Health inspection·February 13, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that residents unable to carry out activities of daily living (ADLs), received necessary care and services to maintain proper grooming and personal hygiene, by failing to provide nail care for two (Residents #8 and #11) of four residents reviewed for ADLs, from a total sample of 16 residents. Residents Affected - Few The findings include: 1. During an interview with Resident #8 on 2/12/24 at 10:10 AM, his left hand was observed to be contracted around a washcloth. He explained that without the washcloth, his fingernails would dig into his palm. The resident's fingernails on both hands were soiled with dark brown substance resembling feces around the cuticles and under each nail. When asked if he was receiving any assistance with handwashing or nail care, he replied, No, I am not. A record review for Resident #8 revealed he was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of medically complex conditions, bipolar disorder, diabetes mellitus, depression, post-traumatic stress disorder and contracture. A review of the 5-day Medicare minimum data set (MDS) assessment, dated 12/15/23, revealed Resident #8 had a brief interview for mental status (BIMS) score of 15 out of 15 points, indicating cognitively intact. The assessment did not indicate any rejection of care. The resident required some help to complete activities of daily living (ADLs) and had upper and lower extremity impairments on one side. The resident was dependent on staff and required substantial to maximum assistance with bathing. A second observation of Resident #8 was made on 2/13/24 at 9:30 AM. He was feeding himself breakfast. The fingernails on both hands were again observed with dark brown matter under the nails and around the cuticles. Resident #8 again denied receiving assistance with handwashing or nail care, explaining he just runs his right hand under the water from the sink in his room to wash it. After confirming he was his own representative, Resident #8 granted permission to photograph his nails. (Photographic evidence obtained) A review of Resident #8's care plan dated 8/9/23, indicated the resident needed assistance with ADLs related to weakness, decreased mobility status-post recent hospitalization/illness. The goal was to maintain and or his improve current level of function through next review date. Interventions included, but were not limited to, encourage and assist with ADLs including bathing and hygiene. (Photographic evidence obtained) Page 1 of 10 105135 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During an interview with Resident #11 in his room on 2/13/24 at 9:38 AM, he was asked about nail care. He showed both hands and fingernails. Both of his hands were severely contracted, and his fingers were bent in several directions. The nails on both hands were elongated and several of them had dark gray matter underneath them. Resident #11 stated he scratches himself a lot and that might be what the dark debris was from. He stated he was his own representative and granted permission for a photo. (Photographic evidence obtained) The resident held his hands out and said his fingernails had grown out; they used to be nubs. He could not report how often his nail care was offered and provided. A record review for Resident #11 revealed he was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of cerebrovascular accident (CVA, or stroke), quadriplegia, multiple sclerosis and hand contracture. A review of the quarterly MDS assessment, dated 1/14/24, revealed Resident #11 had a BIMS score of 15, indicating cognitively intact. The resident was dependent on staff for showering/bathing and required partial to limited assistance with personal hygiene. During a second visit to Resident #11's room on 2/13/24 at 1:30 PM, he was asked if he had ever refused to let staff provide fingernail care. He stated, Not to my knowledge. Resident #11 was care planned on 1/14/24 for an ADL self-care performance deficit related to chronic medical conditions, and CVA. Interventions included provision of appropriate assistance with hygiene. He was also care planned for his behavioral needs, which included his preference to have nails trimmed every week. (Photographic evidence obtained) A review of the Certified Nursing Assistant (CNA) daily tasks found in the last 30 days, showers or a bath was provided on 4 days: 1/19/24, 1/21/24, 2/11/24 and 2/12/2024. Nail care was not included on the CNA task list. An interview was conducted with Employee E, CNA, on 2/13/24 at 9:43 AM. She stated CNAs provide nail care to residents. If a resident needs care they should be provided that care. Resident #8 requires prompts in the morning to complete hygiene. He sometimes refuses, but when he needs it, he demands that care. When asked if she knew he engaged in rectal digging, due to the color of the debris under and around his nails, she stated she believed he might. Resident #8 might also be trying to wipe himself after bowel movements. When shown the photographs of Resident #8 and Resident #11's fingernails, she acknowledged the undesirable conditions. During an interview with Employee F, CNA, on 2/13/24 at 11:00 AM, she was asked who provides nail care to residents. She