Health inspection·January 12, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, record review, interview, and policy review the facility failed to provide care and services related to catheter care for one resident (#25) out of six residents with indwelling catheters. Residents Affected - Few Findings included: A review of admission records revealed Resident #25 had diagnoses to include urinary tract infection, cerebral palsy, and abdominal pain. A review of Resident #25's care plan revealed a care plan for increased risk for urinary tract infection related to presence of indwelling catheter for diagnosis of urinary retention, it noted catheter was changed to suprapubic catheter on 1/25/22. Interventions included change catheter bag monthly and observe/record urine appearance. A review of physician orders revealed the following orders: 1-Cleanse suprapubic site with normal saline, pat dry, apply clotrimazole solution and cover with split 4 x 4 gauze twice daily. Order date 8/28/22. 2-Suprapubic catheter care every shift. Order date 8/28/22. A review of the electronic Treatment Administration Record (eTAR) indicated order 1 was not documented as completed on 23 out of 62 twice daily shifts in December 2022 and order 2 was not documented as completed on 22 out of 62 twice daily shifts. The January 2023 eTAR indicated order 1 was not documented as completed on 7 out of 18 twice daily shifts from 1/1/23 to 1/9/23 and order 2 was not documented as completed on 8 out of 18 twice daily shifts from 1/1/23 to 1/9/23. A phone interview was conducted with the Director of Nursing (DON) on 1/12/23 at 8:31 a.m. She stated catheter care should be documented on the eTAR and would not be documented anywhere else. She confirmed if it isn't documented on the eTAR, there is no way to know that it was done. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 1/12/23 at 8:51 a.m. She stated catheter care is done daily and would be documented on the eTAR. She was observed to check Resident #25's gauze on her suprapubic catheter site. It was observed to be dated 1/9/23. An interview was conducted with Staff H, LPN, Care Team Manager (CTM) on 1/12/23 at 10:34 a.m. Staff H reviewed Resident #25's medical record and confirmed catheter care was not being documented as Page 1 of 11 105037 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0690 completed as ordered. Level of Harm - Minimal harm or potential for actual harm A facility policy titled Catheter Care, Urinary, dated September 2012, was reviewed. The policy stated the following: Residents Affected - Few Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections. Documentation The following information should be recorded in the resident's medical record. 1. The date and time that catheter care was given. 2. The name and title of the individual giving the catheter care 3. All assessment data obtained when giving catheter care. 4. Characteristics of urine such as color and order. 105037 Page 2 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and policy reviews facility failed to ensure one resident (#25) out of thirty-one sampled residents received trauma-informed care in accordance with professional standards of practice and accounted for the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause traumatization. Residents Affected - Few Findings included: A review of Resident #25's Minimum Data Set (MDS,) section I, Active Diagnosis, dated 12/3/22, revealed a diagnosis of Post Traumatic Stress Disorder (PTSD.) A review of admission records indicated Resident #25 was admitted in 2019 with diagnoses to include anxiety, personality changes due to known physiological condition, and persistent mood disorder. A review of Resident #25's care plan revealed no care plans for PTSD or trauma-informed care. On 1/12/23 at 8:28 a.m., an interview was conducted with Staff B, Registered Nurse (RN,) MDS Coordinator, who is currently covering for the Director of Nursing (DON.) When asked if they have care plans for PTSD and Trauma-Informed care she stated, not at this time. She said she didn't think they had any residents with PTSD. When asked who enters the diagnoses into the MDS she stated, I do. When informed of Resident #25 having a PTSD diagnosis in her 12/3/22 MDS she stated, I must have just missed that one. Staff B continued and stated she was surprised Resident #25 had a PTSD diagnosis, but maybe it was related to sexual abuse because she did have issues with exposing herself to men previously. Staff B stated she would add a care plan immediately. