Health inspection·August 6, 2021

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record review, the facility failed to ensure one resident (#161) was not able to self-administer medications by one staff member (C ) leaving the resident without ensuring the resident took the nine medications, and without returning during a medication pass out of a total of thirty-eight sampled residents. Residents Affected - Few Findings included: On 8/3/21 at approximately 10:00 a.m. prior to entering the Resident #161's room, Staff C, Licensed Practical Nurse (LPN) was observed at a medication cart, parked approximately fifteen feet away and at another resident's room. Staff C was observed preparing medications for other residents. On 8/3/2021 at 10:01 a.m. Resident #161 was observed in her room and in bed seated at 45 degrees. Further observations revealed she had the over the bed table positioned over her lap with various items to include two cups of hydration, and a small clear cup of nine medication tablets, which varied in colors to include white, yellow, pink, and orange. When Resident #161 was asked when she received the medications she shrugged her shoulders, she then gripped the cup with her right hand and scooted them to the forward end of the table and replied, I don't know. When Resident #161 was asked if she was planning on taking the medications in the cup, and she replied, I don't know. (Photographic Evidence Obtained) On 8/3/21 at 10:15 a.m. Staff C, LPN was observed at her medication cart now approximately fifty feet from Resident #161's room. There were no other nurses on this hall. During observations at 10:20 a.m., 10:30 a.m. and 10:40 a.m. on 8/3/21 Resident #161 was observed in her room, with her roommate, and still with the cup of medications placed on the over the bed table. Staff D, Certified Nursing Assistant (CNA) and Staff E, CNA at 10:42 a.m. were observed to go in the room to assist Resident #161 with Activities of Daily Living (ADL) care. On 8/3/21 at 10:50 a.m. Staff E, CNA was interviewed and confirmed if there was a cup of medications on the over the bed table for Resident #161. Staff E revealed that she did not know why the medications were left in the room and she did not think the resident was able to self-administer medications. She also said that she was an Agency aide and does not know any of the residents in the building that well. On 8/3/21 at 10:58 a.m. Staff F, Wound Care Nurse was observed to go into Resident #161's room, removed the cup of medications, and then walked them down the hall to the medication cart where Staff C, LPN was at. Staff F, Wound Care Nurse showed Staff C, LPN the medications. An interview was conducted with Staff F and Staff C at this time and Staff C, LPN stated that she is Agency staff and today Page 1 of 17 105029 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was her first day in the building and confirmed she did not know any of the residents much. Staff C revealed that she was not aware of residents on the hall that could self-administer medications and replied, No, I really don't know. Staff C confirmed that she provided Resident #161 with a cup of medications. Staff F, Wound Care Nurse replied, No, she cannot self-administer her own mediations. Staff F then asked Staff C if she left the medications in the room. Staff C told Staff F that she gave the cup to the resident (#161) and watched her take the medications. Staff C, LPN then stuck her fingers in the medication cup and said, See, these are wet, so she did have them in her mouth. Staff C confirmed that she had already documented the medications as given and taken in the Medication Administration Record (MAR). Staff F told Staff C, It doesn't matter if the pills appear wet or not, the pills were not swallowed. Staff C, LPN and Staff F, Wound Care Nurse confirmed that it is a nursing expectation to supervise residents to see them swallow the medications, and not to just leave a cup of medications in the room unsupervised. Review of the admission Record revealed Resident #161 was admitted to the facility on [DATE] and the diagnoses included lack of coordination, anxiety, other neuromuscular dysfunction of bladder, extended spectrum beta lactamase (ESBL) resistance and type 2 diabetes mellitus without complications, and dementia. Review of the electronic record to include the 5 Day admission Minimum Data Set (MDS) assessment, dated 7/28/2021 revealed: the Brief Interview for Mental Status score was a 9 of 15, which indicated the resident had lower cognitive functions. A review of the Nursing admission Assessment, dated 7/24/2021 revealed: Resident assessed and checked as alert to only person; Orientation to facility checked as Resident is unable to demonstrate or verbalize understanding of orientation. Section #22 of the assessment under Medications, indicated No for Do you wish to self- administer medications. A review of the current care plans with next review date of 8/9/2021 revealed: Cognition: Has impaired cognition function r/t (related to) short term memory loss, long term memory loss secondary to AMS/UTI (altered mental status/urinary tract infection), with interventions in place. Psychotropic medications, uses psychotropic medications r/t antidepressant use to manage depressions, antipsychotic to manage mood disorder with interventions included: Administer medications as ordered, observe and document for side effects and effectiveness. On 8/5/2021 at 12:00 p.m. an interview with the Director of Nursing (DON) confirmed that nursing, when passing medications, should ensure residents fully take the medications and are to not just leave a cup of medications on the table and leave the room. They are to