replied all aides provide nail care as needed by the residents. During an interview with the Director of Nursing (DON) on 2/13/24 at 2:30 PM, she was shown the pictures of Resident #8 and #11's fingernails. She confirmed they were unclean and in need of attention. The DON said they were always on the staff about that, and she has already started correcting the concern by having staff make rounds and provide nail care today. A review of the Standards and Guidance ADL care and Services issued 4/2020 and revised 1/2024 stated: Standard: Residents will be provided with care, treatment and services as appropriate to improve 105135 Page 2 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0677 their ability to carry out ADLs. Level of Harm - Minimal harm or potential for actual harm Guideline: Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents Affected - Few Procedure: 1. Residents will be provided with care, treatment and services to ensure their ADL needs are met. 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently including appropriate support and assistance with . a. Hygiene (bathing, dressing, grooming, nail care and oral care) . 105135 Page 3 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure wound care was provided as ordered for two (Residents #2 and #3) of two residents reviewed for wound care, from a total sample of 16 residents. Residents Affected - Few The finding include: 1. On 2/12/24 at 10:40 AM, Resident #2 was observed lying in bed on his left side. His eyes were closed and did not answer to his name being called, resp 16/minute. His right foot was observed to be wrapped in gauze and dated 2/10/24. The bottom of his right foot which was observed wrapped in gauze, which was colored, and dirt was on both the exposed foot (heel) and the gauze. A record review for Resident #2 revealed an admission date of 12/5/23, with diagnoses of congestive heart failure, insomnia, unspecified psychosis, dementia, major depressive disorder, mixed anxiety disorder. A review of 5-day minimum data set (MDS) assessment, dated 12/12/2023, revealed Resident #2 had a brief interview for mental status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. The assessment also documented he exhibited verbal behaviors towards others, had no indication of rejection of cares, and exhibited no functional impairment in range of motion. The resident required physical assistance with showers/baths, personal/ toilet hygiene, and was at risk for pressure wounds. On 2/12/24 at 1:00 PM, a phone call to Resident #2's spouse was made (listed as Emergency Contact #1, POA). She was asked for permission to photograph the resident. She verbally granted permission. She was asked if she had anything she'd like to share about the care and services he receives at the facility. She stated, Generally, they provide pretty good care, I do get concerned about his foot, they tell me it's starting to heal. It's been over 2 months; the wound did happen here. I don't know how it happened, one day I did see it was skinned up. They said it probably happened when he fell. He's been on antibiotics twice. The wound nurse told me recently, last week, that it's getting better. On 2/13/24 at 8:15AM, Resident #2 was observed lying in bed with his eyes closed, resp 16/minute. His right foot was observed with a gauze wrap dressing dated 2/10/24. The right foot was observed with dirt on the open /exposed areas of the bottom of his foot. His left foot sock was observed to have bright red stains on the toe area of the sock. (Photographic evidence obtained) A medical record review for Resident #2 revealed pertinent physician's orders which read: Podiatry consult for wound on bottom of right great toe, cut nails on 12/18/2023, 12/20/23: wound culture to right foot, 12/20/23: wound culture to right foot, 12/20/23, 1/23/24: cleanse right foot wound with wound cleanser pat dry, apply xeroform/gentamycin abdominal rolled gauze QD/PRN, 2/4/24: encourage and assist resident with turning and repositioning when in bed every shift, 2/14/24: weekly skin check, 12/12/23 NAS diet, reg texture thin consistency. On 02/13/2024 at 9:30 AM, an interview was conducted with Employee B Registered Nurse (RN). She was asked to read Resident #2's treatment order. She responded, Cleanse right foot with wound cleanser, 105135 Page 4 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pat dry, apply gentamycin/xeroform ABD rolled gauze every day, on the 7-3 shift and as needed if it comes off. (Photographic evidence obtained) When Employee B RN was asked who performs the wound care. She stated, I do it every day, Monday through Friday and another RN does it on the weekends. When Employee B RN was asked if she performed the wound care on Resident #2 yesterday, she stated, Yes. When asked how often the wounds are evaluated and documented, and where it is documented. Employee B RN said she evaluates the wounds every day when she does the treatments and if she observes any changes, she calls the RN Wound Care Consultant for further recommendations. Employee B RN was informed that Resident #2's dressing had been observed on 2/12/2024 and 2/13/2024, and both days the resident's right foot dressing was dated 2/10/2024. Employee B RN then stated, I didn't do it yesterday, I