Health inspection·April 23, 2021

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 file review, the facility did not ensure a safe, clean, comfortable, and homelike environment during four of four days observed (4/20/2021, 4/21/2021, 4/22/2021, and 4/23/2021) as evidenced by: 1) one of one smoking area observed with cigarette butts on the ground and cigarette butts in a trash can that was not fire rated, 2) seating equipment in disrepair in one (first floor) of two dining rooms, and 3) Twelve (203, 204, 206, 210, 211, 213, 216, 219, 222, 227, 230, 231) of 62 resident rooms with soiled floors, cracked and chipped tiles, unbagged plungers, and walls in disrepair. Findings included: 1. During facility-wide tours on 4/20/2021 at 10:30 a.m., 4/21/2021 at 7:30 a.m., 1:00 p.m., 4/22/2021 at 7:45 a.m. and 2:00 p.m. and 4/23/2021 at 9:00 a.m. the following was observed: The first floor dining room was observed with a door that led from the dining room into a screened in porch. The porch was identified as a smoking area for residents. The porch included two white painted metal tables with peeling paint and heavy rust. The rust was observed in large spots on the top of the table surface and down the table legs. Smoking ashtrays were placed on these two tables. Two of the three fabric and plastic chairs were observed heavily torn and ripped in the seat area. One small red cigarette trash receptacle was placed in the back and behind two chairs making it difficult to access. A large silver tin/metal trash can was observed with a lid that was only coving approximately 1/4 of the top, leaving the inside of the trash can exposed. Further observations revealed over fifty cigarette butts lying on top of the plastic liner in the bottom of the trash can. The lid to the trash can had a sheet of paper on it with the following typed in bold: Trash Only, No Cigarette Butts. This trash can with cigarette butts in it was observed on all four days of the survey. The screened in porch led to an outside courtyard with grass, chairs, tables and a table umbrella. This area was fenced in and noted as an area where residents frequent and also smoke. There were observations of residents smoking in this area on all four days of the survey. In the courtyard area there were chairs and a bench in a grassy and landscaped area which was heavily littered with cigarette butts. There were cigarette butts strewn on the ground over a ten foot by ten foot space. No fire rated trash cans or ash trays were observed in this direct area. Random observations revealed three residents flicked cigarette butts into the grass and landscaped area after they were done smoking. There were no smoking aides/staff in this area during all times/days observed. 2. The first floor dining room was observed during three meal observations on three days of the survey to include 4/20/2021, 4/21/2021, and 4/22/2021. During times observed, there were approximately Page 1 of 27 105037 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0584 Level of Harm - Minimal harm or potential for actual harm fifteen residents being assisted with their breakfast and or lunch meal. All residents were seated in a manner to promote social distancing. Some residents were seated in their wheelchairs and others utilized chair furniture in the room. Further observations revealed five of the nine chairs in the first floor dining room had cracks and tears in the plastic seat area, leaving the surface non cleanable. Residents were observed seated in these chairs while in the dining room. Residents Affected - Some 3. During all four days of survey (4/20/2021, 4/21/2021, 4/22/2021, and 4/23/2021) the following was observed: a. Resident room [ROOM NUMBER] was observed with the main floor tiles cracked and chipped, leaving non cleanable surfaces and trip hazards. There were four to six tiles damaged. Also, the bathroom had an unbagged toilet plunger placed near the wall next to the toilet. b. Resident room [ROOM NUMBER] (a) bed was observed with dark gray non skid strips on the floor on either side of the bed. The strips were peeling and ripped up, leaving a potential trip hazard and non cleanable surfaces. Also, the bathroom walls were peeling and in disrepair. c. Resident room [ROOM NUMBER] had a black sticky substance and stains on the main floor at the door way and in between both beds. The sticky substance was present on all four days of the survey. d. Resident room [ROOM NUMBER] (b) had gray colored non skid strips on the floor at bed side. The strips were torn and ripped leaving non-cleanable surfaces. e. Resident room [ROOM NUMBER] (a) had heavy scraped walls and material peeling off the wall near the bed. The walls in the bathroom were observed in disrepair with heavy scratches and the plastic baseboards in the bathroom and main room were not secured and peeling away from the wall, leaving a non cleanable surface. f. Resident room [ROOM NUMBER] bathroom was observed with an unbagged toilet plunger. g. Resident room [ROOM NUMBER] had a sticky floor that was soiled with a black substance on all four days of the survey. h. Resident room [ROOM NUMBER] had a sticky floor that was soiled with a black on all four days of the survey. Interview with a passing nurse stated, oh that floor is like that all the time. It's from the wheelchairs. i. Resident room [ROOM NUMBER] main floor tiles throughout the entire room were observed sticky with black substance and stained during all four days observed. j. Resident room [ROOM NUMBER] bathroom observed with an unbagged toilet plunger. k. Resident room [ROOM NUMBER] (a) floor tiles between bed wall and roommate's bed was observed soiled with a black sticky substance on all four days observed. On 4/23/2021 at 10:15 a.m. an interview with the Maintenance Director, who was also the Housekeeping Director revealed that it was the responsibility of the housekeeping staff to clean rooms appropriately. The Maintenance/Housekeeping Director reported that meant they clean and disinfect all high touch surfaces in rooms and other resident and employee spaces. She further revealed that staff were 105037 Page 2 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to change trash from resident bathrooms, wipe space/equipment, and sweep and mop in both resident bathrooms and rooms on a daily basis. She was aware that there were floors and walls in disrepair and that they do their best to make repairs, but it's always ongoing. She also revealed that when it comes to the main dining rooms, all equipment, tables, and chairs were to be wiped and disinfected and staff were to sweep and mop after each meal and in between if need be. She was unaware of the chairs that were in disrepair and stated her staff should tell her things like that when they see it. The Maintenance Director/Housekeeping Director also explained that it was maintenance and housekeeping's responsibility to clean and maintain the grounds where residents smoke to include the screened in smoking porch and the outer courtyard where residents frequent and smoke. She revealed that they should be ensuring the areas were clean and free from cigarette butts and picking up cigarette butts on a daily basis. She did not have a cleaning schedule document to include the smoking areas and did not have documentation to show how it was cleaned and when. She did confirm all the cigarette butts that were present on the grass in the courtyard. She also confirmed the tables and chairs in the smoking porch were in disrepair, with paint chipped off and leaving large areas of rust. She also confirmed one fabric chair in the smoking porch was ripped and torn, leaving a non-cleanable surface. A review of the policy and procedure titled Environment with an effective date of 11/26/2016 revealed: Policy: It is the policy of the facility to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible, according to state and federal regulations. Procedure: #3 The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Procedure: #7 revealed; The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. 