Inspection·September 8, 2023

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 failed to prevent medication errors greater than 5% for 2 of 6 residents sampled for medication administration, (#154, #302). There were 2 errors in 31 opportunities by 2 of 2 nurses observed for a medication error rate of 6.45%. Residents Affected - Some Findings: 1. Review of resident #154's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's' disease, heart failure and deficiency of other vitamins. Review of resident #154's physician's orders read, 6/30/23, Vitamin (Vit) D3 50 micrograms (mcg) (1000 units) give 2 tablets (tab) by mouth (PO) for vitamin D deficiency; Senna Plus 8.6-50 milligrams (mg) give 2 tab PO at morning and bedtime for constipation; amiodarone 200 mg give 1 tab PO one time per day for atrial fibrillation; isosorbide mononitrate 60 mg give 1 tab per day for hypertension; and Depakote (divalproex) 250 mg give 2 tab (2x125 mg=250 mg) twice a day for mood. On 9/06/23 at 9:05 AM, Licensed Practical Nurse (LPN) A prepared 10:00 AM medications for resident #154. She pulled 1 tab of Vit D3, 2 tab of Senna Plus 8.6-50 mg, 1 tab of amiodarone 200 mg, 1 tab of isosorbide mononitrate 60 mg, and 2 tab of divalproex 125 mg. LPN A confirmed she had prepared a total of 7 pills for resident #154. At approximately 9:15 AM, she administered the medications to the resident. On 9/06/23 at 2:25 PM, LPN A was asked to review the order for Vit D3. She pulled the blister package for Vit D3 and stated it read, Vitamin D3 25 mcg (1000 IU [international unit]). She compared the label on the Vit D3 to the physician's orders in the electronic system. She then read the order electric order, Vitamin D3 50 mcg 2 tabs, in parenthesis 1000 units. She stated even though the order reads 50 mcg it also indicated 1000 units and the blister pack read 25 mcg / 1000 units. She stated she had questioned this to a charge nurse who no longer worked in the facility and was told to follow the instructions in the packet. LPN A validated she gave 1 tab of Vit D3 that morning. 2. Review of resident #302's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), rheumatoid arthritis, type 2 diabetes, and vitamin deficiency. Review of resident #302's physician's orders read, 8/23/23 Colace 100 mg give 2 capsules (cap) PO every 12 hours for constipation; Simbrinza 1-0.2% instill 1 drop in right eye two times a day for macular degeneration; Wixela 100/50 mcg one puff inhale orally twice daily for COPD; ferrous sulfate 325 mg 1 tab PO every 8 hours for anemia; 8/24/23, amiodarone 200 mg, give one (tab PO once a day for atrial fibrillation; ascorbic acid (vitamin C) give 1 tab (1000 mg) PO for RDA [recommended dietary allowance] support; empagliflozin 10 mg give 1 tab PO daily for diabetes, and furosemide 20 mg give 1 tab PO daily for CHF. On 9/06/23 at 10:02 AM, LPN B prepared 10:00 AM medications for resident #302. She pulled 1 Amiodarone 200 mg, 1 vitamin C 500 mg, 1 Docusate 100 mg, 1 Ferrous sulfate 325 mg, 1 furosemide 20 mg, 1 empagliflozin 10 mg, 1 bottle of Simbrinza 1-0.2% and 1 Wixela 100/50 mcg inhaler. LPN B confirmed she had prepared a total of 6 pills for resident #302. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 2 of 4 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 0759 At approximately 10:15 AM, she administered the medications to the resident. Level of Harm - Minimal harm or potential for actual harm On 9/06/23 at 2:13 PM, LPN B was asked to review the orders for Vitamin C and Docusate for resident #302. LPN B compared the medication bottles to the physician's orders in the electronic system. She acknowledged resident #302 received 1 tab of vitamin C 500 mg and 1 cap of Docusate 100 mg instead of 2 of each. She stated the resident did not get the correct dose and she should have been given 2 pills of each of these medications. LPN B indicated it was important to thoroughly read the order and the medication label for accuracy. Residents Affected - Some On 9/07/23 at 9:36 AM, the Director of Nursing (DON) explained her expectation from nurses included timely administration of medications, following the 5 rights of medication administration, and following the physician's orders. She stated if there were any concerns or discrepancies during medication administration, the nurse needed to stop, discuss with the supervisor, and call the physician to clarify. The DON verbalized the nurse should look at the medication packet and compare it to the electronic order to ensure accuracy and note any discrepancies. She added the over-the-counter medications were problematic at sometimes as the dosage did not always come as ordered by the physician. She indicated regardless, it was the nurse's responsibility to ask and clarify. Review of the Medication Pass Observation Report / Consultant Pharmacist Report dated 6/22/23 identified the following opportunity for improvement: Read labels of OTC and prescription products and reconcile order written on eMAR [electronic Medication Administration Record]. Medication pass recommendations listed, Read all medication labels and follow instructions. The report included, Consultant's recommendations are above to have a successful and safe medication pass for our veterans. Review of the Medication Pass Observation Report completed on 6/22/23 by the Pharmacy Consultant showed an error rate of 12%. Review of the Medication Pass Observation Report / Consultant Pharmacist Report for July and August 2023 identified the following opportunity for improvement: Read labels of prescription products and reconcile order written on eMAR. Review of the Medication Pass Observation Report completed on 7/26/23 by the Pharmacy Consultant showed an error rate of 23%. On 09/08/23 at 6:29 PM, the Pharmacy Consultant stated she made observations of medication pass monthly or as needed. She indicated she notified nursing of any medication changes needed on the physician's orders based on table formulation they have on hand. She explained nursing was responsible for notifying the physician and updating the orders. She explained she made notations on the orders she reviewed and gave a copy to nursing. She indicated the strength for Vitamin D3 was 25 mcg / 1000 units. She explained this vitamin did not come in 50 mcg strength, therefore, the nurse needed to give 2 tablets. She stated they carried Vitamin C 500 mg and Docusate 100 mg. She said, You have to read the labels. She shared she looked for these things during her monthly medication pass audits. She indicated when she presented her audit findings at the Quality Assurance & Performance Improvement (QAPI) meetings and recommended re-education to the nurses. She explained the DON and Staff Developer were responsible for the nurses education unless they requested pharmacy's assistance. Review of LPN B's Agency Nurse Orientation booklet revealed she acknowledged and attested she had a chance to review these policies and procedures on 5/17/23. Review of the Medication Pass/Treatment section read, Remember the 10 R's: right resident, right medication, right dose . The Nurse Skills / Education Competency Checklist form signed on 5/17/23 LPN B revealed she was competent for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 3 of 4 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 0759 Medication Administration. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure titled Medication Administration dated 12/31/21 read, The facility will ensure that Medications are administered in a safe and timely manner, and as prescribed. The procedures revealed Medications must be administered in accordance with the orders, including any required timeframe. It specified the individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration prior to giving the medication. Residents Affected - Some Review of the Facility Assessment reviewed by the QAPI Committee on 7/26/23 revealed the facility provided services and care based on their residents' needs including administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 4 of 4