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 1/12/23 at 8:51 a.m. She confirmed she was currently assigned to Resident #25. She stated she did not know the resident had a PTSD diagnosis. She said she has had the resident previously and has not seen any behaviors and doesn't know what the PTSD diagnosis was related to. An interview was conducted with Staff J, Certified Nursing Assistant (CNA) on 1/12/23 at 9:00 a.m. She confirmed she was familiar with Resident #25. She stated she did not know she had PTSD and hasn't seen any behaviors but said the resident does refuse baths. An interview was conducted with Staff H, LPN, Care Team Manager (CTM) on 1/12/23 at 10:28 a.m. She stated she was unaware of Resident #25's PTSD diagnosis. She was observed reviewing the resident's medical record. She confirmed PTSD was listed on the resident's MDS. On 1/12/23 at 10:40 a.m., an interview was conducted with Resident #25. She stated she has had trauma in her past but did not elaborate on what it was. The resident stated she was not seeing a therapist but thought talking to someone may help her. Staff H, LPN, CTM was informed of the resident's desire to talk to someone. Psychiatric notes were requested, but the facility was unable to provide any. On 1/12/23 at 11:55 a.m., Staff B, RN, MDS states she spoke to the psychiatrist, and they hadn't seen the resident since 2019. She was trying to reach another provider. No further information was received. A facility policy titled Care Plans, Comprehensive Person Centered, dated December 2016, was 105037 Page 3 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0699 reviewed. The policy stated the following: Level of Harm - Minimal harm or potential for actual harm Policy Statement Residents Affected - Few A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The care planning process will b. include an assessment of the resident's strengths and needs, and c. incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: b. describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporate identified problem areas, h. incorporate risk factors associated with identified problems, 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 105037 Page 4 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident-centered plan of care related to Dementia Care for one (#21) of one resident reviewed for dementia care out of 21 facility residents with dementia related diagnosis or Alzheimers' disease. Residents Affected - Few Findings included: A record review for Resident #21 revealed admission to the facility in 2020 with diagnoses that included dementia, communication deficit and mood disorder, according to the Face sheet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section I revealed diagnoses that included Non-Alzheimer's Dementia. Review of a behavioral health note dated 10/18/2022 listed a secondary diagnosis of Dementia. Review of the resident's care plan on 01/11/2023 did not reveal a focus area related to Dementia care. During an interview on 01/11/2023 at 01:38 PM with Staff B, Registered Nurse (RN), MDS Coordinator, she stated the Social Services department was responsible for behavioral and Dementia care planning. On 01/11/2023 at 01:58 PM an interview was conducted with the Social Services Director (SSD). The SSD confirmed the Social Services department was responsible for development of a Dementia care plan if the resident had a diagnosis of Dementia. The SSD reviewed the clinical record and confirmed the resident should have a care plan related to dementia, stating, that is on me. He continued, stating he was on his own for several months, and this resident may have fallen through the cracks. During an interview with the Interim Director of Nursing (IDON) on 01/11/2023 at 03:30 PM she confirmed a resident with a diagnosis of Dementia should have a resident-centered care plan related to Dementia. Review of a facility-provided policy titled Dementia - Clinical Protocol dated March 2015 revealed: Treatment/Management: 1. For the individual with a confirmed Dementia, the IDT [interdisciplinary team] will identify a resident-centered care plan to maximize remaining function and quality of life. 105037 Page 5 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

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 observation, staff interview and policy review the facility failed to store food in accordance with professional standards for food service safety as evidenced by failure to discard food items that were expired, unlabeled and undated food items in the kitchen and one of two medication storage rooms, and one dietary staff member not wearing a hair net in the kitchen area. Findings Included: An observation, during the initial kitchen tour on 01/09/23 at 9:25 AM, revealed two (2) low-fat 1% gallons of milk that had an expiration of 12/28/2022. An immediate interview on 01/09/23 at 9:25 AM, Dietary Staff C confirmed the milk was expired and stated, hopefully no one used it. An observation, on 01/09/23 at 9:30 AM, revealed a handful of yellow colored hard tubular food product that was wrapped up with plastic wrap that was not labeled or dated. An immediate interview on 01/09/23 at 9:30 AM, Dietary Staff E stated, what is that and identified the food product as left-over