Inspection·December 8, 2020

F 0755 was transcribed to the Medication Administration Record (MAR) as written by the physician. Level of Harm - Minimal harm or potential for actual harm The Order Audit Report revealed the order for Isosorbide Mononitrate 60 mg was created in the electronic medical record (EMR) on 11/06/20 at 4:59 PM. The order supply summary indicated the facility's pharmacy supplied Isosorbide Mononitrate ER 60 mg tablet extended release 24 [hour] instead, to be administered via G-tube. Residents Affected - Some Isosorbide Mononitrate is a medication that widens blood vessels and prevents chest pain by making it easier for blood to flow through them and easier for the heart to pump. The manufacturer instructs Do not crush, chew, or break an extended-release tablet. Swallow it whole. Crushing an extended release drug breaks the protective film or membrane, causing the release of a large dose at once rather than a gradual release of small doses over time. (Retrieved on 12/11/20 from www.drugs.com). On 12/08/20 at 1:58 PM, Charge Nurse B explained all newly admitted residents' medications are reviewed on admission by the Director of Nursing (DON) and both Charge Nurses. She confirmed the medication blister pack clearly directed nurses not to crush the medication. Charge Nurse B said, We missed that the medication was extended release and should not be crushed. Charge Nurse B stated her expectation was nurses would read directions and administer medications appropriately. On 12/08/20 at 5:24 PM, the DON stated medication orders for all newly admitted residents were entered into the EMR by the admission nurse after reviewing them with the physician. She explained the orders were then transmitted electronically to the pharmacy. The DON stated she expected pharmacy staff to conduct an additional review of the orders to ensure any concerns are identified and brought to the facility's attention. The DON stated the order was entered into the EMR accurately by nursing staff, but the pharmacy changed it to the extended release form of the drug. She said, They should have called and clarified with us and they should have seen that it was via G-tube. The DON acknowledged all nurses should have read and noted the instructions printed on the blister pack regarding not crushing the medication, and contacted the physician and/or pharmacy for appropriate orders. The Pharmacy Services policy and procedure, issued on 8/01/17 read, It will be the standard of this facility to provide pharmacy and pharmacist services to meet the needs of the residents. The guidelines indicated a licensed pharmacist would review each resident's medication regimen at least monthly and report any irregularities to the physician, medical director and DON. The pharmacy conducted an Interim Review of resident #105's medication regimen on 11/08/20, and a monthly review on 11/29/20. The concern regarding crushing an extended release pill for G-tube administration was not identified, and the pharmacists made no recommendations. Review of the MARs for resident #105 revealed she received Isosorbide Mononitrate ER 60 mg via G-tube once daily from 11/07/20 to 12/08/20. The extended release medication was crushed, dissolved and administered via G-tube 32 times, contrary to the instructions by the manufacturer and pharmacy. During her 1-month stay in the facility, this medication was administered to resident #105 by 8 of 8 assigned nurses, RNs A, F and I, and Licensed Practical Nurses C, D, E, G and H. The policy and procedure for Medication Administration Via an Enteral Feeding Tube revised in November 2016 read, Some medications and dosage forms should not be crushed. If there are any questions regarding the crushing of medications, call pharmacy. The facility's policy and procedure for Medication Administration revised 11/01/16 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106144 If continuation sheet Page 2 of 3 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 106144 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apopka Health and Rehabilitation Center 2001 Alston Bay Blvd Apopka, FL 32703 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm medications should be administered according to physicians' orders. The document indicated nurses would follow accepted standards of practice related to medication administration to ensure .the right medication, right dosage, right time and right method of administration are verified. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106144 If continuation sheet Page 3 of 3