4. On 4/21/21 at 9:47 AM, an observation was conducted in resident room [ROOM NUMBER]A. The over the bed table had thick dried yellow-brown matter on the base. There were faded brown splatters on the wall across from the left side of the bed. On 4/23/21 at 9:19 AM, another observation was conducted in room [ROOM NUMBER]A. The base of the over the bed table still had the thick dried yellow-brown matter on it. The wall across from the left side of the bed also still had the splatters on it. Staff L, CNA (certified nursing assistant) was present during the observation. An interview was conducted with Staff L, CNA. She said housekeeping cleans the rooms once a day and comes back around a second time later. CNAs only clean the tops of the bedside tables after meals and as needed. On 4/23/21 at 10:28 AM, an interview was conducted with the Environmental Services Director. Photographic evidence was shared with her during the interview. She said every resident room was cleaned daily. She confirmed that part of their duties included cleaning walls and bases on tables. She confirmed housekeeping services should have cleaned the table base and wall. Review of the policy, Infection Control-Cleaning and Disinfection/Non-Critical Care and Shared Equipment, revised 5/30/18, revealed the following information: 105037 Page 3 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0584 Purpose: Level of Harm - Minimal harm or potential for actual harm What is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with state and federal regulations, and national guard lines. Residents Affected - Some Procedure: 1. Cleaning and disinfection of the facility including resident rooms is completed in accordance with environmental services policies and procedures. 4. Environmental services staff is to focus on cleaning and disinfection of high touch surfaces such as TV remotes, call buttons, over-bed tables, etc. Photographic evidence was obtained. 105037 Page 4 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0656 Level of Harm - Minimal harm or potential for actual harm 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** 2. A review of Resident #59's current active care plan revealed the following: Residents Affected - Few -Resident #59 smokes on a regular basis, (last reviewed 12/31/2020), with interventions to include but not limited to: Encourage him not to have lighters in his room. Inform resident of appropriate areas and redirect as needed. Assess for safety per policy and as needed. Notify Administrator of non-compliance. On 4/20/2021 at 10:30 a.m., an interview with Resident #59 revealed he smokes sometimes and did not remember if there was scheduled times for smoking. He was asked if he keeps his cigarettes and his lighter. The resident pointed to his left front pant pocket referring to the cigarettes and proceeded to pull out the lighter from the same pocket. On 4/20/2021 at 12:45 p.m., Staff A, Licensed Practical Nurse (LPN) was asked if there were any residents on her unit that smoked. She reported that Resident #59 smoked and was unsure when he went out to smoke. Staff A was asked about the safekeeping of cigarettes and lighting devices. Staff A stated that she believed the residents were not allowed to keep lighters and cigarettes and that they should be kept at the nurses' station. She was unsure if Resident #59's cigarettes and lighting device were at the nurses' station at that time. She was asked to check with the resident because he told the surveyor he had his cigarettes and lighter on him. Staff A did not return to speak to the surveyor with any information on this day. On 4/21/2021 at 8:30 a.m., Resident #59 was observed in his room, seated upright in bed and watching television. Resident #59 reported that he smoked sometimes. He reported that he smoked, downstairs, outside in the porch. He was asked where he gets his cigarettes. Resident #59 took his left hand and brought it to his left pant pocket and said, I keep them here. He was asked how he lights his cigarettes and Resident #59 again pointed at his left pant pocket and said, I have a lighter with me. He confirmed that he does not go to nursing to get his cigarettes and/or lighter devices. He said he keeps them on his person at all times. Review of Resident #59's medical record revealed he was admitted to the facility on [DATE] and was at the facility for long term care. Review of the advanced directives revealed Resident #59 was his own decision maker. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognitive impairment. Review of the smoking assessment dated [DATE] revealed a Score of 2 which indicates a minimal risk of resident harm while smoking tobacco products. These Residents are deemed independent and responsible for their actions while smoking at the facility. The narrative section of the smoking assessment noted: safe smoker. On 4/23/2021 at approximately 9:00 a.m., an interview was held with the Director of Nursing (DON) and Nursing Home Administrator (NHA) related to smoking. They both indicated that residents were not allowed to keep any smoking devices, supplies and/or lighting devices. They reported that staff were to keep those supplies at the nurses' station and provide them to the resident upon request. They also revealed that when residents were finished smoking, whether they are safe smokers or not, the supplies were brought back to the nurse to keep in either the nurses' station or medication cart. The NHA believed that Resident #59 stopped smoking and they did not think he had any cigarettes and or 105037 Page 5 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0656 Level of Harm - Minimal harm or potential for actual harm lighting devices on him. The DON confirmed Resident #59's current care plans revealed he was a smoker and that he should not have a lighter on his person. On 4/23/2021 at 9:00 a.m., the NHA provided the policy titled Smoking Policy - Residents last reviewed 6/24/2018. The policy revealed This facility shall establish and maintain safe resident smoking practices. Residents Affected - Few The procedure section revealed residents with smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. Based on observations, interviews, and review of clinical records and policies and procedures, the facility failed to develop a care plan for one (#30) of 32 sampled residents related to respiratory care and behaviors and failed to implement care plan interventions related to smoking for one (#59) of 32 sampled residents. Findings included: 1. On 04/21/21 at 9:41 a.m., Resident #30 was observed lying in the bed flat on his back. The head of the bed was not elevated. The resident was sleeping. An oxygen concentrator was noted in the room running. Resident #30 was noted to have the oxygen tubing with a nasal cannula lying in the bed beside him. A review of the medical record for Resident #30 indicated the resident had a diagnosis of congestive heart failure, hypertension, and obstructive sleep apnea. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of the physician orders indicated the following active orders related to respiratory care: Atrovent administer one vial via nebulizer every six hours for shortness of breath or wheezing; check oxygen saturation every shift; oxygen 2 liters per minute via nasal cannula to keep oxygen saturation above 93%; auto CPAP 5-15 sonometers with heated humidification (dated 4/12/21). A review of the provider progress notes for Resident #30 indicated the following: -a visit dated 4/7/21 noted Resident #30 stated to the provider he was supposed to be assessed for a CPAP machine and the provider plan requisition the hospital for a sleep study. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. -a visit dated 4/12/21 noted Resident #30 reported experiencing sleep apnea that wakes him frequently while sleeping and an infrequent cough that is non-productive. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. Provider plan for automated CPAP at 5-10 sonometers with heated humidity. -a visit dated 4/20/21 noted a follow up for CPAP. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. The resident reported in a discussion to had used the CPAP only once. The resident reported a history of sleep apnea while in the hospital and was told to use a CPAP machine. He stated he had used a CPAP at home. The provider noted a repeat sleep study can wait until discharge and the resident should use an automated CPAP with heated humidification without a study. 105037 Page 6 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/22/21 at 1:40 p.m., Resident #30 was observed lying in the bed in his room with oxygen on at 2 liters per nasal cannula via an oxygen concentrator. An interview was conducted with Resident #30 who stated he had not had a test for sleep apnea while at the facility. Resident #30 stated a nurse brought in the sleep apnea machine and put it on him for one night for about four hours, but the machine came apart at the tube and the nurse never came back in to put it back on. He stated he had not had the CPAP on again since that time. Resident #30 stated he does get short of breath and it wakes him up a lot in his sleep. He stated he had a CPAP machine at home before he became sick. He indicated he did wear it at home and would do so if the machine was working. The CPAP machine was noted on the bedside table in a bag. Photographic evidence was obtained. A nebulizer machine was noted on the bedside table with the tubing and mask chamber on the floor under the resident's bed. Photographic evidence was obtained. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/22/21 at 2:30 p.m. The ADON confirmed an order for CPAP dated 4/12/21 for Resident #30. The ADON stated no sleep study had been done and the therapy was ordered by the ARNP after she evaluated the resident. The ADON stated the resident received the machine and it was put on one time by the nurse. She stated the resident did not like the machine and he took it off. She stated the CPAP machine was not fitted for him to her knowledge. The ADON was asked if Resident #30 was refusing to wear the CPAP and if documentation supported the refusal. She indicated refusal was not documented for the CPAP therapy. The ADON confirmed the CPAP therapy for Resident #30 was not being provided by nursing as ordered. A review of the Comprehensive Care Plan for Resident #30 revealed no focus areas associated with respiratory care or behaviors related to refusing care and treatments related to respiratory care. An interview was conducted with Staff J, Registered Nurse, MDS Coordinator on 4/22/21 at 2:46 p.m. Staff J stated if a resident is on oxygen therapy, CPAP therapy, or refuses care related to the therapies prescribed these items should be a focus area on the Comprehensive Care Plan for the resident. She stated she was responsible for the initial care plan. Staff J, RN MDS stated she goes to see each resident and reviews the chart to get the initial care plan information. Staff J, RN MDS indicated all care plan items were reviewed by the care team to make sure the focus areas are accurate. Staff J, RN MDS reviewed the current care plan for Resident #30 and confirmed there were no focus areas associated with respiratory care or refusal of care on the comprehensive care plan. She stated she would make sure the focus areas were updated. A review of the facility policy entitled Comprehensive Care Plan with an effective date of 11/26/16 and a revised date of 5/25/18 indicated the following: Purpose: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service, and intervention. It is utilized to plan for, and mange resident care as evidenced by documentation from admission through discharge for each resident. Procedure: 2-The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10 (c)(2) and 483.10(c)(3), that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: a-the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40. b-any services that would otherwise be required under 483.24, 483.25 or 483.40 but 105037 Page 7 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0656 are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105037 Page 8 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interviews, and policy review the facility did not ensure systems and processes for treatment of a pressure ulcer were implemented related to timely treatment of infection, appropriate disinfection of treatment supplies, maintenance of dressings on a pressure ulcer, adequate cleansing of the pressure ulcer, and appropriate application of the ordered treatment in a manner to prevent the worsening of a pressure ulcer for one resident (#40) of two residents sampled for care and services for pressure ulcers. Residents Affected - Few Findings included: Resident #40 was admitted to the facility with a diagnosis of type II diabetes mellitus, according to the face sheet in the admission record. A review of the history and physical from the hospital, dated 11/4/20, reflected a chief complaint of pressure sore on coccyx. A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 03/03/21, section H, bladder and bowel, revealed Resident #40 was always incontinent of urine and bowel. Review of Section M, skin conditions, reflected a stage 4 pressure ulcer present on admission or readmission. A review of physician's orders in the medical record reflected the following findings: 4/13/21 2 view x-ray of sacrum/coccyx 4/14/21 culture wound to coccyx on 4/15/21 coccyx wound tx (treatment) changed -cleanse with normal saline (NS), pat dry, apply Santyl, calcium alginate and cover with padded dressing. 4/19/21 Place PICC line, may use 1% lidocaine Vancomycin 1 gram IV (intravenous) Q (every) 24 hours for 6 weeks. Pharmacy to dose. Vancomycin, BMP, Sed rate, CRP weekly while on Vancomycin. Indication/dx (diagnosis) MRSA Chest x-ray to be done after PICC inserted for placement. On contact precautions. 4/20/21 Apply triple antibiotic solution (GCP irrigation solution) to coccyx area BID (twice a day) with a dry padded dressing. Draw Vancomycin trough and serum creatinine on Wednesday, 4/21/21 30 minutes before dose is given. Fax results to pharmacy. 4/21/21 Continue previous treatment to coccyx until abt (antibiotic) solution arrives. 4/22/21 clarification order: ok to hold IV until PICC line placed and verified placement. 105037 Page 9 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 Start Vancomycin 1 gm IV Q 24 Hrs for 6 weeks. Pharmacy to dose vanco. BMP, sed rate, CRP, weekly while on vanco. Need Cxr (chest x-ray) to verify placement. Level of Harm - Minimal harm or potential for actual harm Cxr 1 view PICC line placement check Residents Affected - Few Review of nurses' notes revealed the following: 4/4/21 coccyx wounds cleansed with NS (normal saline), dry, medihoney and calcium alginate applied and padded dressing. No s/s (signs symptoms) of infection noted. 4/13/21 coccyx wound order changed to cleanse with NS, pat dry, apply Santyl, calcium alginate, and cover with padded dressing. Seen by wound dr (doctor). Dr also ordered CRP, CBC, because resident's wound looks worse. Also a 2 view X-ray to sacrum/coccyx. 4/19/21 Culture results for coccyx wounds reviewed. Notified ARNP. New orders to place PICC line. Start Vancomycin 1 gram Q (every) 24 hours x 6 weeks. Pharmacy to dose. BMP, sed rate, CRP weekly labs while on Vanco. Resident placed on isolation for MRSA in wound. Called the IV company. Spoke to tech and confirmed IV nurse to come today to insert Midline. 