told the nurse up there to do it, and I didn't hear back from her. On 2/13/2024 at 12:37 PM, Resident #2 was asked for permission to observed his wound care treatment, which he agreed. Employee B RN/Wound Care Nurse, Wound Care Consultant and a male CNA were present. The dressing that was previous on the resident's right foot on 02/13/2024 (dated 02/10/2024) was observed to have been replaced with a bordered gauze dated 2/13/2024. Employee B RN removed a soiled bordered dressing from the top of the resident's right foot. The wound bed was 100% covered with yellow slough. The Wound Nurse Consultant measured the wound. While wearing the same gloves that she wore to remove the soiled dressing from the top of Resident #2's right foot, Employee B RN painted the left foot 2nd digit with a betadine solution. While wearing the same gloves that she had just used to treat the left foot 2nd digit, Employee B RN then proceeded to treat the top of right foot wound (she did not change gloves, she did not sanitize or wash her hands in-between these procedures). Employee B RN cleansed the wound on top of right foot with wound cleanser, applied Silvasorb gel, covered with xeroform, then covered with ABD pad, wrapped with Kerlix dressing, removed gloves, discarded in pink bag, taped and dated the dressing, and then washed her hands. After the treatment Employee B RN was asked if she had sanitized her hands during the treatments. She stated, No, I didn't wash or sanitize my hands after I removed the soiled dressing, and no I did not wash my hands or sanitize in-between treatments. I was just trying to get finished, but it's ok. 2. A record review for Resident #3 revealed an admission date of 12/20/2023 and discharged date of 01/31/2024, with diagnoses of left foot osteomyelitis, partial traumatic trans phalangeal amputation of the left thumb, end stage renal disease, peripheral vascular disease, hypertension, type 2 diabetes mellitus, and major depression. A review of Resident #3's pertinent physician's orders were reviewed that included: wound vac to left heel, cleanse with normal saline the apply wound vac, change every 3 days, on 7-3 shift Mon-Wed-Fri (12/24/2023), wound vac to left heel, cleanse with NS then apply wound vac change every 3 days, on 7-3 shift Tues-Thurs-Sat (12/24/2023). Cleanse left foot top area with NS then wound gel cover with dry dressing (12/23/2023). Consult wound care: DX left foot incision on wound vac (12/22/2023), Consult wound care for wound to left foot with wound vac (12/21/2023), Check wound vac placement and function every shift, if malfunctioning notify provider (12/20/2023), Isolation-Contact precaution every shift for osteomyelitis left foot. A 12/21/23 progress note for Resident #3 noted: the resident was asking about wound vac, he has a dressing to left lower extremity (LLE) that was clean dry and intact (CDI), Wound care is consulted for wound management. A 1/21/2024 progress note revealed resident requested wound care from DON and was told his nurse was working and wound be in shortly. A review of the medication administration record/treatment administration record for Resident #3 revealed there was no documentation of wound care/treatments or wound vac application from 12/20/2023 105135 Page 5 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0684 (admission date) to 12/25/2023. (Photographic evidence obtained) Level of Harm - Minimal harm or potential for actual harm On 2/13/24 at 9:30 AM, an interview was conducted with Employee B RN, Wound Care Nurse regarding Resident #3. She stated that Resident #3 was admitted to the facility without the wound vac in place, but he came with an order for the wound vac. She did not know if he was admitted from the hospital or not because she was not present. She stated, The facility called me and asked if there was a wound vac in the facility. Employee B RN confirmed that Resident #3 had an order for the wound vac the day he was admitted to the facility, but he didn't bring it with him from the hospital, the facility was to supply the wound vac. She had already ordered one before Resident #3 was admitted , because she had to send a used one back to the new company they now use. The new company replaces it, which takes about 3 days for the wound vac to come. Employee B RN stated she does the initial skin assessment on admissions and the Wound Consultant visits the resident when she comes weekly. She stated, I was on vacation so another RN would have done the initial assessment, and the initial assessment would be documented under progress notes, or under the general note or health status note. Employee B RN was asked to explain why the resident was admitted on [DATE] but the wound vac was not applied until 12/25/2023, according to the MAR/TAR. (Photographic evidence obtained) Employee B RN stated, I'm not sure about that because I was not here. When asked what kind of treatment the resident received from 12/20/2023 to 12/25/2023. Employee B RN reviewed Resident #3 electronic health record (HER) and stated, I'm not sure, because I wasn't here, but I don't see any treatments documented for 12/20/2023 through 12/25/2023. When asked if treatments would be documented anywhere else in the record. Employee B RN stated, I don't see any