supervise the resident take each 105029 Page 2 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0554 Level of Harm - Minimal harm or potential for actual harm of the medications that are ordered unless the resident is assessed to self-administer. The DON confirmed that the resident is not assessed to be able to self-administer medications. The DON further revealed that lack of ensuring the resident takes their medications fully, can result in other residents taking the medications, and or a resident having side effects or adverse reactions from not taking the prescribed medications. Residents Affected - Few A review of the facility policy and procedure titled, Medication Administration General Guidelines, dated 9/2018, revealed : Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The procedure section of the policy, under Medication Preparation, #1, revealed: Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications; #4 revealed: Medications are to be administered at the time they are prepared; #5 revealed: The person who prepares the dose for administration is the person who administers the dose; #13 revealed: Explain to resident the type of medication being administer and the procedure; and #20 revealed: The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR (Medication Administration Record), and action is taken as appropriate. 105029 Page 3 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility record review, the facility failed to ensure resident areas and shower equipment were clean, maintained and sanitized during four of four days observed (8/3/2021, 8/4/2021, 8/5/2021, and 8/6/2021), in three community shower rooms (1st floor 100 Unit, two on 2nd floor 200 Unit) of four community shower rooms, one dining room (main) of two dining rooms, and one smoking porch of one smoking porch. It was determined that 1. a constant water drip from the ceiling was pooling and flowing down the main hallway (100 Unit); 2. shower room chairs, walls, and water nozzles were observed with black biogrowth (where); 3. the main dining room was observed with ceiling vents caked with black and gray dust/debris; and 4. the outside smoking porch was observed with a ceiling fan that had all fan blades in disrepair, water-logged and pointing down to the ground. Findings included: Tours of facility to include the 2nd floor (200), and 1st floor (100), on 8/3/2021 at 10:30 a.m., 1:00 p.m.; 8/4/2021 at 6:55 a.m., 11:00 a.m. and 1:00 p.m.; 8/5/2021 at 7:02 a.m., 10:00 a.m., and 1:30 p.m.; and on 8/6/2021 at 7:04 a.m., and 8:45 a.m. revealed the following observations: 1. The first floor community shower room [ROOM NUMBER] Unit next to resident room [ROOM NUMBER] was observed with one of two shower chairs with black and pink biogrowth on the plastic tubing and plastic backing joints, and black biogrowth on two of the four wheel castors. Further, the shower head nozzle was observed with approximately twenty small sprayers. There was black biogrowth built up on the entire surface of the nozzle head where the water comes out. The grout lines on the walls and floor were observed with black biogrowth. (Photographic Evidence Obtained) The second floor community shower room [ROOM NUMBER] Unit next to resident room [ROOM NUMBER] was observed with one (1st one on right) of three shower stalls with the shower head sprayer with black biogrowth on most of the sprayers on the head. The metal handrail was observed with heaving rusting, leaving a noncleanable surface. The floor in the back shower stall was observed with a green in color foam pad, folded over on itself. The pad was observed with approximately 1 foot by 1 1/2 foot section with black biogrowth. The grout lines on the walls and floor were observed with black biogrowth. (Photographic Evidence Obtained) The second floor shower room [ROOM NUMBER] Unit next to resident room [ROOM NUMBER] was observed with one of two shower chairs with black biogrowth on all four plastic legs, at the joint areas, and near the wheel castors. Further, one (second one) of two shower stalls were observed with spotting of black biogrowth on the floor and walls, within the grout lines. Also, the metal piping on the shower wall was observed with heavy spotting of black biogrowth. (Photographic Evidence Obtained) 2. On 8/4/2021 from 10:00 a.m. to 2:00 p.m., the 100 Unit hall floor, between resident rooms [ROOM NUMBERS], was observed with a folded towel that was soaked through and with water pooling from the towel and running down the hallway approximately five feet from the towel. There was a wet floor sign and a towel on the floor only. There was no bucket to catch the water which was leaking steadily from the ceiling tile and light fixture. Interviews with various aides and housekeeping staff revealed they did not know what happened nor did they know who put the towel on the floor. It was also unknown if the maintenance department was aware of the leaking ceiling. Note: It had been raining most of the day. (Photographic Evidence Obtained) 105029 Page 4 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 8/5/2021 at 7:07 a.m. the same area on the main hall floor between resident rooms [ROOM NUMBERS] was again observed with heavy pooling of water. The ceiling tile and light fixture had a steady drip on a spread out bed sheet. The bed sheet was soaked through and with water flowing down the hall approximately five to six feet. (Photographic Evidence Obtained) On 8/5/2021 at 7:09 a.m. an interview with Staff N, Certified Nursing Assistant (CNA), revealed she was aware of the leak and thought the Maintenance Director was aware. She confirmed it was hard to bring the soiled linen cart though this area and out the door because of the pooled water. The Director of Nursing (DON) also walked up to the area and confirmed the pooled water from the ceiling leak. She said, I thought this was taken care of by the Maintenance Director yesterday. We thought this was fixed. She revealed that she would get a bucket immediately and also confirmed that a bucket should have been used rather than a towel or a bedsheet. On 8/6/2021 at 7:04 a.m. the main hall floor between rooms [ROOM NUMBERS] was observed with the ceiling leaking water. This time the water was dripping in a bucket and with wet floors signs surrounding the area. There had not been any rain in the area the past few hours and up to current observation time and ceiling was still leaking water. 