gave him a report on Resident #1, but he could not read it. An interview was conducted on 8/10/23 at 10:50 a.m. with Staff G, LPN (agency staff). Staff G, LPN confirmed she cared for Resident #1 on 7/29/23 from 7:00 a.m. to 11:00 p.m. She said she is an agency nurse, and that was her first time at this facility. She said Resident #1 had just been re-admitted to the facility. Staff G, LPN said Resident #1 was not in the electronic medical record system. She said she notified Staff D, LPN, the Weekend Supervisor, who let her know she would get to putting the resident and orders in. Staff G, LPN said she was a late call in, and she got to the unit around 8:00 a.m. She said she notified Staff D, LPN that Resident #1 was not in the system for the first time around 8:30 a.m. She said she checked with Staff D, LPN about four times throughout the day asking if the resident's admission was completed yet. She said each time she was told by Staff D, LPN, she was working on. Staff G, LPN said she typically doesn't do admissions and she had not be trained to do them. She said she did find it odd doing the admission would take so long. She also said she did not administer any medication because she 106103 Page 5 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few didn't know what medications Resident #1 was on and the resident didn't request any medications. Staff G, LPN said she did assess the resident and do vitals. She also said the CNA cared for the resident. She said she wrote the notes in her notebook but was not able to chart on the resident since she was not in the system. She said she did not have any paper charting options. Staff G, LPN said the DON called her a couple of days later and asked her to write a statement and write her resident assessment on paper. She said finally around 10:00 p.m. when she went to the Weekend Supervisor (Staff D, LPN) for the last time, Staff D, LPN told her how to enter the resident into the census on the electronic medical record and she did so at that time. An interview was conducted on 8/9/23 at 11:50 a.m. with Staff F, Registered Nurse (RN). Staff F, RN confirmed he cared for Resident #1 on Sunday 7/30/23 and he had also taken care of her previously. He said he got report on his residents and proceeded to start his medication pass and assessments. He said when he got to Resident #1, maybe around 9:00 or 9:15 a.m., he saw her MAR for 7/30/23 was empty and he went to the room to confirm she was really there. He said when he reached her, he knew something was different. He said Resident #1 was slightly unresponsive and couldn't talk. He said the resident's eyes were sort of shaking, closing and opening, closing and opening. Staff F, RN said this was not how the resident was before. He said after about 5 minutes the resident revived and could communicate. He said she was not responding the way she should and when he saw there was no medication, he knew she needed to be assessed in case this was due to missing her medication. Staff F, RN said he called 911 and notified the doctor that Resident #1 was being sent out for seizure activity and there had been no medication orders in the system. An interview was conducted on 8/9/23 at 10:16 a.m. with the DON. She said she would have expected Staff D, LPN, the weekend supervisor, to review the census and make sure the admission was accurate. She said, It is part of her job responsibilities. She said she would have expected her to fix the issues, especially since Staff H, LPN/UM called her to check on it. The DON said Staff D, LPN should be reconciling the census on the weekends. The DON confirmed no documentation was entered for Resident #1 from the time of her readmission on [DATE] until she was being sent to the Emergency Department on 7/30/23. She said the notes in the computer now were late entry notes and the paper documentation was done a few days later when staff came in to give their statements. An interview was conducted on 8/9/23 at 10:40 a.m. with the Assistant Director of Nursing (ADON.) He stated he was called Sunday and the nurse (Staff F, RN) told him nothing was being done on Resident #1 and there were no orders in the system. Staff F, RN told the ADON the resident was being sent to the hospital. The ADON asked him, What do you mean there are no orders, if the resident was in the building they should have been admitted . He said he logged into the system from home and saw there were no progress notes or orders for Resident #1. He said he called Staff D, LPN, the weekend supervisor, and asked if he was seeing it correctly or was his system messed up. He asked her, didn't you review the chart, that is what the weekend manager is supposed to do. The ADON said Staff D, LPN said the resident was in the facility since Friday and the admission should have already been done. The ADON said he called Staff H, LPN/UM and she read him text messages between her and the DON. He said on the texts, Staff H, LPN/UM had asked for help and the DON told her she was sure the first floor UM (Staff P, LPN/UM) was going to help. The ADON said Friday evening (7/28/23) he left the building between 8:00-9:00 p.m., at the same time as Staff H, LPN/UM. He said on Friday (7/28/23) he was in the building, but no one asked him for help. He said he spoke with the agency nurse (Staff J, LPN) before