other documentation in the chart. When asked what the facility process for receiving progress notes, when residents visit providers outside of the facility. Employee B RN stated, Normally we would have notes from any provider outside of the facility, but the resident kept all his notes and paperwork and would not give us anything accept the orders, there were no new orders that were received, the doctor's office gave verbal orders to change the wound vac every 3 days which was the same order we already had. Residents Affected - Few A review of the facility's Wound Care and Treatment Policy/Procedure (issued 03/2020 and revised on 1/2024) read: Standard: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Guideline: Only staff trained to complete physician orders will complete wound care and treatments as prescribed. Procedure: Preparation: 1. Verify that there is a physician's order for this procedure. Steps in the Procedure 2. Perform hand hygiene thoroughly 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene thoroughly. 105135 Page 6 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0684 6. Put on gloves Level of Harm - Minimal harm or potential for actual harm Documentation: The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, and change in condition, and problem or complaint made by the resident related to the procedure, If the resident refused the treatment and the reason(s) why, the signature and title of the person recording the data. (Photographic evidence obtained) Residents Affected - Few 105135 Page 7 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, interviews, and facility policy review, the facility failed to practice proper infection control measures by 1) failing to wear required personal protective equipment (PPE) for one (Resident #12) of one resident reviewed for transmission base precautions, and 2) failing to prevent the potential development and transmission of infection by not following infection prevention techniques during a wound care dressing change for one (Resident #2) of one resident observed during wound care, from a total sample of 16 residents. Residents Affected - Few The findings include: 1. On 2/12/24 at 11:44 AM, Employee D, Certified Nursing Assistant (CNA) was observed entering Resident #12's room without donning personal protective equipment (PPE). The door for Resident #12's room was observed to contain a PPE hanger with pockets that were observed to contain a box of gloves, a package of disposable blue gowns, N95 face masks, and face shields and a sign stating, Contact Precautions. The sign was observed to say: Put on gloves before room entry. Discard gloves before room exit. Put gown on before room entry. Discard gown before room exit. When Employee D came out of the room, she was asked if she was required to don PPE prior to entering this room. She stated, Yes, but I was just handing him his lunch tray at the door. On 2/12/24 at 11:47 AM, Employee D was observed entering the same room with PPE on. When she exited the room, she removed her PPE outside the room. She was then observed walking down the hall with the PPE (disposable blue gown and gloves) in her hands. A record review for Resident #12 revealed an admission date of on 12/8/23, with diagnoses of cellulitis right lower limb, cellulitis left lower limb, major depressive disorder, anxiety disorder, and unspecified psychosis not due to a substance or known physiological disorder. A review of Resident #12's physician's order dated 2/3/24 read: Permethrin external cream 5%: apply to back, buttocks topically one time a day for rash for 5 days. Place once a day and wipe off after 10 hours. Physician's order dated 2/10/24 read: Permethrin external cream 5%: apply to trunk, buttocks, and back topically one time a day for scabies until 2/14/24: apply on for 10 hours wash off x 5 days. On 2/13/24 at 8:00 AM, Employee C, Patient Care Assistant (PCA) was observed inside Resident #12's room without any PPE on. The door for this room was observed to contain a PPE hanger with pockets that were observed to contain a box of gloves, a package of disposable blue gowns, N95 face masks, and face shields and a sign stating, Contact Precautions. When Employee C exited the room, she was asked if she knew what precautions Resident #12 was on. She stated, He has scabies, the man in the D bed. When asked if she had been trained to don PPE when entering a room with a precaution sign on the door. She stated, I've only been here for a week. Someone did tell me, I think. I was just making the beds. Resident #12 was observed inside the room. During an interview with the Infection Preventionist on 2/13/24 at 11:00 AM, she was asked about the contact precautions for Resident #12. She stated, Resident #12 had a rash, and I couldn't get a dermatologist in to see him, so his regular doctor here did go in and see the resident and he didn't feel it was anything contagious, but the family had concerns, so the doctor did order a treatment of Permethrin. When asked if the resident was placed on Contact Precautions because of the rash, she stated, Yes. When was asked what Contact Precautions means for anyone entering the room, the Infection 105135 Page 8 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Preventionist