4/20/21 Resident seen by wound Dr. Tx (treatment) orders to coccyx has changed to apply triple abt (antibiotic) solution -cover with padded dressing. Resident also on antibiotic for wound infection. There were no further notes in the record related to PICC line, iv antibiotic, or new treatment to the coccyx. Review of the wound evaluation and management summary from the wound care consultant reflected the following measurements and assessments: 2/2/21 1.7 x 1 x 1 cm stage 4 pressure wound of the right coccyx etiology: pressure exudate (drainage): light sero-sanguainous granulation tissue: 100% The report indicated the physician debrided the wound to remove biofilm, and ordered leptospermum honey daily for 16 days with a gauze island border dressing. 2/9/21 1.7 x 1 x 1 cm stage 4 pressure wound of the right coccyx exudate: moderate serosanguainous 105037 Page 10 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 granulation tissue: 100% Level of Harm - Minimal harm or potential for actual harm wound progress: no change The physician continued the previous treatment. Residents Affected - Few 2/16/21 2 x 2.8 x 1 cm exudate: light serosanguainous slough: 5% granulation tissue: 95% wound progress: deteriorated Physician changed the treatment to collagen powder and leptospermum honey once daily for 30 days with a gauze island border dressing. 2/23/21 2 x 2.8 x 1 cm exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change The physician changed the treatment to collagen sheet twice a week for 30 days, with a NPWT (negative pressure wound therapy) pump. 3/2/21 2 x 2.8 x 1 undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change 105037 Page 11 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 The physician indicated to continue the current treatment. Level of Harm - Minimal harm or potential for actual harm 3/9/21 2 x 2.8 x 1 cm Residents Affected - Few undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change Dressing treatment plan: continue collagen sheet twice a week with NPWT 3/16/21 2 x 2.8 x 1 cm Periwound radius: surrounding DTI (deep tissue injury) (purple/maroon) undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change Dressing treatment plan: leptospermum honey, alginate calcium and a foam silicone border dressing twice a day 3/23/21 2 x 4 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% 105037 Page 12 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 granulation tissue: 95% Level of Harm - Minimal harm or potential for actual harm wound progress: deteriorated Dressing treatment plan: continue treatment twice a day Residents Affected - Few 3/30/21 2 x 4 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous slough: 5% granulation tissue: 95% wound progress: no change Dressing treatment plan: continue treatment twice a day No assessment from physician or nurse was provided for the week of 4/6/21. 4/13/21 3.7 x 4 .2 x 1 cm undermining: 0.5 cm at 9 o'clock exudate: moderate serosanguainous Thick adherent devitalized necrotic tissue: 20% slough: 20% granulation tissue: 60% wound progress: deteriorated Please draw ESR/CRP and repeat CBC (labs). Patient had elevated WBCs, possibly due to a UTI (urinary tract infection) however wound was also worse and concerns for wound infection. Please obtain 2 view x-ray sacrum/coccyx rule out osteomyelitis, in addition to labs. Santyl was added to the twice daily treatments, and the leptospermum honey was discontinued. 4/20/21 3. 5 x 4 x 1 cm 105037 Page 13 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 undermining: 0.5 cm at 9 o'clock Level of Harm - Minimal harm or potential for actual harm exudate: moderate serosanguainous Thick adherent devitalized necrotic tissue: 20% Residents Affected - Few slough: 20% granulation tissue: 60% wound progress: improved Dressing treatment plan: triple antibiotic solution twice daily and foam silicone border dressing additional wound detail Patient on IV (intravenous) ABT (antibiotic) for 6 weeks for suspected osteomyelitis Review of the 4/14/21 radiology report for a 2 view x-ray of the sacrum/coccyx revealed the following: conclusion: cannot exclude osteomyelitis, recommend MRI workup. The report was initialed by a nurse who indicated the ARNP (advanced registered nurse practitioner) was notified and ordered a wound culture. Review of the lab report dated 4/15/21 for the culture and sensitivity of wound and abscess reflected moderate MRSA (methicillin resistant staphylococcus aureus), few E. Coli (Escherichia coli), and rare Proteus mirabilis The susceptibility report dated 4/19/21 reflected the MRSA susceptibility to Vancomycin On 4/22/21 at 11:35 AM an observation was conducted during pressure ulcer care with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN reported that the order was changed to GCP (triple antibiotic) Tuesday but the pharmacy doesn't have it. They are supposed to send it today. The doctor said it is ok to continue the current treatment until it arrives. Staff F, LPN donned a gown and gloves after gathering supplies for the treatment; Santyl, normal saline syringes, dressing, calcium alginate, and gauze 4 x 4's. After knocking on the door, Staff F, LPN placed all the supplies on a paper towel on the bed side table. Resident #40 requested a pain pill. Staff F, LPN removed the PPE (personal protective equipment) and performed hand hygiene. When Staff F, LPN returned she said the resident's nurse said she can't have a pain reliever again until 1: 00 PM. Staff F, LPN put on another gown, performed hand hygiene, and put on a pair of gloves. Staff F, LPN informed Resident #40 she could not have the pain pill again until 1:00. Staff F, LPN asked Resident #40 if she could do the treatment or would she rather wait until after 1:00. Resident #40 said it was ok to do the treatment now. Staff F, LPN removed her gloves and washed her hands in the bathroom sink. She put on a new pair of gloves. Then Staff F, LPN assisted Resident #40 to her right side. Resident #40 was clean and groomed and free from any odor. There was not a PICC line observed on either of Resident #40's arms. Staff F, LPN removed the brief tab from Resident #40's left side and pulled the brief down to expose Resident 105037 Page 14 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #40's coccyx area. There wasn't a dressing on the wound. Staff F, LPN said no one reported the dressing came off. She changes it every day. The brief appeared to be dry. The wound was on the resident's right coccyx area about a half inch about her anus. It was about a one inch length by a half inch wide and a depth of about an inch. The wound was a stage 4, deep tissue injury. There was a small amount of slough (yellow, necrotic tissue) at about 4:00 on the right side of the wound. No odor was detected. The wound bed was bright red. The surrounding tissue was red and slightly dry and flaky and excoriated (inflamed and irritable). Staff F, LPN removed the gloves and performed hand hygiene. Then she put on a clean pair. Staff F, LPN opened one of the saline syringes and squeezed the contents onto a gauze 4 x 4. Then Staff F, LPN used the saline dampened gauze to dab and pat all around the wound on the periwound (surrounding tissue) completing a circle around the wound. Staff F, LPN used a clean gauze 4 x 4 to pat the periwound dry. Again dabbing all around the wound. Staff F, LPN did not clean the wound or the slough on the right outer edge of the wound. Staff F, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff F, LPN put on a clean pair of gloves and opened the dressing packaging and the calcium alginate. Staff F, LPN removed a pair of scissors and a felt tipped marker