uncooked spaghetti. Dietary Staff stated that should have been labeled and dated. An observation on 01/09/23 at 9:40 AM, revealed a package of brown powder like substance that was opened but wrapped with plastic wrap on the shelf. An immediate interview, on 01/09/23 at 9:40 AM, Dietary Staff E stated, we have been looking everywhere for that cocoa powder. An observation on 01/09/23 at 9:45 AM, revealed a package of hard yellow shells not stored in the original packaging that was sticky to touch on the outside of the package and was not labeled and dated. An immediate interview, on 01/09/23 at 9:45 AM, Dietary Staff E stated, That is sticky why is it sticky? I will throw those taco shells away. Additional observations in the kitchen on 01/10/23 at 12:30 PM, revealed Dietary Staff D was not wearing a hairnet. An immediate interview with Dietary Staff E confirmed that Dietary Staff D was not wearing a hair net but stated that Staff D was usually in compliance with wearing hairnets and this was very rare for Staff D. Staff D stated a hairnet was worn earlier but somehow it must have come off while working in the kitchen. An observation of the medication storage room located on the first floor, on 01/11/23 at 1:16 PM, revealed a frozen pumpkin pie with no name and date. During an interview on 01/11/23 at 1:16 PM, Licensed Practical Nurse (LPN) Staff F confirmed the refrigerator in the medication storage area was designated as a resident refrigerator. LPN Staff F 105037 Page 6 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that the food in the refrigerator should have been labeled with resident's name and date. LPN Staff F confirmed there was no name or date on the pumpkin pie. An observation of the medication storage room located on the first floor, on 01/11/23 at 1:16 PM, revealed a grocery bag of unlabeled individually wrapped frozen hot pockets. There was a resident name on the outside of the grocery bag but no date indicating a use by date. During an interview on 01/11/23 at 1:16 PM, LPN Staff F, confirmed the observation of the grocery bag with no use by date. Review of the facility policy titled, Food Receiving and Storage revised 11/29/21 stated, Foods shall be received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at al times. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated use by date. 8. Once opened, all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 14. b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. d. Other opened containers must be dated and sealed or covered during storage. 105037 Page 7 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the binding arbitration agreement explicitly informed the resident or their representative of the right to not sign it for three residents (#12, #41, and #24) of three residents sampled. Residents Affected - Some Findings included: 1. Review of Resident #12's Face Sheet revealed Resident #12 was admitted on [DATE]., with diagnoses that included end stage renal disease, insomnia, and depression. Review of the Minimum Data Set (MDS), provided by the facility and dated 1/12/23, Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was a 15 out of 15, indicating the resident was cognitively intact. Review of the binding arbitration agreement revealed it was signed by the facility representative (Staff G, admission Coordinator) and Resident #12 with no date documented. Further review of the binding arbitration agreement revealed the agreement did not show an explicit statement that the resident or representative did not have to sign the arbitration agreement. 2. Review of Resident #41's Face Sheet revealed Resident #41 was admitted on [DATE] and readmitted on [DATE], with diagnoses to include major depressive disorder, and single episode, unspecified, paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS), provided by the facility and dated 1/12/23, Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was a 15 out of 15, indicating the resident was cognitively intact. Review of the binding arbitration agreement revealed it was signed by the facility representative (Staff G, admission Coordinator) and Resident #41 with no date documented. Further review of the binding arbitration agreement revealed the agreement did not show an explicit statement that the resident or representative did not have to sign the arbitration agreement. 3. Review of Resident #24's Face Sheet revealed Resident # 24 was admitted on [DATE], with diagnoses to include disease of esophagus, unspecified, disease of upper respiratory tract, and a urinary tract infection. Review of the binding arbitration agreement revealed it was signed by the facility representative (Director of Post-Acute) and Resident #24 with no date documented. Further review of the binding arbitration agreement revealed the agreement did not show an explicit statement that the resident or representative did not have to sign the arbitration agreement. On 1/12/2023 at 9:48 a.m., an interview was conducted with Staff G, admission Coordinator. Staff G stated she explains what the arbitration agreement is and they do have an option not to sign the 105037 Page 8 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0847 form. She confirmed the binding arbitration agreement did not include a statement giving the resident or their representative the option not to sign the agreement. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 105037 Page 9 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to provide Pneumococcal vaccinations for three (Residents #4, #12, and #33) of five residents sampled for Pneumococcal vaccinations, failed to provide influenza vaccinations for three (Residents #12, 33, and 63) of five residents sampled for influenza vaccinations, and failed to provide COVID-19 vaccinations for two (Residents #33 and 63) out of five residents sampled for COVID-19 vaccinations. Residents Affected - Some Findings included: A request was made for pneumococcal, flu, and COVID vaccination consent/refusal and proof of administration for five residents on 1/11/23 to Staff B, Registered Nurse (RN)/Minimum Data Set (MDS Coordinator,) who was covering in the absence of the Director of Nursing (DON.) A record review for Resident #12 indicated he was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal, flu and COVID vaccines with Resident #12's name on it. The form was not filled out or signed. There was no proof the resident received flu or pneumococcal vaccines. The resident was listed on the facility's spreadsheet as having his COVID vaccine. A record review for Resident #4 indicated she was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal, flu and COVID vaccines. The form provided consent by the resident to receive the pneumococcal vaccine, but there was no proof the vaccination was given to the resident. A record review for Resident #33 indicated she was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal and flu vaccines dated 10/11/20. The form consented to the flu vaccine and refused the pneumococcal vaccine. There was no current documentation provided. There was no signed refusal for the COVID-19 vaccinations and the resident was not listed on the facility provided spreadsheet as receiving the vaccine. A record review for Resident #63 indicated she was admitted to the facility on [DATE]. Staff B, RN provided an Authorization for Treatment for pneumococcal, flu and COVID vaccines, dated 1/26/22. The form provided consent by the resident to receive the flu vaccine and stated she wanted the COVID-19 vaccine. There was no proof the vaccines were given. The resident was not listed as receiving the COVID-19 vaccine on the facility's provided spreadsheet. A Vaccine Consent Form, dated 10/12/22, was checked as stating the resident requested the flu vaccine, but was unsigned. An Authorization for Treatment for pneumococcal, flu and COVID vaccines, also dated 10/12/22, indicated the resident did not want the flu vaccine; the pneumococcal and COVID-19 vaccine sections were not filled out. An interview was conducted with Staff B, RN on 1/12/23 at 10:08 a.m. Staff B stated the documentation provided was the only documentation in the residents records. She stated they have no proof vaccines were received or any more up to date consents or refusals. A facility policy titled Pneumococcal Vaccine, dated December 2012, was reviewed. The policy stated the following: All residents will be offered the Pneumovax (pneumococcal vaccine) to aid in preventing 105037 Page 10 of 11 105037 01/12/2023 Palms at Sebring Nursing and Rehabilitation The 725 S Pine St Sebring, FL 33870

F 0883 pneumococcal infections. Level of Harm - Minimal harm or potential for actual harm 1. Prior to or upon admission, resident will be assessed for eligibility to receive the Pneumovax, and when indicated, will be offered the vaccine within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Residents Affected - Some 5. Residents/Representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccine. 6. For residents who receive the vaccine, the date of the vaccine, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. A facility policy titled Influenza, Prevention and Control of Seasonal, dated August 2014, was reviewed. The policy stated the following: Vaccination 1. The Infection Preventionist will promote and administer seasonal influenza vaccine. 2. Unless contraindicated, all residents and staff will be offered the vaccine. A facility policy titled COVID-19 Vaccine Education, dated 9/22, was reviewed. The policy stated the following: The purpose of this policy is to maintain compliance with local, state, and federal guidelines relating to COVID-19 vaccination requirements. COVID-19 vaccines are effective at protecting you from getting sick and is an important tool to help us get back to normal. 105037 Page 11 of 11