stated, Wear PPE when entering the room, gloves, a mask, and a gown. When she was asked if she was aware that two different staff members were observed Resident #12's room without wearing PPE. She stated, Yes I was told yesterday that one was in there. I asked her why, she said she was bringing him his lunch tray. When the Infection Preventionist was asked if she was aware of a second employee going into Resident #12s room without donning PPE this morning. She stated, Yes, I spoke to her after I was told she went into the room without PPE. She said that was her first time up on the unit. I told her that wasn't an excuse, that when you see something on the door, that's not a normal case, and if you see a sign you need to ask. She's a Patient Care Assistant (PCA) and she said she didn't know.2. On 2/13/2024 at 12:37 PM, Resident #2 was asked for permission to observed his wound care treatment, which he agreed. Employee B RN/Wound Care Nurse, Wound Care Consultant and a male CNA were present. The dressing that was previous on the resident's right foot on 02/13/2024 (dated 02/10/2024) was observed to have been replaced with a bordered gauze dated 2/13/2024. Employee B RN removed a soiled bordered dressing from the top of the resident's right foot. The wound bed was 100% covered with yellow slough. The Wound Nurse Consultant measured the wound. While wearing the same gloves that she wore to remove the soiled dressing from the top of Resident #2's right foot, Employee B RN painted the left foot 2nd digit with a betadine solution. While wearing the same gloves that she had just used to treat the left foot 2nd digit, Employee B RN then proceeded to treat the top of right foot wound (she did not change gloves, she did not sanitize or wash her hands in-between these procedures). Employee B RN cleansed the wound on top of right foot with wound cleanser, applied Silvasorb gel, covered with xeroform, then covered with ABD pad, wrapped with Kerlix dressing, removed gloves, discarded in pink bag, taped and dated the dressing, and then washed her hands. After the treatment Employee B RN was asked if she had sanitized her hands during the treatments. She stated, No, I didn't wash or sanitize my hands after I removed the soiled dressing, and no I did not wash my hands or sanitize in-between treatments. I was just trying to get finished, but it's ok. A record review for Resident #2 revealed an admission date of 12/5/23, with diagnoses of congestive heart failure, insomnia, unspecified psychosis, dementia, major depressive disorder, mixed anxiety disorder. A review of 5-day minimum data set (MDS) assessment, dated 12/12/2023, revealed Resident #2 had a brief interview for mental status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. The assessment also documented he exhibited verbal behaviors towards others, had no indication of rejection of cares, and exhibited no functional impairment in range of motion. The resident required physical assistance with showers/baths, personal/ toilet hygiene, and was at risk for pressure wounds. A medical record review for Resident #2 revealed pertinent physician's orders which read: Podiatry consult for wound on bottom of right great toe, cut nails on 12/18/2023, 12/20/23: wound culture to right foot, 12/20/23: wound culture to right foot, 12/20/23, 1/23/24: cleanse right foot wound with wound cleanser pat dry, apply xeroform/gentamycin abdominal rolled gauze QD/PRN, 2/4/24: encourage and assist resident with turning and repositioning when in bed every shift, 2/14/24: weekly skin check, 12/12/23 NAS diet, reg texture thin consistency. A review of the facility's policy titled Infection Control- Infection Prevention and Control Program (revised 6/2023) revealed: Standard: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 105135 Page 9 of 10 105135 02/13/2024 Riverwood Center 2802 Parental Home Road Jacksonville, FL 32216

F 0880 Level of Harm - Minimal harm or potential for actual harm Guidelines: The infection and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is based on accepted national infection prevention and control standards in accordance with local, state, and federal regulations and guidelines. Residents Affected - Few Prevention of Infection: 1. Important facets of infection prevention include: c. Educating staff and ensuring that they adhere to proper techniques and procedures; (Photographic evidence obtained) A review of the facility's Wound Care and Treatment Policy/Procedure (issued 03/2020 and revised on 1/2024) read: Standard: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Guideline: Only staff trained to complete physician orders will complete wound care and treatments as prescribed. Procedure: Preparation: 1. Verify that there is a physician's order for this procedure. Steps in the Procedure 2. Perform hand hygiene thoroughly 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene thoroughly. 6. Put on gloves Documentation: The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, and change in condition, and problem or complaint made by the resident related to the procedure, If the resident refused the treatment and the reason(s) why, the signature and title of the person recording the data. (Photographic evidence obtained) . 105135 Page 10 of 10