he left that evening. He said she was working on her medication cart at the time, and they talked for about 30 minutes. He said the nurse never told him she didn't know how to use their charting system, she never asked for help, or mentioned the admission not being done. The ADON said the DON, Staff 106103 Page 6 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few H, LPN/UM and the first floor UM (Staff P, LPN/UM) all knew multiple admissions were coming in. He said no one told him the residents were in the building. He said Staff H, LPN/UM was having to work a cart and could not do the management part. The ADON said there seemed to be a breakdown in communication regarding when the resident arrived and what time the nurse found out the resident was in the facility. He said the weekend supervisor (Staff D, LPN) also did not follow up and ensure the admission was done. He said each agency nurse (Staff J, LPN, Staff O, LPN, and Staff G, LPN) didn't question and follow through with why the resident wasn't in the computer, adding to the problem. He said he did find it odd the UM was having to work the floor. He said he has only seen that one time and that time an agency nurse was called in to take the assignment so the UM could do the managerial duties. He said no one has given him an answer as to why no one was called in on Friday, 7/28/23. The ADON said he had not been trained by the facility on doing an admission. He said being a nurse for so long, he could figure it out if he needed to. He said he has seen an admission check list when they review admissions in the morning meetings. He said he used to work the cart at least once a week but has not done an admission. He said he has asked for training on it and will have to see when that happens. The ADON said the facility has an orientation binder for agency nurses to go through before they work in the facility. He retrieved the binder and confirmed there was no information in the binder on completing a resident admission or re-admission. Multiple attempts were made from 8/8/23 to 8/9/23 to contact Staff D, LPN/Weekend Supervisor via the phone number provided and no contact was made. Attempts were made by the facility staff and the ADON confirmed Staff D would not respond to their attempts as well. An interview was conducted on 8/9/23 at 2:43 p.m. with Resident #1's primary care physician. He stated he does not recall being notified the resident had returned to the facility on Friday, 7/28/23. He also said he was not notified Resident #1 had missed any medications until Monday, 7/31/23. He said the expectation is medication orders should be followed when a resident is admitted . An interview was conducted on 8/10/23 at 12:14 p.m. with the DON. The DON said she felt Resident #1 was taken care of but what happened was wrong, absolutely. She added that is was wrong nursing practice. She said they treated the incident as a medication error. A facility provided document titled Incident Timeline, undated, showed the facility completed audits of the three other re-admission on the weekend of 7/28/23 to 7/30/23; this would include Resident #19 and #11. The facility showed no other admissions were missing medication order and there were no errors noted. 2. Review of admission Record showed Resident #19 was admitted on [DATE] with a readmission date of 7/29/23, diagnoses included epilepsy, anoxic brain damage, acute respiratory disease, history of sudden cardiac arrest, acute embolism and thrombosis or left axillary vein, and conversion disorder with seizures or convulsions. Review of progress notes for Resident #19, dated 7/29/23 at 6:05 p.m., showed the following: Resident arrived to facility via Stretcher, unaccompanied by family. No personal belongings brought with resident. Dischage [sic] medication list given to writer by EMT [Emergency Medical Technician.] Allergies noted to be Penicillin, ASA [aspirin,] Depakote, and CABamazepine [sic.] Resident unable to verbally confirm Allergy. REsidnet [sic] is alert, and can intermittently follow simple commands. RE-oriented to room, call light, bed controls, lights and rooms=ates [sic.] Unable to verbalize understanding. Resident is currently resting in bed. so [sic] S&S [signs and symptoms] of distress or 106103 Page 7 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 pain noted. Level of Harm - Immediate jeopardy to resident health or safety The admission Pain Assessment for Resident #19 was reviewed. It showed it was completed on 7/29/23 at 9:24 p.m. by Staff D, LPN, the weekend supervisor. The Pain Assessment noted the resident had Vocal complaints of pain and Facial expression (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). Residents Affected - Few The admission Assessment showed it was completed by Staff G, LPN on 7/29/23 at 10:06 p.m. and noted no seizure activity and the Wong-Baker FACES pain level showed, A little more pain. The Wong-Baker FACES pain scale is a pain scale that uses facial expressions to rate pain for those that have difficulty communicating. Review of the Hospital Discharge Medications showed medications to continue including the following: Baclofen 20 mg every 6 hours Clonazepam (Klonopin) 2 mg 3 times a day Lacosamide (Vimpat) 300 mg 2 times a day Lamotrigine (Lamictal) 200 mg 2 times a day Levetiracetam (Keppra) 15 ml every 