3. On 8/3/2021 to 8/6/2021 observations of the outside smoking porch, which was located at the end of the main dining room, revealed a covered area with several tables and chairs and two ceiling fans hanging from the covered area. One of the two ceiling fans, located just outside the entrance/exit door was observed with all five wooden blades hanging directly down, vertically from the ceiling mount, and further observed waterlogged and soaked with water. The blades were also observed with heavy dust/debris caked on them. The fan was not operable per an interview with the smoking monitor, and residents who were seated outside. (Photographic Evidence Obtained) On 8/6/2021 at 11:00 a.m. the Housekeeping Director provided a housekeeping cleaning schedule and expectations of what she and her staff do in each space to include resident rooms and shower rooms. She revealed that spaces are cleaned daily and as needed. She further revealed that the shower rooms are also cleaned daily, and the equipment is pressure washed once a month. She confirmed the areas that needed to be additionally cleaned and would get with her staff to ensure they continue to look at those areas on a more frequent basis. Also, the main dining room was observed with two air return vents, located on the ceiling, and were caked with dust/debris. The air return vents blow air directly down over tables in the room. (Photographic Evidence Obtained) On 8/6/2021 at 12:00 p.m. an interview was conducted with the Housekeeping Director, and the Maintenance Director. The Maintenance Director revealed that he was aware of the drooping fan outside in the smoking area and just has not had a chance to replace it. He said it is totally not working and the blades are soaked up from all the rain and humidity. He also confirmed that the ceiling vent/ceiling tiles near rooms [ROOM NUMBERS] have a leak from the air conditioner condenser and has multiple people to look at it. He said this has been an ongoing issue for about a week now. He did confirm that he did not have any buckets available for staff to use during the night and early shift and that was why they used towels and bed sheets. He confirmed that neither worked very well and that water still pooled all over the floor. The Maintenance Director then confirmed that he has a schedule that tells him to clean various vents in the building and that the timeframe is usually about every month. He did confirm that the vents pointed out in the dining room and kitchen were full of dust and debris. The Maintenance Director was unable to provide proof of work orders/tickets from the electronic 105029 Page 5 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0584 ticketing system used for maintenance requests. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 105029 Page 6 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that one resident (#47) out of 9 sampled vulnerable residents was free from a physical restraint which could not be self-released. There was no medical symptom identified as the basis of the need for the restraint, and the facility failed to ensure that monitoring and evaluation for the continued use of the physical restraint was ongoing. Residents Affected - Few Findings included: Resident #47 was observed on 08/03/21 at 12:00 p.m. She was seated in a wheelchair in her room and there was a wide brown belt observed attached to the wheelchair and fastened across her lap with fabric hook and loop fasteners. The resident was not able to respond coherently to questions, not able to identify what the belt was for, and was unable to bring her attention or gaze to the belt, touch the belt, or release the belt when asked about it. On 08/04/21 at 9:39 a.m. the resident was observed seated in a wheelchair in her room with the same belt fastened across her lap. The resident was not engageable. On 08/04/21 at 2:50 p.m. the resident was observed asleep in bed. The wheelchair was present in the room an observation confirmed that the belt was fastened to the chair. (Photographic Evidence Obtained.) On 08/05/21 at 10:03 a.m. Resident #47 was observed seated in a wheelchair in her room with the same belt fastened across her lap. There was a tray table placed in front of her. The resident was not able to attend or respond coherently to engagement. Staff O, Certified Nursing Assistant (CNA) was in the room providing care to the resident's roommate. He said the lap belt observed on Resident #47 was to keep them from falling forward if they lean forward. He said, some of them will mess with it and then we have to keep a closer eye on them. Staff O said that the resident was always pleasant but was not oriented to anything going on around her and was dependent on facility staff for all her care and needs. He said Resident #47 didn't mess with her belt and said she could not take it off. Upon request, Staff O asked the resident to remove the lap belt and he pointed to the belt as a cue. The resident was not able to follow his verbal direction or the physical cue, did not bring her attention to the belt, and did not make any initiation to remove the belt. Staff O said the regular routine with Resident #47 was to put the lap belt on whenever she was put in her wheelchair. Review of Resident #47's admission Record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, cognitive communication deficit, and lack of coordination. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 which meant the resident had severe cognitive impairment. The MDS revealed the resident had continuous difficulty focusing attention, continuous disorganized thinking or incoherent, and fluctuating altered level of consciousness. The MDS revealed the resident required extensive physical assist of one for bed mobility, extensive physical assist of two for transfers, extensive physical assist of one for locomotion on the unit, was dependent for toileting and bathing, and required extensive physical assist of one for dressing. The MDS revealed that no devices or restraints were used in a chair or out of bed. A review of the care plan revealed a focus area for self-care performance deficit which included the following intervention initiated 09/03/19 and revised 03/12/20: .self releasing [Hook and Loop Fastener] belt. 105029 Page 7 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the most recent completed nursing quarterly assessment dated [DATE] revealed the resident did not require a restraint. A review of a document titled, Standard of Care, initiated on 09/2019, for Resident #47 revealed a section titled restraints which was last updated on 02/20/20, and documented no restraint in use, [Hook and Loop Fastener] belt is not a restraint, resident is able to release at will. An entry made in the section titled falls dated 09/28/19 revealed, resident was witnessed standing up from w/c (wheelchair) and then fell to the floor. Initially [Hook and Loop Fastener] belt (self releasing) in place, MD (medical doctor) & family aware and agree with place. A section titled other discussion revealed an entry dated 03/11/20: resident leaned forward at nurse's station and went to knees in front of wheelchair .will initiate [Hook and Loop Fastener] belt for positioning. That was the most recent entry regarding the use of the lap belt in the record. An interview was conducted with Staff I, Licensed Practical Nurse (LPN)/Unit Manager on 08/05/21 at 3:19 p.m. Staff O said, She's had the belt since I've known her. Staff O said a restraint was defined as Anything they can't remove on command or if needed. Regarding the evaluation process for determining whether a lap belt met the definition of a restraint she said, As they show significant changes we re-evaluate. She said that if a significant change was noted and a resident was unable to demonstrate self-release of a lap belt, the process was to contact their physician, their family, and request a therapy screen. She said, I don't know the process if it is a restraint because we don't do restraints here. Staff I said Resident #47 was always able to self-release the belt and insisted on trying herself to show the resident could remove the belt. On 08/05/21 at 3:24 p.m. an observation was conducted of Staff I with Resident #47. The resident was in bed. Staff I and another staff member transferred the resident into the wheelchair. Staff I asked the resident to fasten and unfasten the belt. The resident did not respond verbally or physical and did not bring her attention to the belt. Staff I said that wasn't what the resident normally did and said normally she would take hold of the belt and fasten it. Staff I said, I'll put in a therapy screen. An interview was conducted with the Director of Nursing (DON) on 08/05/21 at 3:46 p.m. She said a restraint was defined as anything that impedes a resident from moving freely. She said a lap belt was not considered a restraint if the resident could self-release it. Regarding the facility process for ensuring ongoing monitoring and assessment of the continued use of a physical restraint she said, We have a decision tree that we do to determine not a restraint. She could not answer what the standard was for frequency of re-assessment and said, I believe it's quarterly, but I just want to make sure. She revealed in the Electronic Health Record (EHR) for Resident #47 that the only assessment related to restraint use was in the most recent quarterly nursing assessment dated [DATE] which contained a section titled Restraints with the question Does the resident require a restraint? which was documented as No. There were no additional details in the assessment referencing the lap belt or any evaluation of the resident's ability to self-release it. An interview was conducted on 08/05/21 at 4:34 p.m. with the Director of Rehabilitation (DOR), Staff I, LPN/Unit Manager and the Risk Management Consultant. The DOR said that a therapist's role related to the use of a lap belt was to look at the ability to follow commands or positioning needs. He said, It doesn't take a skilled service to determine whether a patient can remove a device or not .the belt, unless for positioning, isn't really therapeutic or something we'd recommend .typically what we're looking at is more positioning .from a therapy standpoint would recommend this resident would need frequent supervision if they did not have the cognition to keep themselves safe without a belt. The Risk Management Consultant said the expectation for re-evaluating use of restraint was part of the nursing quarterly assessment. She said there was a policy for restraints, but they were not 105029 Page 8 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0604 used very commonly. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the DON on 08/05/21 at 5:30 p.m. She confirmed that facility nurses were expected to determine if a restraint was in use or not in their quarterly assessment and said that for a device like a lap belt the nurse was expected to ask the resident to remove it on command and if they could, it would not be considered restraint, but if they could not it would be considered a restraint. She said it was not common to use a physical restraint in the facility, but if it's needed then we do. She said in the case of Resident #47's [family member] wanting the lap belt, they would have to get a consent form signed by the family and a physician order. Residents Affected - Few An interview was conducted with the DON on 08/06/21 at 9:30 a.m. following a record review which revealed a new physician order had been entered on 08/05/21 for lap belt use: may wear [Hook and Loop Fastener] belt when up in wheelchair for safety. May remove for care and services every shift for unspecified dementia. She confirmed that after the lap belt had been brought to their attention yesterday, the resident's physician was informed that the family wanted the lap belt and so an order was put in place. The DON said that no matter whether considered a restraint or not there should have been an order for the lap belt. She said there should have been an order in place for the lap belt for Resident #47 before 08/05/21 and said, There's no explanation for why there wasn't. The DON confirmed that the lap belt had been deemed a restraint as of 08/05/21 and the paperwork and requisite consent forms had been put in place on 08/05/21. Review of the facility policy titled, Restraint Management, effective February 2021 revealed, Restraints will be used only when necessary to treat a medical symptom and not used for staff convenience. The facility will demonstrate and document the presence of specific medical symptom (s) that requires the use of the restraint to treat the cause of the symptom. The Interdisciplinary Team (IDT) will assess medical symptom by evaluating resident condition, circumstances and environment. The evaluation includes determining if a device is a restraint or assistive device .The team follows a systematic process for reducing restraints. The policy's definitions of restraints included: Physical restraint: Any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy included the following as types of restraint: Lap cushions, lap trays or safety belts the resident cannot remove. The guidelines for restraint management revealed that alternative interventions must be trialed prior to consideration of restraint, restraint must be used to treat underlying causes of the medical signs/symptoms/condition, a physician's order for restraint use must be obtained and include a plan for restraint reduction/elimination. 105029 Page 9 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to implement care plan interventions related to monitoring and providing assistance for eating for one resident (#160) of thirty-eight sampled residents. Findings included: On 8/4/2021 at 7:55 a.m. floor staff were observed to bring in a breakfast meal tray into Resident #160's room and placed it on the over the bed table. The resident was observed in bed lying on her right side, facing the window. Staff placed the meal tray on the table and left the room. The lid was left on and the tray, along with lids left secured on the hot cereal bowl and the milk carton was left unopened. The staff member did not set the meal tray up for the resident. Then at 8:10 a.m. Resident #160's meal tray was still observed in the same place with the lids on and with the resident still lying on her side facing the window. No staff were observed coming back into the room to set up the meal tray or assist with eating. Following this observation, at 8:50 a.m. Staff A, Certified Nursing Assistant (CNA) was observed to go into Resident #160's room after donning personal protective equipment (PPE) and was observed to assess the room as part of an observation for cleanliness and maintenance. She did not speak with Resident #160, nor did she ask about her breakfast tray. Staff A left the room at 8:52 a.m. Observations in the room at 8:52 a.m. revealed the meal tray was still at bedside on the over the bed table and with the lid on the main plate, and lids secured tightly on two bowls. The milk carton was not opened as well. Then at 9:01 a.m. Staff B, Registered Nurse (RN) was observed to don PPE and went into the room to pass a medication. Once she left the room at 9:06 a.m. she was interviewed and Staff B, RN was asked if the resident was assisted with or cued related to her meals. She said, I believe so, but I don't know if she refuses. She confirmed that the tray should have been at least set up for the resident. She also revealed she would check with the aides and see if she needs assistance and educate them on not leaving the tray and not checking on the resident for so long. Review of the admission Record revealed Resident #160 was admitted to the facility on [DATE]. The diagnoses included dementia with behavioral disturbance. Several attempts to interview Resident #160 were made on 8/4/2021, and 8/5/2021 and she was not able to answer questions related to her care and services, as she appeared with cognitive deficits. Review of the current Physician Order Sheet dated for the month of 8/2021 revealed Resident #160 had a diet order to include: Regular Diet, Regular texture, Regular thin liquid (as of 7/24/2021). Review of the nurse progress notes revealed: * 8/2/2021 10:39 (a.m.) Social Service Note - [Family Member] noticed change in her memory and since then has become progressively