Based on observation, record review, staff interview, and facility policy and procedure review, the facility failed to ensure residents' personal privacy during medical treatment for one (Resident #1) of two residents observed during medication administration. Resident #1 was not provided privacy during medication administration via her gastrostomy tube (feeding tube). The findings include: On 8/2/23 at 1:00 p.m., Licensed Practical Nurse B was observed preparing medications for Resident #1. A review of the resident's medication orders revealed that all her medications were administered through her gastrostomy tube (feeding tube). LPN B was observed administering two medications through the gastrostomy tube to Resident #1. LPN B did not provide privacy to the resident during the medication administration process. LPN B did not pull the privacy curtain or close the door to the room. The resident was visible from the hallway during this medication administration. LPN B then prepared an additional medication that was due but did not provide privacy to the resident during the medication administration process. LPN B did not pull the privacy curtain or close the door to the room. LPN B was asked how she provided privacy to residents during medication administration. She stated, By pulling the curtain. She was asked why she did not provide privacy for Resident #1 during her medication administration. She replied, I don't know, I guess I just thought because you were watching I didn't have to. A review of facility policies and procedures revealed: Medication Administration (revised 4/28/23) Policy Explanation and Compliance Guidelines: 7. Provide privacy Medication Administration via Enteral Tube (revised 4/28/23) 8. Procedure: d. Provide privacy by pulling the privacy curtain or closing the door to a private room. .

Based on observation, record review, and facility policy and procedure review, the facility failed to ensure that services provided met professional standards of quality for one (Resident #30) of two residents observed during administration of medication. Medication orders were not verified prior to twice attempted administration of medicated eye drops in the resident's wrong eye. The findings include: On 8/1/23 at 9:33 a.m., Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #30. A review of the resident's medication orders revealed the following: Pilocarpine (medication used for treatment of glaucoma and ocular hypertension) 1% eye drops: Administer one drop to right eye twice a day. LPN A was observed positioning the Pilocarpine eye drop bottle over Resident #30's left eye in order to administer the medication. The resident said, Not that eye. LPN A again attempted to position the eye drop bottle over the resident's left eye. The resident raised his left arm to block the eye drop bottle stating, Wrong eye, it's my right eye. LPN A then stopped and stated, Oh, you're right. LPN A then proceeded to administer the eye drop in the resident's right eye. A review of facility policies and procedures revealed: Medication Administration (revised 4/28/23) Policy Explanation and Compliance Guidelines: 11. Compare medication source with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time. Administration of Eye Drops (revised 4/28/23) Policy Explanation and Compliance Guidelines: 1. Verify orders and labeling prior to administration: c. Confirm which eye requires treatments. .

Based on observation, record review and staff interview, the facility failed to ensure insulin and blood glucose monitoring were administered/performed in accordance with professional standards of quality for 1 (Resident #26) of 1 resident observed during administration of insulin, from a total of 13 residents in the sample. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner ' practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: On 11/19/19 at 10:30 am, observation of medication administration was conducted with Employee A, Licensed Practical Nurse (LPN), and Resident #26. Employee A had performed blood glucose testing at 10:10 am. The result was a blood glucose level of 446. Employee A reviewed the sliding scale insulin order to determine how much insulin needed to be given. She determined 6 units of Humalog insulin were needed. Also, the order stated for blood glucose levels greater than 430, the physician was to be notified. Employee A prepared 2 syringes with insulin. She drew up 5 units of Levemir insulin in one syringe and 6 units of Humalog in the other. She entered the resident's room and administered the 2 syringes of insulin to Resident #26. A review of the physician's orders revealed the Levemir insulin was scheduled for administration at 7:30 am, however, it was not given until 10:30 am. The orders also included instructions to administer 2 units of Humalog before each meal and this was due at 11:30 am. There was no dose given at 11:30 am. Blood glucose monitoring was ordered every four hours and the next one due was at 2:00 pm. At 2:30 pm, an interview was conducted with Employee A. She was asked what the resident's blood glucose level was at 2:00 pm. She said she had not done it yet, as she was assisting the wound physician. She verified that she did not give the morning dose of Levemir at 7:30 am as ordered. She gave it after she performed the 10:00 am blood glucose test, along with the sliding scale insulin. She also confirmed she did not give the 11:30 am dose of Levemir due before lunch, since she had given the other dose late. On 11/19/19 at 4:30 pm, Employee A was observed preparing 2 syringes of insulin. One syringe contained 3 units of Levemir scheduled for 5:00 pm, and the other contained 2 units of Humalog, based on sliding scale, and 3 units due before the meal. Employee A was asked what time she performed the blood glucose testing and she said at 4:15 pm. When asked what time the blood glucose testing was scheduled, she said 2:00 pm. When asked why the insulin administration and blood glucose tests were not done timely, she said, Time got away from me. A review of the medication orders for Resident #26 included the following: Levemir 5 units at 7:30 am and 3 units at 5pm. Humalog 2 units before meals. Accuchecks every 4 hours with sliding scale Humalog insulin Humalog per sliding scale: If 180-229 = 1 unit 230-279 = 2 units 280-329 3 units 330-379= 4 units 380-429 =5 units If greater than 430 give 6 units and call MD. A review of the facility's policy, Administering Medications, included: Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example before or after meals). .