from her pocket. Staff F, LPN did not clean the scissors. She used the contaminated scissors to cut a piece of alginate about one inch by half an inch. She placed it back on the package. The surveyor asked if the scissors came from her pocket and Staff F, LPN confirmed they did. She said she cleaned them with bleach before she put them in her pocket. Staff F, LPN then dipped her contaminated gloved right finger into the medication cup with the Santyl in it. She applied the Santyl to the area of slough on the right mid-lower corner of the wound. Then Staff F, LPN placed the calcium alginate on top. Staff F, LPN removed her gloves and washed her hands in the bathroom sink. Then Staff F, LPN put on a clean pair of gloves and used the felt tipped marker to date the dressing. Next, Staff F, LPN covered the wound with the adhesive dressing. Staff F, did not apply any of the calcium alginate to the wound bed. Then Staff F, LPN removed the gloves and disposed of the remaining supplies. Staff F, LPN washed her hands in the sink, and put on clean gloves. Staff F, LPN reapplied the brief tab, and assisted Resident #40 to her back, after placing a foam wedge behind her back. Then Staff F, LPN removed the gown and gloves, and washed her hands in the sink. Staff F, LPN exited the room and used a bleach wipe to clean the scissors and the felt tipped marker. She placed them on a paper towel on top of the treatment cart. At 12:03 PM on 4/22/21, an interview was conducted with Staff F, LPN. The surveyor asked if Staff F, LPN only cleaned the periwound and not the wound bed. Staff F, LPN replied, Is that what you saw me do?The surveyor replied that is correct. Staff F, LPN confirmed she did not clean the inside of the wound. Staff F, LPN said the order says to do Santyl then alginate, it does not say inside the wound. On 4/22/21 at 1:27 PM, an interview was conducted with the resident's nurse, Staff G, LPN. Staff G, LPN said they are waiting for the pharmacy technician to put the PICC line in. The PICC was ordered the day before yesterday. Staff G, LPN said Resident #40 is not getting antibiotics. They are waiting for the PICC. During the interview, the order was reviewed for the PICC and Vancomycin. Staff G, LPN confirmed the PICC and Vancomycin were ordered on 4/19/21. She said the IV nurse is here now putting the PICC line in. On 4/22/21 at 1:57 PM an interview was conducted with the second floor unit manager and risk manager at the facility. She confirmed Resident #40 had MRSA in the wound. The unit manager said 4/19/21 was when they got the final culture. It was reported to the primary (physician). The wound physician was here on the twentieth and was also made aware. The primary ordered Vancomycin IV and a PICC. The unit manager said it is usually four hours to get a PICC line inserted. They travel from out of the area. All of us nurses are responsible for it. It is an IV company. They were contacted via 105037 Page 15 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few telephone multiple times. The unit manager said she notified the physician this morning (three days later). She said she was sure the other nurses notified the primary also. She is here every day. She is an ARNP (Advanced Registered Nurse Practitioner). The ARNP said it was ok to hold the Vancomycin until the PICC was placed and verified. On 4/22/21 at 2:19 PM an interview was conducted with Staff H, Certified Nursing Assistant (CNA). Staff H, CNA said she changed Resident #40 after breakfast around 10:00, and she changed her a little bit ago again. The dressing fell off because she had a bowel movement (bm). The wound nurse was downstairs. The bm is always going to go in the wound because of where the wound is. So when they change her they clean her real good to make sure it isn't getting in there. On 4/22/21 at 5:07 PM a telephone interview was conducted with the ARNP overseeing Resident #40's care. She said she was notified on the twentieth and the twenty-first that the PICC was not inserted. The ARNP said she asked staff yesterday and was told they were having trouble getting hold of the IV company. Staff reported the IV nurse didn't come and they had called the company every day. The ARNP said she doesn't think that there is going to be a significant outcome. She is monitoring the wound with the wound doctor and treatment nurse. She said it doesn't typically take this long to get a PICC. She said she orders more midlines than PICCs, but the length of treatment is six weeks. I ordered a PICC on her on the 20th. She doesn't have osteomyelitis. She said the PICC is in now and the x-ray was completed. She was waiting for the x-ray result. On 4/22/21 at 5:47 PM an interview was conducted with the DON. She said she was made aware of the delay yesterday. They called the pharmacy and the IV nurse contracted with the pharmacy. You all came Tuesday and so nobody made me aware it was not done. Staff left voice messages and were told the IV nurse would be out the next day. She is contracted with the pharmacy and she is supposed to come out within twenty-four hours. She did not come. When I got the message last night I reached out to the IV nurse line. Nobody answered. I called for the on-call nurse, nobody answered. I called the pharmacy and was told they would reach out to her and get back to me. I told them it was not acceptable. I told the NHA (nursing home administrator) who also reached out to them, and we got a call she would be out today. I let the ARNP know. She usually writes 'may hold antibiotic until PICC is placed'. Resident #40 has a lot of comorbidities. If we saw a fever or altered mental status signs we would send her to the hospital. It is not acceptable and we will address it with the pharmacy to see how we can get better service related to that. The ARNP did a progress note 'may hold vanco until PICC placed'. That was 4/20. We would send her to the hospital if she had a fever or symptoms. That is why we got an order to keep the previous treatment until we get the GCP solution. This is a newer treatment. It's not something we have had before. It seems like there is a problem getting it right away. It takes two to three days to get it. I can call them and see how long it's going to take. That's why we kept the previous treatment, so we have something until it comes in. I think we have used other solutions until the triple antibiotic solution came in. The wound doctor comes every Tuesday so the nurse puts whatever he orders. I will reach out to the pharmacy because I have a lot of concerns. It's kind of left to interpretation on how to clean a wound. If the doctor wants to irrigate it he would write an order. If it says to clean it you would use a 4x4 gauze and a cleaning solution. I would go dirtiest to the cleanest. I would clean the inside, but I would clean it last. You would do the outside then the inside with a different gauze. She should have cleaned the whole area. I would think if something is that bad with tunneling he should order some irrigation and clean it with a syringe. She was nervous. I think it's up to the nurse to clean it in the way she interprets the order. If the staff knew the dressing came off they should have went to the nurse so she could put a dressing on. They probably need to use a different dressing, something that sticks. 