Health inspection·March 12, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined, the facility failed to provide timely necessary care and services to 1 of 2 sampled residents (Resident #1), as evidenced by delay in reporting abnormal test results and subsequent delay in treatment. Residents Affected - Few The findings included: Clinical record review conducted on 03/11/25 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Atrial Fibrillation, Congestive Heart Failure and Pulmonary Edema. Minimum Data Set, admission assessment with reference date of 01/09/25 indicated the resident was assessed as moderately impaired for skills of daily decision making, was receiving antidepressant, anticoagulant, antiplatelet and diuretic medications and received oxygen therapy. Care Plan tilted, Resident on medications related to COVID dated 01/15/25 documents the goal as resident will not exhibit signs of respiratory distress. The interventions included: Administer medications as ordered, administer oxygen as ordered, assess changes in condition, droplet precautions and monitor for signs of respiratory distress and vital signs as ordered. The record indicates Resident #1 had elevated temperature 102.3 on 01/15/25. Progress notes dated 01/15/25 documents Resident tested positive for COVID-19, notified practitioner. Droplet precautions implemented for ten days. Physician's order dated 01/15/25 at 12:51 PM documents If no allergies start Paxlovid twice daily for five days, pharmacy to dose. Give Tylenol 1000 milligrams now for fever then twice a day for three days for fever. Placed on droplets precautions . Do Chest X-ray Dexamethasone 6 mg daily for ten days, Claritin 10 mg daily for seven days, Albuterol Sulfate aerosol solution 108 mcg inhaler, inhale two puffs every four hours as needed for shortness of breath and Tessalon [NAME] 100 mg three times a day as needed for cough. Progress notes dated 01/18/25 documents Went on to Trident Care website and printed out chest x-ray report from 01/16/25, shows increased opacity, may be due to pneumonia. Faxed it to Dr. P And new orders received for Augmentin 875 mg orally twice a day for five days and Doxycycline 100 mg orally twice a day for five days . Page 1 of 5 686128 686128 03/12/2025 Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Physician's order dated 01/18/25 documents Augmentin 875 mg orally twice a day for five days and Doxycycline 100 mg orally twice a day for five days. Medication administration record documents the prescribed antibiotic therapy was initiated on 01/19/25. Review of the chest x-ray results revealed the test was completed on 01/16/25 and the results were completed on 01/17/25 at 11:19 AM. The results documents Increased left hilar opacity, that may be due to pneumonia or a left hilar mass. Recommend follow up with a CT exam for further evaluation. Interview with the Director of Nursing (DON) on 03/11/25 at approximately 3:28 PM revealed the process to obtain radiology results. The facility uses TC company and they fax all the results directly to the nurses station. The nurses are responsible for notifying the physician of the results when received. The DON was asked regarding the process for tracking pending results and explained there is a log, mainly used for that all nurses have access to the radiology portal so they can get test results. The DON reviewed the clinical record and was unable to provide an explanation as to why the abnormal chest x-ray results were not faxed or received on 01/17/25 and reported to the physician. On 03/12/25 at approximately 11:30 AM, the DON was asked the reason for not starting the antibiotic therapy on 01/18/25, when the order was received, and explained the nurse who received the order just before 9 PM, scheduled the first dose for the next morning. Documentation of the facility Emergency Pharmacy Kit, indicates the facility has both Augmentin and Doxycycline available for immediate use. The investigation determined Resident #1 was diagnosed with a respiratory virus on 01/15/25, a chest x-ray was ordered and completed on 01/16/25. The test results dated 01/17/25 at 11:19 AM were not reported to the physician in a timely manner. The results were reported on 01/18/25 at 8:49 PM and subsequent antibiotic therapy was not initiated until 01/19/25 at 8 AM, despite availability of the drugs. 686128 Page 2 of 5 686128 03/12/2025 Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, it was determined, the facility failed to obtain pharmaceutical services for 3 of 3 sampled residents (Resident #2, #5 and #6) as evidence by failure to acquire and administer medications in a timely manner. The findings included: 1) Clinical record review conducted on 03/11/25 revealed Resident #2 was admitted to the facility on [DATE] at 3:57 PM with diagnoses of Hydrocephalus, Hypertension, Diabetes, Epilepsy, Bipolar, Anxiety and Dementia. Medications orders included the following: Atorvastatin Calcium 10 mg at bedtime for Hyperlipidemia. Carvedilol 25 mg twice a day for Hypertension. Divalproex Sodium 250 mg twice a day for Boipolar Disorder. Metformin 500 mg twice a day for Diabetes. Nystatin Triamcinolone cream 100,000-0.1 units apply to groin and buttocks for erythematous condition every shift. Medication Administration Records indicate