Based on observations, record reviews and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on 31 opportunities with four errors for Resident #26. This resulted in an error rate of 12.9%. The findings include: On 11/19/19 at 10:30 am, observation of medication administration was conducted with Employee A, Licensed Practical Nurse (LPN), and Resident #26. Employee A had performed blood glucose testing at 10:10 am. The result was a blood glucose level of 446. Employee A reviewed the sliding scale insulin order to determine how much insulin needed to be given. She determined 6 units of Humalog insulin were needed. Also, the order stated for blood glucose levels greater than 430, the physician was to be notified. Employee A prepared 2 syringes with insulin. She drew up 5 units of Levemir insulin in one syringe and 6 units of Humalog in the other. She entered the resident's room and administered the 2 syringes of insulin to Resident #26. A review of the physician's orders revealed the Levemir insulin was scheduled for administration at 7:30 am, however, it was not given until 10:30 am. The orders also included instructions to administer 2 units of Humalog before each meal and this was due at 11:30 am. There was no dose given at 11:30 am. Blood glucose monitoring was ordered every four hours and the next one due was at 2:00 pm. At 2:30 pm, an interview was conducted with Employee A. She was asked what the resident's blood glucose level was at 2:00 pm. She said she had not done it yet, as she was assisting the wound physician. She verified that she did not give the morning dose of Levemir at 7:30 am as ordered. She gave it after she performed the 10:00 am blood glucose test, along with the sliding scale insulin. She also confirmed she did not give the 11:30 am dose of Levemir due before lunch, since she had given the other dose late. On 11/19/19 at 4:30 pm, Employee A was observed preparing 2 syringes of insulin. One syringe contained 3 units of Levemir scheduled for 5:00 pm, and the other contained 2 units of Humalog, based on sliding scale, and 3 units due before the meal. Employee A was asked what time she performed the blood glucose testing and she said at 4:15 pm. When asked what time the blood glucose testing was scheduled, she said 2:00 pm. When asked why the insulin administration and blood glucose tests were not done timely, she said, Time got away from me. A review of the medication orders for Resident #26 included the following: Levemir 5 units at 7:30 am and 3 units at 5pm. Humalog 2 units before meals. Accuchecks every 4 hours with sliding scale Humalog insulin Humalog per sliding scale: If 180-229 = 1 unit 230-279 = 2 units 280-329 3 units 330-379= 4 units 380-429 =5 units If greater than 430 give 6 units and call MD. A review of the facility's policy, Administering Medications, included: Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless otherwise specified (for example before or after meals). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate medication orders and medication administration records for 1 (Resident #46) of 5 residents reviewed from a total of 13 sampled residents. The findings include: A record review for Resident #46 revealed she was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, muscle weakness, anxiety disorder, psychotic disorder, macular degeneration, gastroesophageal reflux disease and cerebral infarction. A review of Resident #46's November 2019 physician's order sheets revealed orders for the following medications: Ativan Tablet 0.5 milligrams (MG), 1 tablet in the AM for anxiety at 9:00 AM with a start date of 8/6/2019 and a second order for Ativan Tablet 0.5 MG, 1 tablet in the AM for anxiety at 7:30 AM with a start date of 11/10/2019. A review of the November 2019 Medication Administration Record (MAR) revealed the Ativan Tablet 0.5 MG was given at 9:00 AM from 11/1/2019 through 11/20/2019 and a second Ativan 0.5 MG tablet was given at 7:30 AM from 11/10/2019 through 11/20/2019. Further review of the November 2019 physician's orders found orders for Tramadol HCI (Hydrochloride) Tablet 50 MG, 1 tablet as needed for pain twice a day with a start date of 5/11/2019 and Tramadol HCI Tablet 50 MG, 1 tablet every 6 hours as needed for pain with a start date of 9/16/2019. During an interview with the Director of Nursing (DON) on 11/20/19 at 9:24 AM, she was asked for the physician's orders for the two doses of Ativan. She looked in the computer, confirmed both of the orders and stated she would need to speak to the physician. The DON was also asked to provide the physician's orders for the Tramadol. During an interview with the DON on 11/20/2019 at 10:18 AM, she stated Resident #46 was receiving the Ativan once in the morning. She stated on 11/9/2019 the physician went in the facility computer system and put in a new order so it could be delivered and did not discontinue the previous order. The DON also stated the as needed Tramadol was listed twice on the MAR for the same reason as the Ativan. She stated the physician added his new orders on 9/16/2019 and did not discontinue the old order. The DON provided the controlled substance sheet for the Ativan order that was filled on 11/9/2019. A review of the controlled drug record revealed Resident #46 received Ativan at 9:00 AM on 11/11/2019, 11/12/2019, 11/13/2019, 11/14/2019, 11/15/2019, 11/18/2019, 11/19/2019 and on 11/16/2019 and 11/20/2019 at 8:00 AM. The controlled substance sheet had no record of the Ativan being given on 11/17/2019. A count of the medication with the DON found 9 tablets missing from the package validating the Ativan was not given on 11/17/2019. A review of the Medication Administration Record for November 2019 revealed the nurse documented she gave the Ativan on 11/17/2019 at 7:30 AM and at 9:00 AM. .