worse. * 8/4/2021 03:46 (a.m.) - Resident refused meal. 105029 Page 10 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0656 * 8/4/2021 03:46 (a.m.) - Amount eaten 0-26% for 3 meals. Level of Harm - Minimal harm or potential for actual harm Review of the admission Assessment completed on 7/24/2021 revealed: Alert and only alert to Person; Resident is unable to demonstrate or verbalize understanding of orientation; .Self-care Section revealed Assistance with eating and to Assist 1 Supervision or touching assistance, care plan update Eating with intervention to include: EATING: Assist of 1. The Assessment also indicated Resident #160 could benefit from a Restorative Nursing Program for a functional decline or maintenance with relation to Eating/Dining; and indicated interventions for Eating to include Restorative dining for breakfast and lunch and dinner, Provide only the assistance necessary to ensure adequate meal intake. Residents Affected - Few Review of the current care plans with the next review date of 10/22/2021 revealed the following: - Cognition: Resident has impaired cognitive function/dementia or impaired thought process related to Dementia, with interventions in place. - Nutritional: Resident has a potential nutrition problem r/t (related to) Risk for unavoidable wt. (weight) loss and malnutrition r/t dx. (diagnosis) of dementia, with interventions in place. - Resident has ADL (Activities of Daily Living) self-performance deficit with interventions to include but not limited to: EATING - Assist of 1; EATING - Meal location may change per resident choice; SELF PERFORMANCE - level may fluctuate throughout the course of the day, provide assistance as appropriate. - Behavioral: Resident is noted with the following behaviors: Aggressive with staff at times, refuses care and services at times, with interventions to include but not limited to: If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. On 8/5/2021 at 12:00 p.m. an interview with the Director of Nursing (DON) revealed she was made aware that on 8/4/2021 staff was not going into the room frequently to cue and or assist Resident #160 with her breakfast meal. She confirmed that the resident has been exhibiting with some refusal behaviors recently, but staff still should not have left her in the room for over an hour without checking on her or trying to cue her to eat. She further confirmed that staff should not have just placed the tray on the table next to the bed and leave the plate lid on, the bowl lids on and milk and juice cartons unopened. The DON expressed that it is the responsibility of staff to set up the meal tray even if the resident may refuse initially. She also confirmed that the care plan should have been followed related to staff checking back with the resident every 5-10 minutes if she did indeed refuse her meal. On 8/6/2021 at 1:00 p.m. the Director of Nursing revealed they did not have a specific policy and procedure for implementation of care plans. 105029 Page 11 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide needed treatment and services related to a leakage of a suprapubic tube for one resident (#64) out of 9 residents receiving catheter care. Findings included: A review of Resident 64's admission Record revealed a readmission date of 1/15/2021 and diagnoses to include seizures, urinary tract infection, and neuromuscular dysfunction of bladder. A review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status score of 13, which indicated that Resident #64 had no cognitive impairment. Section G (Functional Status) revealed that Resident # 64 required two-person physical assist for toileting, personal hygiene, and bed mobility. Section H Bladder and Bowel revealed Resident #64 had an indwelling catheter. On 08/03/21 at 10:15 a.m. Resident #64 was observed lying in bed and a strong foul-smelling odor was noted. Upon entering the room, a catheter drainage bag was observed hanging appropriately on the bed frame. During an interview with Resident #64 on 08/03/21 at 3:49 p.m. she that she has a suprapubic tube that leaks onto her abdomen, her clothing and bed linen. She stated that the CNAs (Certified Nursing Assistants) placed towels to absorb the leakage of the urine, but her abdomen and clothing gets wet regardless of the placement of the towels. Resident #64 opened her gown and revealed folded towels on her abdomen, covering the suprapubic tube site. On 08/05/2021 at 1:49 p.m. an interview was conducted with Staff J, CNA. Staff J stated that Resident #64's suprapubic tube leaks a lot. She stated that she usually places a towel across the resident's abdomen to prevent leakage on her skin and clothing. She stated that Resident #64's clothing and bed linen is usually wet with urine on her rounds. Staff J stated that she usually reports the leakage to the charge nurse. On 08/05/21 at 3:35 p.m. an interview with Staff I, Licensed Practical Nurse (LPN)/Unit Manager (UM) was conducted. Staff I stated that she was not informed by the CNAs that Resident #64's suprapubic tube has been leaking. Neither was she aware the suprapubic tube was leaking. She confirmed that Resident #64 primary care physician should have been notified related to the leakage and a changed of condition should have been documented in her medical record. On 08/05/21 at 3:38 p.m. during an interview with the Director of Nursing (DON), she stated that she was not aware that Resident #64 suprapubic tube was leaking. In a follow up interview with the DON on 08/05/21 at 4:56 p.m., she stated that the facility has a process in which the CNAs are required to notify the nurses or document in Stop and Watch which would alert the nurses if a leakage or any problem is observed with the resident's suprapubic tube. She stated that the nurses are also required to do weekly skin assessment and catheter care and should be aware if the suprapubic tube was leaking. 