105037 Page 16 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 Level of Harm - Minimal harm or potential for actual harm On 4/23/21 at 10:18 AM a follow up interview was conducted with the ARNP. She said she has seen the wound and she referred the resident to wound care. They are following the wound. If I catch the wound care nurse I go in with her. If I miss her she takes a picture and brings it to me. Yes, they need to pack the wound. Santyl isn't going to work on healthy tissue. It has been taking forever to get the delivery of care over the last couple of weeks. They used to be same day. We expect twelve to twenty-four hours. Residents Affected - Few On 4/23/21 at 12:12 PM a follow up interview was conducted with the DON. She confirmed the scissors need to be cleaned before using them during a clean treatment. On 4/23/21 at 12:42 PM a telephone interview was conducted with the consultant pharmacist. She said she was not notified about the GCP solution. She will call the pharmacy and follow up. She said the pharmacy contracts with a company who inserts the PICCs. The facility can call the pharmacy and the pharmacy contacts the company with the consult. She doesn't hear that as a consultant. This is very concerning. When the surveyor asked what the potential outcome could be related to the delay, she said further infection or spread. Others can get infected also. Usually if they order a treatment it should be at the facility on the next run. She would have to see if that was anything special that would require a special preparation. The PICC line should be as long as it takes for someone to drive there after the order is received. She was not aware of these concerns. The pharmacy manager would be the person who would be notified of the delay with the PICC. On 4/23/21 at 1:48 PM a telephone interview was conducted with the wound care physician. The surveyor asked what the potential outcome of an untreated infection of the wound might be. The physician said, further infection if it is not treated as soon as possible. He said he suspects it is probably chronic osteomyelitis. The antibiotic probably should have been started within twenty-four hours. The IV treatment was more important than the topical. He did the topical as an adjuvant to go along with the IV. The resident didn't have a fever. The order should be to cleanse the wound with normal saline and then dry it. Santyl should be applied with a swab and tongue depressor, and then apply a dressing. He also confirmed the treatment should be applied to the wound bed. A review of the policy, Treatment/Services to Prevent/Heal Pressure Ulcers, revised 5/24/18, reflected the following: Purpose It is the policy of the facility to ensure it identifies and provides needed care and services that a resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: a. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and b. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from 105037 Page 17 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0686 developing. Level of Harm - Minimal harm or potential for actual harm 5. Interventions will be implemented in the residence plan of care to prevent deterioration and promote healing of the pressure sore. Residents Affected - Few 7. The pressure sore will be evaluated weekly and the nurse will document the size, location, odor if any, drainage if any, and current treatment ordered. A review of the policy, Wound Care, revised 3/5/18, revealed the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Procedure The nurse will follow the physicians orders for treatment using clean technique and following infection control procedures. 105037 Page 18 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review the facility failed to ensure a root cause analysis and meaningful interventions were implemented to prevent accidents for one (#8) of three residents reviewed for falls. Findings included: Resident #8 was admitted to the facility with diagnoses of dementia and history of falling, according to the face sheet in the admission record. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 3, indicating Resident #8 had severe cognitive impairment. Review of the 72 hour charting/report reflected Resident #8 was transferring herself from bed to wheelchair and her leg gave out and fell to her bottom on 4/3/21. A review of the facility documentation for Resident #8 reflected she had fallen on the following dates: 12/11/20 1/9/21 1/16/21 2/28/21 3/3/21 4/3/21 Review of the care plan dated 10/28/20 revealed no new interventions following the 4/3/21 fall had been implemented. A review of the 4/3/21 fall documentation revealed Resident #8 was going from her bed to the wheelchair and fell due to her leg giving out. No apparent injuries noted. She was noted as non compliant with interventions for falls, unable to educate on safety. The documentation revealed no intervention was implemented following the 4/3/21 fall. On 4/22/21 at 2:57 PM, an interview was conducted with Staff I, LPN (Licensed Practical Nurse) MDS coordinator. Staff I, LPN said Yes, we write the new interventions on the care plan. If they have a fall we write them in. When we do the review we write a new intervention. When a resident has a fall, the manager on the floor brings the chart to the morning meeting and the IDT (interdisciplinary team) discusses it, and we update the care plan. Staff I, LPN said the new intervention should be on the care plan. Staff I, LPN reviewed the care plan and confirmed there wasn't an intervention for the 4/3/21 fall. Staff I, LPN said she doesn't necessarily update the care plans. Sometimes she does, but the unit managers or DON (director of nursing) usually update the care plans in the morning 105037 Page 19 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0689 meetings. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the second floor unit manager and risk manager for the facility on 4/22/21 at 3:14 PM. The second floor unit manager said Resident #8 was non-compliant. She said they have done a medication review and referred Resident #8 to therapy who gave her a new walker. Resident #8 won't use the new walker. She gets up unassisted all the time. Therapy put her in a wheelchair. The intervention was to continue the current plan of care since she was non-compliant. She hasn't had a fall in a month. She doesn't walk anymore. She still tries to get up to go to the bathroom all the time by herself. The second floor unit manager also confirmed Resident #8 has dementia. Residents Affected - Few On 4/22/21 at 6:10 PM, an interview was conducted with the DON. The DON confirmed there should be a new intervention after every fall. If they have behaviors, sometimes we continue the previous intervention. We run out of interventions, especially if it's a behavior. There should be some intervention, even if it's continue previous interventions. We talk about it in our morning meeting. Resident #8 was Spanish speaking with dementia. Staff say what she says doesn't always make any since. She was very stubborn. You can ask her to use a walker and she will walk by herself. We tried several things with her. We have changed walkers, and went to a wheel chair. We discuss Resident #8 quite a bit. Review of the policy, Falls and Fall Risk Management, dated 7/29/13, revealed the following: Purpose: To identify possible interventions that address the resident's specific fall risk factors and to minimize the falls the resident incurs and potential complications from the fall. Standard: To prioritize approaches to help manage falls and fall risk and thereby minimize the potential for falls and associated injuries. Process: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to minimize the falls the resident incurs while also trying to minimize complications from falling. 1. The nursing staff and Interdisciplinary team will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once) to try to minimize serious consequences of falling. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the nature or category - root cause analyses of the fall, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. If a resident refuses an intervention the risk and benefits will be reviewed with the resident and/or responsible party. Additional and/or alternative interventions may be implemented at that time. 105037 Page 20 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0689 Level of Harm - Minimal harm or potential for actual harm 10. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 11. If irreversible risk factors exist that continue to present a risk for falling or injury to the resident, the Interdisciplinary Team will document the basis of that conclusion. Residents Affected - Few 105037 Page 21 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