that Resident #2 did not receive the evening doses for the medications listed above on 01/20/25 and on 01/21/25 the morning dose for the Carvedilol was not administered. The nurse documented the rationale for not giving the prescribed medications Drug/Item unavailable. The interview with the Director of Nursing (DON) and the Assistant Director of Nursing on 03/11/25 starting at 3:49 PM revealed the facility has an onsite pharmacy, from 8 AM to 4:30 PM. After hours the pharmacy is Omnicare and they deliver medications twice a day, with cut off times 10 AM and 10 PM and medications will be delivered within six hours. The DON was asked to find documentation that the nursing staff advised the provider that the medications were not available for administration and interventions to manage the missing doses. The DON stated that 01/20/25, was a holiday, so their pharmacy was closed and provided a copy of a fax to Omnicare requesting all the medications prescribed for Resident #2. There is no documentation of follow up with the pharmacy to obtain the medications and there is no documentation of physician notification that the drugs were not available. On 03/12/25 at approximately 11:20 AM, the DON was asked for the after hours pharmacy policies and procedures and provided a copy of signed agreement and pharmacy information. The information included the following information. Be sure to reorder 3-5 days before you run out, Reorders must be sent 686128 Page 3 of 5 686128 03/12/2025 Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few via electronic medical records, if you reorder after cutoff time, your medication will be delivered the following date. Emergency medication procedure: If medication is needed prior to your next schedule delivery and is not in your starter/emergency/back-up supply, please follow your regular process to submit the order, then call to request the medications STAT. There is no evidence the facility followed the instructions to obtain the medications timely. 2) Record review conducted on 03/12/25 revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alzheimer's, and Dysphagia. Physician's orders dated 02/19/25 documents Lactobacillus Rhamnosus one capsule via gastric tube daily and Multivitamin with Iron give 15 milliliters via gastric tube daily. Medication Administration Records revealed the facility did not administer the prescribed medications as follows: On 02/22/25, 02/24/25 and 02/25/25 the Lactobacillus was not given, the nurse documented Drug/Item unavailable. On 02/24/25 and 03/04/24 the Multivitamin with Iron was not given, the nurse documented Drug/item unavailable and waiting for delivery. Interview with the Director of Nursing (DON) on 03/12/25 at 11:31 AM revealed the facility has Lactobacillus Acidophilus, not the Rhamnosus, so that explained why some nurses documented the drug as given, using what they had on hand and some nurses did not, because it was not the correct label. The DON is not sure what the difference is between the two drugs, and added she had spoken to the nurses in regards to the liquid multivitamin with iron and was told some of them were using a pill form and crushed them, despite the order being written for the liquid form, until the pharmacy sent it. The DON confirmed there is no documentation from the pharmacy clarifying the orders or from the nurses to obtain the right medications in a timely manner. 3) Record review conducted on 03/12/25 revealed Resident #6 was admitted to the facility on [DATE] at 12:20 PM with diagnoses including Metastatic Prostate Cancer. Physician's orders dated 01/20/25 documents Lorazepam 0.5 mg once in the evening, Morphine 15 mg at bedtime, Morphine 30 mg at bedtime. Medication Administration Records dated 01/20/25 documents the nurse did not administer the medications, Drug/Item unavailable. Progress Notes 01/20/25 8:15 PM documents Writer spoke to Omnicare regarding Ativan and Morphine prescription and was informed that medication will we sent on 2:00 am run. Resident requested to have meds sooner. Progress Notes dated 01/20/25 10:33 PM documents Resident new admit alert and able to verbalize 686128 Page 4 of 5 686128 03/12/2025 Ardie R Copas State Veterans Nursing Home 13000 SW Tradition Parkway Port Saint Lucie, FL 34987

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needs, .Resident very concerned about his medications which is not available, Omnicare pharmacy contacted also hospice. still waiting for an answer to see when medications will be available, resident stated he cannot sleep without his pain medications. Progress Notes dated 01/21/25 at 4 AM documents Call placed to Omnicare regarding delivery time of medications. Medications have been shipped standard delivery .Review of Supplemental orders containing comfort packet medications. These orders remain active in the hospice system and are due to arrive from Omnicare today. Interview with Director of Nursing (DON) conducted on 03/12/25 at 12:18 PM revealed the facility does not have a narcotic emergency kit, all narcotics are delivered by Omnicare. The DON reviewed the record and stated they were working with hospice to get the medications sooner and confirmed there is no documentation medications were requested STAT for prompt delivery. 686128 Page 5 of 5