Health inspection·March 5, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided for oxygen administration for 1 of 3 Residents, Resident #5, reviewed for respiratory services. Residents Affected - Few Findings include: Record review of Resident #5's clinical record documented the resident was admitted with diagnosis that included: anemia, atherosclerosis heart disease, pulmonary hypertension, and chronic obstructive pulmonary disease. Review of Resident #5's physician orders dated 3/3/2025 read, Oxygen at 4LPM [liters per minute] via NC [nasal cannula] every shift. Review of Resident #5's care plan dated 2/6/2025 read, Focus: The resident has oxygen therapy r/t [related to] COPD [chronic obstructive pulmonary disease]. Interventions/Tasks: Give medications as ordered by physician. During an observation on 3/3/2025 at 10:08 AM of Resident #5, the resident was sitting at bedside. Oxygen was being administered at 3 liters per minute via nasal cannula. (Photograph evidence obtained). During an interview on 3/3/2025 at 1:16 PM Resident #5 stated, I do not change the settings [oxygen]., Normally I am on 4 liters when I am up walking around and 3 liters when I'm resting. During an observation on 3/3/2025 at 1:16 PM with Staff A, Registered Nurse (RN) Resident #5 was observed sitting at bedside with oxygen administered at 3 liters per minute via nasal cannula. During an interview on 3/3/2025 at 1:16 PM Staff A, RN verified the physician orders were for oxygen to be administered at 4 liters per minute via nasal cannula. During an interview on 3/3/2025 at 1:30 PM the Director of Nursing (DON) stated, The physician orders have to be followed, and the rate should be 4 liters a minute. Review of the policy and procedure titled Oxygen Therapy dated 1/22/2025 read, Policy: III. A. 1. Specific delivery device, liter flow or concentration .Procedure: IV. A. Set up oxygen utilizing appropriate delivery device according to physician's order, or according to protocol. Page 1 of 3 106105 106105 03/05/2025 Skytop View Rehabilitation Center 2145 North Don Wickham Drive Clermont, FL 34711

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review and interview, the facility failed to ensure a rationale was in the medical record for psychotropic PRN (pro re nata/as needed) medications being prescribed for greater than 14 days for 1 of 5 residents, Resident #84, reviewed for unnecessary medications. Findings include: Review of the pharmacist's consultation report, dated 2/17/2025, read [Resident #84's Name] has a PRN order for a sedative/hypnotic, without a stop date: Zolpidem 10mg [milligrams] q [every] HS [hour of sleep] PRN for insomnia. Recommendation: Please discontinue PRN Zolpidem, or a stop date that is less than 14 days from initiation. If the medication cannot be discontinued at this time, document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Review of Resident #84's physician's orders dated 2/17/25 read Zolpidem Tartrate Oral Tablet 10MG [milligrams] (Zolpidem Tartrate) *Controlled Drug* Give 1 tablet by mouth every 24 hours as needed for Difficulty Sleeping for 30 days. The physician's order did not contain documented rationale for prescribing the medication for more than 14 days. Review of a physician's visit encounter note, dated 2/17/2025, read Zolpidem Tartrate 10mg 1 tab [tablet] q24 [every 24] hours PRN x 30 days (end 3/19/25). During an interview on 3/4/2025 beginning at 12:04 PM, the Director of Nursing stated she was unable to answer whether or not the physician had documented in Resident #84's clinical record the rationale for prescribing hypnotic medication for more than 14 days. Review of the policy titled Drug Regimen Review, last reviewed 1/22/2025, read, I. PURPOSE: This department process explains how this facility follows State and Federal Regulations, by having the Consultant Pharmacist review each resident's clinical chart monthly. Apparent irregularities will be reported in writing to the Director of Nursing, Medical Director, Attending Physician, Provider and Administrator. The facility will review and follow through on the Consultant Pharmacist's recommendations to ensure all residents maintain the highest practicable level of functioning .D. Follow up on Consultant Pharmacist Recommendations: .b. Clinical justification will be documented in the chart if a recommendation is declined by the physician/provider. 106105 Page 2 of 3 106105 03/05/2025 Skytop View Rehabilitation Center 2145 North Don Wickham Drive Clermont, FL 34711

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 secure medications for 1 of 3 wings, the south. Findings included: During an observation on 3/3/2025 at 10:08 AM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. (Photograph evidence obtained). During an observation on 3/3/2025 at 12:18 PM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. During an interview on 3/3/2025 at 12:22 PM Resident #5 stated, My wife brought them to me and I use them as needed at least daily. During an interview on 3/3/2025 at 12:30 PM Staff A, Registered Nurse (RN) verified the Saline Nasal Mist and bottle of normal saline eye solution medications unsecured at Resident #5's bedside. Staff A, RN stated, Medication cannot be kept at the bedside, all medications have to be secured. During an interview on 3/3/2025 at 1:16 PM the Director of Nursing stated, Medications cannot be at the bedside unsecured. Review of the policy and procedure titled Medication Storage dated 1/22/2025 read, This department process explains how medications and biologicals are stored safely, securely, and properly . B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended to by persons with authorized access. 106105 Page 3 of 3