105029 Page 12 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/05/21 at 5:12 p.m. an observation revealed the DON went to Resident #64's room and requested Resident #64's permission to examine her suprapubic tube site. The DON, upon loosening Resident #64's brief, confirmed towels were placed on her abdomen. The DON removed the folded towels and confirmed leakage of the suprapubic tube, and a brownish foul-smelling drainage was observed on the towel. The suprapubic tube site was reddened, and the perimeter surrounding the suprapubic tube insertion site was slightly excoriated. The DON stated that she would have expected the nurses to call Resident #64's primary care physician and reported the leakage. She confirmed that a change of condition should have been documented in Resident #64 electronic medical record. A review of the Treatment Administration Orders dated 7/1/21-7/31/2021 revealed a physician order to drain suprapubic catheter bag every shift and prn every shift with a start date of 6/22/21. Additionally, and order showed a discontinued (D/C) date of 8/5/2021. The TAR also documented a physician order for change suprapubic catheter care every shifts and PRN (as needed); and order to change suprapubic catheter as needed for leakage/blockage or dislodgement as needed and document in resident's record with a start date of 6/22/21. A review of Resident #64's nurses progress notes dated 7/1/21-8/3/2021, did not reveal documentation related to a leakage of her suprapubic tube; and no documentation was found indicating that the suprapubic catheter was changed for leakage. A review of Resident#64's plan of care for the suprapubic catheter revised on 1/15/21 included a focus on the risk for infection and or complications related to neurogenic bladder. The interventions included: Provide catheter care every shift & as needed and Observe, document and report to MD (medical doctor) for S/S (signs or symptoms) of UTI (urinary tract infection) Foul smelling urine etc . A review of the policy and procedure titled, Bowel & Bladder Continence Program, effective February 2021, showed no outlined care specifically for suprapubic /indwelling catheter. However, on page 4, titled Unable to Participate Program e. Reads: Resident or patient has no ability to maintain or attain continence through a retaining program or a structured continence program. Individual needs will be met through ongoing nursing care. Assessment an indication leading to continuous bowel/bladder management program may include, but not limited to: Indwelling urinary catheter required to treat an irreversible medical condition. 105029 Page 13 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure that suction canisters were changed consistent with the physician order for two residents (#64 and #101) out of four sample residents reviewed for tracheostomy care/tracheal suction. Residents Affected - Few Findings included: 1. A review of the admission Record revealed Resident #64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include chronic respiratory failure, benign neoplasm of larynx, cervicalgia, dysphonia, and dysphagia, chronic obstructive pulmonary disease and tracheostomy status. On 08/03/21 at 10:15 a.m. Resident #64 was observed lying in bed, with the trachea in place connected to a humidified air at 2 liters per minute via oxygen and dated 7/28/21. The suction and canister were observed on the nightstand at ¾ full and dated 7/28/21. A review of Resident #64's Treatment Administration Record (TAR) dated 7/1/21-7/31/21, revealed a physician order to change the suction canister every 3 days and or when ¾ full, start date of 6/22/21. On 08/04/21 at 8:18 a.m. Resident #64 was observed lying in bed, with the trachea in place and the suction and canister were observed on the nightstand at ¾ full and dated 7/28/21. On 08/06/21 at 12:42 p.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN). She stated that suction canisters are scheduled to be changed every (Q) 72 hours or when 3/4 full. She stated that all nurses are responsible for changing the suction canisters, if the suction canister is 3/4 full or is in place for 72 hours. She stated the change for the canister is scheduled on the 11 (p.m.) -7 (a.m.) shift, However a prudent nurse will change the canister if there is a need. In an interview with Staff I, LPN/Unit Manager (UM) on 08/06/21 at 12:50 p.m., Staff I confirmed that suction canisters are scheduled to be changed every 72 hours or when they are 3/4 full. She stated that all nurses are responsible for changing the suction canisters. On 08/06/21 at 2:54 p.m. during an interview with the Director of Nursing (DON), she stated that she was not aware that suction canisters were not changed. She stated that it is her expectation that suction canisters are changed every 72 hours or when they are 3/4 full. 2. On 08/03/21 at 12:00 p.m. Resident #101 was observed lying in bed with a tracheostomy and a suction canister that was 2/3 full and located on the resident's nightstand. Written on the top of the canister was the date of 7/28/21. On 08/03/21 at 2:39 p.m. Resident #101 was observed resting in bed and a suction canister that was 2/3 full was observed on the resident's nightstand. Written on the top of the canister was the date of 7/28/21. Review of Resident #101's admission Record revealed an admission date of 3/28/2017 with diagnoses to include tracheostomy status and chronic respiratory failure with hypoxia. 