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 reviews the facility failed to provide necessary respiratory care and services, related to proper storage of a nebulizer machine and continuous positive airway pressure (CPAP) treatments, consistent with professional standards of practice for one (Resident #30) of one resident investigated for respiratory care. Residents Affected - Few Findings included: A review of the medical record for Resident #30 indicated the resident had a diagnosis of obstructive sleep apnea. A review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #30 had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. A review of the physician orders indicated the following active orders: Atrovent administer one vial via nebulizer every six hours for shortness of breath or wheezing; auto CPAP 5-15 sonometers with heated humidification (dated 4/12/21). A review of the provider progress notes for Resident #30 indicated the following: -a visit dated 4/7/21 noted Resident #30 stated to the provider he was supposed to be assessed for a CPAP machine and the provider plan requisition the hospital for a sleep study. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. -a visit dated 4/12/21 noted Resident #30 reported experiencing sleep apnea that wakes him frequently while sleeping and an infrequent cough that is non-productive. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. Provider plan for automated CPAP at 5-10 sonometers with heated humidity. -a visit dated 4/20/21 noted a follow up for CPAP. Physical exam revealed abnormal breath sounds/voice sounds with rales and crackles heard. The resident reported in a discussion to had used the CPAP only once. The resident reported a history of sleep apnea while in the hospital and was told to use a CPAP machine. He stated he had used a CPAP at home. The provider noted a repeat sleep study can wait until discharge and the resident should use an automated CPAP with heated humidification without a study. A review of the Medication Administration Record (MAR) for Resident #30 dated April 2021 revealed an order written in for auto CPAP 5-15 sonometers with heated humidification dated to begin on 4/12/21. No nurse documentation was noted indicating the therapy had been provided as ordered on any date in April 2021. On 4/22/21 at 1:40 p.m., Resident #30 was observed lying in the bed in his room with oxygen on at 2 liters per nasal cannula via an oxygen concentrator. An interview was conducted with Resident #30 who stated he had not had a test for sleep apnea while at the facility. Resident #30 stated a nurse brought in the sleep apnea machine and put it on him for one night for about four hours when the machine came apart at the tube, and the nurse never came back in to put it back on. He stated he had not had the CPAP on since that time. Resident #30 stated he does get short of breath and it wakes him up a lot in his sleep. He stated he had a CPAP machine at home before he became sick. He indicated he did wear it at home and would do so if the machine was working. The CPAP machine was noted on the 105037 Page 22 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bedside table in a bag. A nebulizer machine was noted on the bedside table with the tubing and mask chamber on the floor under the resident's bed. Photographic evidence was obtained. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/22/21 at 2:30 p.m. The ADON confirmed an order for CPAP dated 4/12/21 for Resident #30. The ADON stated no sleep study had been done and the therapy was ordered by the ARNP after she evaluated the resident. The ADON stated the resident received the machine and it was put on one time by the nurse. She stated the resident did not like the machine and he took it off. She stated the CPAP machine was not fitted for him to her knowledge. The ADON was asked if Resident #30 was refusing to wear the CPAP and if documentation supported the refusal. She indicated refusal was not documented for the CPAP therapy. The ADON confirmed the CPAP therapy for Resident #30 was not being provided by nursing as ordered. An interview was conducted with the Director of Nursing (DON) on 4/22/21 at 3:20 p.m. The DON indicated she was aware of the CPAP order for Resident #30. She stated the ARNP explained a sleep study was not required for the settings ordered and wanted to get the therapy going due to the resident having it at home prior to admission. She indicated she did not know why the resident was not receiving the therapy as ordered. A telephone interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on 4/22/21 at 5:18 p.m. The ARNP stated she was aware Resident #30 had only worn the CPAP machine one time and she planned on speaking to the resident about it. She indicated Resident #30 was having obstructive sleep apnea and did require the CPAP therapy she ordered. A review of the facility policy entitled CPAP/BPAP Support with an effective date of 3/9/15 and a revised date of 8/1/19 indicated the following: Purpose: 1-To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2- To improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3-To promote resident comfort and safety. General Guidelines: 1-CPAP and BPAP can be used in conjunction with ventilation to improve oxygenation. 4-CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. Documentation: 1-General assessment (including vital signs, oxygen saturation, respiratory, circulatory, and gastrointestinal status) prior to procedure. 2-Time CPAP was started and duration of the therapy. 3-Mode and settings for the CPAP. 4-Oxygen concentration and flow if used. 5-How the resident tolerated the procedure. 6-Oxygen saturation during therapy. Reporting: 1-Notify the physician if the resident refuses the procedure. 105037 Page 23 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations and interviews the facility did not ensure appropriately stored refrigerated controlled substances in two of two medication refrigerators in two of two medication storage rooms on two of two nursing units (the first and second floors). Findings included: On 4/20/21 at 10:13 AM an observation was conducted on the second floor in the medication storage room with Staff A, LPN. The medication refrigerator contained a locked controlled substance box on the top shelf that was not secured to the refrigerator. Photographic evidence obtained. During the observation an interview was conducted with Staff A, LPN who said she was not aware it needed to be secured to the refrigerator. On 4/22/21 at 8:46 AM an observation was conducted in the medication room on the first floor with Staff K, RN (registered nurse). The locked controlled substance box was sitting on a shelf in the refrigerator, unsecured. Staff K, RN removed the locked box from the refrigerator and placed it on the counter. She unlocked it and opened it and removed a bottle of lorazepam 2 mg/ml. Staff K, RN closed the box and secured the lock and returned it to a shelf in the refrigerator. In an interview with Staff K, RN, she said she was not aware it needed to be secured to the refrigerator. On 4/22/21 at 5:27 PM an interview was conducted with the Director of Nurses (DON). The DON said she thought if the controlled substance kit was behind two locks it met the regulation requirement. On 4/23/21 at 12:42 PM a telephone interview was conducted with the consultant pharmacist. She said the narcotic boxes in the medication refrigerators have come up before. They have talked about it. We are in the process of changing the E-kits (emergency kits), and they possibly need a different size box to be connected to the refrigerator. 