12 hours Oxycodone/APAP (Percocet 5-325) 1 tab every 8 hours. Review of Resident 19's July 2023 MAR showed her medication orders were discharged on 7/29/23 and put in to restart on 7/30/23. The medications were not set to begin upon her return to the facility on 7/29/23 at 6:05 p.m. The July 2023 MAR showed the resident was taking Clonazepam (Klonopin) 2 mg 3 times a day for epilepsy. The resident missed one dose of Klonopin on Saturday, 7/29/23, at 10:00 p.m. She received four doses of Klonopin on Sunday, 7/30/23, instead of the ordered three doses. The July 2023 MAR showed the resident was taking Lacosamide (Vimpat) 300 mg 2 times a day for epilepsy. The resident missed three doses, one on 9:00 p.m. on Saturday, 7/29/23, and two on Sunday, 106103 Page 8 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 7/30/23, at 9:00 a.m. and 9:00 p.m. Level of Harm - Immediate jeopardy to resident health or safety The July 2023 MAR showed the resident was taking Lamotrigine (Lamictal) 200 mg 2 times a day for epilepsy. The resident missed one dose of Lamictal on Saturday, 7/29/23, at 9:00 p.m. Residents Affected - Few The July 2023 MAR showed the resident was taking Levetiracetam (Keppra) 15 ml every 12 hours for epilepsy. The resident missed one dose of Keppra on Saturday, 7/29/23, at 9:00 p.m. The July 2023 MAR showed the resident was taking Oxycodone/APAP (Percocet 5-325) 1 tab every 8 hours for pain. The resident missed one dose of Percocet on Saturday, 7/29/23, at 10:00 p.m.and three doses on Sunday, 7/30/23, at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Review of the July and August 2023 MAR showed regular pain monitoring was not in place from 7/30/23 through 8/7/23. Review of Resident #19's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 8/7/23 at 10:10 a.m., showed the resident was found by staff with her g-tube (gastrostomy tube) on the bed next to her, fully intact. The resident was transported to the hospital. Review of Resident #19's August 2023 MAR showed the resident did not miss her seizure medication on 8/7/23 due to her PEG tube being dislodged. The resident missed her seizure medication 8 and 9 days prior when her orders were not entered correctly. The seizure medication included: Clonazepam (Klonopin) 2 mg 3 times a day Lacosamide (Vimpat) 300 mg 2 times a day Lamotrigine (Lamictal) 200 mg 2 times a day Levetiracetam (Keppra) 15 ml every 12 hours An interview was conducted on 8/11/23 at 11:28 a.m. with Resident #19's primary care physician. He stated the provider should be called when a resident returns to the facility to activate medications and nurses should administer the medications accordingly. The physician said he was not notified Resident #19 missed her anti-seizure and pain medications. He said on the weekends, the provider will make a 3-day emergency dispersal if needed. The physician said his office has doctors available 24 hours a day 7 days a week. He said, There is no reason for missed doses. He said for Resident #19 the specific effects of missing 3 or 4 doses of medication are unknown, but missing regularly scheduled medications puts the resident at higher risk for increased seizures and lowers the threshold for breakthrough seizures. An interview was conducted on 8/10/23 at 5:17 p.m. with the DON and the Regional Clinical Reimbursement Nurse (RCRN). The DON said she didn't know why Resident #19 did not get her medications. She 106103 Page 9 of 10 106103 08/11/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few said normally when a resident transfers out of the facility, all of the medications go back to the pharmacy. She said, They may not have had a script [prescriptions]. I don't know if we had the medication in the EDK [Emergency Drug Kit.] I will have to check. The facility's emergency medication stock is in the electronic dispensing machine. During a follow-up interview on 8/11/23 at 10:55 a.m., the DON said if the medications are unavailable, the pharmacy should be called. 3. Review of admission Record showed Resident #11 was admitted to the facility on [DATE] and a re-admission date of 7/29/23 with diagnoses including Alzheimer's disease, adult failure to thrive, Parkinson's disease, depression, unspecified convulsions, anxiety, chronic pain, and schizoaffective disorder. Resident #11 was re-admitted at 1:15 p.m. on 7/29/23 following a planned procedure on 7/27/23 performed at an acute care facility. An email sent to the management staff from the facility's admission Director on 7/29/23 at 10:21 a.m. showed Resident #11 was arriving after lunch. Review of the Observation Detail Report for Resident #11, dated 7/29/23 at 6:31 p.m., showed the resident arrived by ambulance with a family member. The report identified the resident had disorganized thinking, impaired memory, and had a gastric/enteral tube. Review of a progress note for 7/29/23 (at 6:22 p.m.) showed Resident #11 returned from an acute care facility as a readmission, vitals were within normal limits (wnl), skin was intact, had a new gtube and showed the resident was to receive bolus nutrition 6 times a day which had been tolerated. The one progress note for 7/29/23 did not show the physician was notified of the resident's return or that medications had been reconciled with the physician. The Medical Certificati[TRUNCATED] 106103 Page 10 of 10