105029 Page 14 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #101's physician orders for August 2021 included: Maintain suction set up at bedside and change suction canister every 72 hours and /or when 3/4 full, start date 7/5/19; Clean oxygen filter weekly, every Friday, start date 7/5/19; and Suction trach every shift and as needed, revision date 5/31/19. A review of the Quarterly Minimum Data Assessment (MDS) conducted on 7/8/21, documented in Section G, Functional Status, the resident as total dependence, two-person extensive assist. Further review of Section O, Special Treatments, Procedures and Programs revealed that Resident #101 required oxygen therapy, suctioning and tracheostomy care. A review of Resident #101's care plan dated 5/3/21 revealed a focused areas of: [Resident #101] has oxygen therapy r/t (related to) chronic respiratory failure. Interventions included: - Special equipment: Humidified oxygen at 2 liters with 28% FiO (fraction of inspired oxygen [concentration of oxygen in the gas mixture]) per tracheostomy continuously - Administer oxygen as ordered - Suction as needed - Change and date respiratory equipment tubing weekly and PRN (as needed) - Keep exterior of respiratory equipment clean, [Resident # 101] has a tracheostomy r/t respiratory failure Trach is a [Brand Name] cuffless size 6 Interventions include: - Give humidified oxygen as prescribed - Maintain ambu-bag and replacement trach at bedside per order - Suction as needed - Trach care per order. On 08/05/21 at 3:00 p.m. during an interview Staff H, LPN confirmed that only licensed staff take care of resident tracheostomy and suction equipment. CNAs (Certified Nursing Assistants) are not allowed to do anything with either the tracheostomy or the suction equipment. If they have a concern, they are to notify the licensed nurse on the hall. Respiratory care staff visit the resident twice weekly, Monday and Wednesday and perform complete trach care. The licensed staff of the facility will do care on the remaining days as needed, per physician orders. On 08/05/21 at 3:15 p.m. during an interview the DON stated that only licensed staff provide care for tracheostomies, and suction equipment, following physician orders. The orders (physician) include suction and oxygen administration. The expectation is that the suction canister is changed out every 72 hours or more frequently as needed. The DON stated that there was not a policy related to 105029 Page 15 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cleaning and maintenance of suction equipment, and that the clinical staff follow physician orders regarding suction equipment. A review of the facility policy titled, Tracheostomy Care Disposable and Non-Disposable Inner Cannula, with an effective date of November 2020, showed: The facility requires that qualified Respiratory Therapists or licensed nursing personnel perform tracheostomy care at least daily and as needed or per practitioners' orders to prevent buildup of secretions and infection of the airway around the tracheostomy tube. 105029 Page 16 of 17 105029 08/06/2021 Community Convalescent Center 2202 W Oak Ave Plant City, FL 33563

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews the facility failed to maintain the kitchen and kitchen equipment were maintained in a clean and sanitary manner during two of two days observed (8/3/21 & 8/6/21) related to heavy black biogrowth and dust debris observed on two of two large air return vents and a motor housing with plastic venting, positioned directly above food items in one of one walk in refrigerators. Findings included: On 8/3/2021 at 9:35 a.m. the kitchen was toured with the Dietary Manager. During the tour, the walk in refrigerator was observed to have a fan motor housing vent grating with heavy black biogrowth matter throughout the entire grating. (Photographic Evidence Obtained) Also, the main kitchen area was observed with two large air conditioning air ducts hanging down from the ceiling. One above and to the side of the steam table, and the other hanging above and to the side of a food preparation table. Both were observed to be caked heavily with dust and debris. Further, the areas around the vents and ceiling were observe with heavy cracking/blistering and chipping of paint. The air from the vents blows past the chipped/blistered areas and dust debris and blows down towards the food preparation areas and steam table, where exposed food is kept. There were very small pieces of chipped paint on the floor and food preparation table. (Photographic Evidence Obtained) An interview was conducted with the Dietary Manager concurrent with the observations and confirmed the observations. The Dietary Manager explained that the Maintenance Department usually handled the vent cleaning and maintenance. She was not aware of the large areas of paint chipping/blistering in and around the vent areas and explained that she should call Maintenance to take care of it. On 8/6/2021 at 10:35 a.m. during an additional tour of the kitchen the main motor vent housing in the walk-in refrigerator was observed with black biogrowth and dust/debris. The Dietary Manager revealed that it had been cleaned but did not notice all the biogrowth on the inside of the housing vent. She explained she would have Maintenance clean it again. An interview with the Maintenance Director on 8/6/2021 at 12:00 p.m. confirmed the soiled vents in the walk-in refrigerator and main kitchen. He revealed he had an Electronic Maintenance Ticket System that lets him know when to clean the vents and they are to be cleaned monthly. He did not have any documentation to support this. Further, the facility did not have a policy/procedure related to kitchen ventilation cleaning maintenance. 105029 Page 17 of 17