105037 Page 24 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility did not ensure two (#282, #17) of two sampled hospice residents had a record of the benefit of election for hospice and a hospice plan of care or indication of hospice personnel involved in hospice care and working in collaboration with the facility. Findings included: During multiple facility tours throughout the survey, Resident #282, a hospice resident was observed laying in bed, appeared to be resting. A review of Resident # 282's clinical record revealed an admission date of 03/30/21 with diagnoses to include: unspecified systolic (heart failure), acute encephalopathy, Gastro-esophageal reflux disease, unspecified dementia, essential hypertension, hypothyroidism, hyperlipidemia, heart disease, unspecified atrial fibrillation, dehydration, history of dementia and hypothyroid. Continued review of the record revealed no hospice physician consult order, no benefit of election, no plan of care for hospice or indication of hospice personnel involved in hospice care and no hospice contact information. A review of an admission MDS (minimum data set) dated 04/6/21 revealed under section C: a BIMS (Brief interview for mental status) of 14 indicating cognitive intact status. Section O, special treatments, procedures, and programs revealed Resident #282 was on hospice care prior to admission and while a resident. During multiple facility tours, Resident #17 was observed self propelling in the hallways. Resident #17 was noted spending most of her days outside the nurses' station. Clinical record review revealed Resident #17 was admitted to the facility on [DATE] with a diagnoses to include a history of atrial fibrillation, chronic hyponatremia, severe anemia, hypertension, cerebral atherosclerosis, and vascular dementia. A quarterly MDS (minimum data set) dated 02/8/21 revealed a BIMS (Brief interview for mental status) of 11, indicating moderate impairment. Section O, special treatments, procedures, and programs indicate resident #17 was admitted to Hospice care while a resident at the facility. Following record review, Resident #17's chart did not include a hospice physician consult order, benefit of election, plan of care or indication of hospice personnel involved in hospice care or contact information. On 04/22/21 at 09:37 a.m., Staff K, RN (registered nurse) was asked how she would know what care to provide a resident who was on hospice. Staff K, RN stated that a hospice assessment should be in the resident's chart to include a plan of care. Staff K, RN looked through Resident #282 and #17's medical record and could not find a plan of care. A follow-up interview was conducted with the ADON (Assistant Director of nursing) on 04/22/21 at 09:53 a.m. ADON stated that the plan of care should be in the resident's medical record but if it is not, we will get it. ADON looked through Resident #282 and #17's medical record and could not find 105037 Page 25 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the hospice physician consult order nor the plan of care. ADON confirmed that these documents should be available to facilitate appropriate care. On 04/22/21 at 4:35 p.m., ADON was asked how the nurses would know what treatment areas they were working on with hospice residents. ADON reiterated that the nurses should review the plan of care. ADON confirmed that it should be in the medical record. When asked how she ensures communication with the Hospice agency, ADON stated that they call them if needed. ADON was asked how she would know when to expect the Hospice agency without a plan of care. ADON stated, We know the frequency because these residents have been here for a very long time. On 04/22/21 at 11:42 a.m., ADON and NHA (nursing home administrator) confirmed that the paperwork was not in the medical record, but it was now. NHA stated that Resident #282 came from the hospital and they did not request the paperwork at the time. Resident #17 had been here for a very long time. When asked if she was aware that she was supposed to have the election statement, consents, and plan of care in the facility to collaborate care, NHA stated, Yes, we do now. An interview was conducted with ARNP (advanced registered nurse practitioner) on 04/22/21 at 04:40 p.m. When asked what the expectation would be regarding access to a hospice plan of care, ARNP stated that she expects the plan of care to be on file at the facility. ARNP said, We review them to establish continuum of care. On 04/23/21 at 12:14 p.m., an interview was conducted with DON (director of nursing) she was asked what the expectation would be regarding to having hospice plans of care available here at the facility. DON sated that there was a tab in the resident's medical record that should hold these documents. DON stated that they have some Hospice agency's that are not good about making sure we have the information, but that they will put the plan in place to ensure consistency. The DON stated that it was brought to her attention yesterday that Resident #282 and Resident #17 did not have a hospice plan of care in their records and that was why we initiated a plan to correct. Further review following interview confirmed that the hospice election statements were now present in the charts as well for Resident #282 and #17. Resident #282 entered the hospice agreement on 09/22/20 and Resident #17 entered the agreement on 08/05/20. A review of the facility's policy titled, Hospice Services with a revision date of 05/30/18, under purpose revealed: It is the policy of the facility to provide collaborative care with hospice providers to ensure that our resident's end of life preferences and choices are honored. Under (2.) When hospice care is furnished on the facility through an agreement, the following requirements will be met: (iii) The services the LTC (long term care facility) will continue to provide based on each resident's plan of care. (iv.) A communication process, including how the communication will be documented between the LTC facility and the hospice provider to ensure that the needs of the resident are addressed and met 24 hours per day. Section 5. (d) The designated interdisciplinary team member is responsible for obtaining the following information from hospice including: (i) the most comprehensive plan of care specific to each patient, (ii) Hospice election form (iii) physician certification and recertification of the terminal illness. A review of an agreement titled [Hospice Company Name], Agreement for Nursing Facility, inpatient and Inpatient respite services, entered as of 02/01/21 and is effective as of 04/01/21 by and between [Hospice Agency] and [Facility] page 5, under delineation of roles; 2.1.4 In the provision of care 105037 Page 26 of 27 105037 04/23/2021 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to Hospice patients, the facility shall be responsible for providing services as contained in the hospice plan of care, and communicating to designated . personnel any changes in condition. 2.1.5 medical records documentation, Facility shall permit the inclusion of . care plans and other appropriate documentation in the hospice patient's facility medical record to ensure documentation of services is completed as applicable for hospice patients. 2.1.7, Plan of care, . shall establish, modify, and provide the Facility a copy of a hospice plan of care for each hospice patient admitted to facility. 105037 Page 27 of 27