Health inspection·September 7, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure advanced care planning with a legal appointed designated health care proxy or power of attorney (POA) was completed for one (Resident #9) out of the sampled twenty-one residents. Findings included: On 09/05/23 at 12:12 p.m. Resident #9 was observed lying in bed. Resident #9 was not able to respond to questions in an attempted interview. A review of the admission Record for Resident #9 did not reflect the resident had a health care proxy or a POA. Resident #9 was admitted on [DATE] with diagnoses to include anxiety disorder and cognitive communication deficit. A review of the admission Minimum Data Set (MDS), dated [DATE], Section C- Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score was not obtained and showed the resident was rarely/never understood. A review of Resident #9's annual MDS, dated [DATE], Section C - Cognitive Patterns revealed a BIMS score was not obtained and showed the resident was rarely/ never understood. The MDS also showed the resident had memory problems and cognitive skills were severely impaired. A review of the active care plan for Resident #9, initiated 08/23/22 and revised 08/08/23, revealed the resident had expressed wishes as Full Code with interventions to include: - discuss Advanced Directives with resident and/or appointed health care representative, - contact appointed health care representative for health care decisions. A review of Resident #9's active care plan, initiated 08/29/22 and revised 08/08/23, revealed alteration in communication due to primary language [not English]. A review of Resident #9's consents, revealed the following consents were signed by family members. - Authorization for treatment while residing at healthcare center, signed 08/22/22 by Family Member #1, Page 1 of 12 105149 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0578 - Psychotropic Medication Informed Consent, signed 08/22/22 by Family Member #1, Level of Harm - Minimal harm or potential for actual harm -Informed Consent for Influenza Vaccine, signed 08/22/22 by Family Member #1, - Informed Consent for Pneumococcal Vaccine, signed 08/22/22 by Family Member #1, Residents Affected - Few - Authorization for treatment while residing at healthcare center, signed 08/26/22 by Family Member #1, - Psychotropic Medication Informed Consent, signed 11/08/22 by Family Member #1, -Patient Consent Form, verbal consent 12/06/22 by Family Member #2, - Psychotropic Medication Informed Consent, signed 12/06/22 by Family Member #3. On 09/07/23 at 1:37 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN), who stated Resident #9 primarily used gestures to communicate and was unable to make decisions. Staff B contacted [Family Member #1] for healthcare decisions. On 09/05/23 at 3:08 p.m., a review of the medical record for Resident #9 revealed the record was silent of documentation of/for Advanced Directive and/or Healthcare Proxy documentation. On 09/06/23 at 12:57 p.m., Resident #9 was observed in her room repeating words [not English], gesturing to move her wheelchair away from bedside. She was not able to respond to questions in an attempted interview. On 09/06/23 at 1:11 p.m., an interview was conducted with the Social Services Director (SSD), who confirmed Advanced Directive and healthcare proxy documentation was not available for Resident #9. The SSD verified interventions related to advance care planning listed in Resident #9's care plan were not completed. The SSD confirmed [Family Member #1] signed consents for the resident. The SSD confirmed [Family Member #1] was not considered a legal representative. The SSD stated he has a notation to look at this (documentation of a healthcare proxy) but has not. He stated the next step was to get a health care proxy consent or complete a POA/ Advanced Directive from Resident #9's family member. On 09/07/23 at 2:20 p.m. in an interview, the Director of Nursing (DON) stated staff had responsibilities to ensure the legal health care proxy or POA was identified. Review of the facility's policy titled, Advance Directives, revised on 12/2016, showed: Policy Interpretation and Implementation -3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's representative. -6. Prior to admission of a resident, the Social Services Director or designee will inquire of his/her family members and /or his or her legal representative, about the existence of an advanced directive. 105149 Page 2 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure the physician was informed about refusal of medications and dialysis services for one (Resident #194) of six sampled residents. Findings Includes: On 9/5/2023 at 11:45 a.m., Resident #194 was observed in her room sitting up in her wheelchair with her call light within reach. The resident was well groomed. The room was clean and well lit. A review of the admission Record showed Resident # 194 was admitted to the facility on [DATE] with diagnoses to include but not limited to Epilepsy, Cognitive Communication, Conversion Disorder with Seizures or Convulsions, End Stage Renal Disease, and Dependence on Renal Dialysis. A review of admission Minimum Data Set, dated [DATE], Section C, Cognitive Patterns, C0600, Titled, Should the Staff Assessment for Mental Status be conducted, Code entered showed 0, indicating No. The resident was able to complete a Brief Interview for Mental Status. A review of the Order Summary Report dated 9/7/2023, showed an active verbal order to Send to emergency room for Evaluation, one time only for 1 day. Additional review of the order summary showed an active order dated 8/25/2023, for Hemodialysis M-W-F at [name of dialysis center]. Pick up 05:00 am Chair time 6:00 a.m. An active written order dated 8/24/2023, for Lacosamide Oral Table 200 MG, give 1 tablet by month two times a day for Conversion Disorder with Seizures or Convulsions. An active verbal order for LevEtiracetam Solution 100 MG/, give 10 mL by month two times a day for seizure. An active written order dated 8/24/2023 for NIDEdipine ER Oral Tablet Extended Release 24 Hour 60 MG (Nifedipine), give 1 tablet by month one time a day for Cardiac related to Hypotension, Unspecified. A review of the Electronic Medication Administration Record (eMAR) dated 9/4/2023 at 21:34 (9:34 p.m.) showed an incomplete progress note referencing the resident refused medication. The progress note did not show the resident's physician was notified about refusal. A review of daily skilled note dated 9/4/2023 at 16:54 (4:54 p.m.), showed Resident # 194 refused all medication this shift, stating I only take daytime medications. Additional review of the daily skilled note showed the resident's physician was not notified about the resident's refusal of medications. A review of the eMAR, dated 9/3/2023 at 20:59 (8:59 p.m.), showed Resident # 194 refused all medications. Additional review of the eMAR showed Resident #194 physician was not notified about the refusal of medication. A review of the eMAR dated 9/2/2023 at 20:39 (8:39 p.m.) showed Resident #194 refused medication again after repeated education. Additional review of the eMAR showed Resident #194's physician was not notified about the refusal of medication. A review of the eMAR, dated 8/31/2023 at 9:48 a.m., showed Resident #194 refused. Additional eMAR review showed the resident's physician was not notified. 105149 Page 3 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the eMAR dated 8/30/2023 at 22:46 (10:46 p.m.), showed Resident #194 refused medication. Additional review of the eMAR showed Resident #194's physician was not notified about the refusal of medication. A review of narrative nurses note dated 8/30/2023 at 20:55 (10:55 p.m.), showed Resident #194 refused medications, it was noted the resident was explained the importance and adverse effects of not taking seizure, cholesterol, and blood pressure medications. Resident #194's, blood pressure was 180/72. The review showed resident stated, I Don't care. Additional review showed Resident #194's physician was not notified about the refusal of medications and blood pressure. During an interview on 9/6/2023 at 4:27 p.m. with the Medical Director, Resident #194's primary care physician, he said he was not notified about Resident #194's condition because he was on vacation when she was admitted to the facility and another provider covered for him during that time. The facility would have used his on-call service on the weekend if they needed to report to an physician. During an interview on 9/6/2023 at 4:48 p.m. with Staff I, the covering physician for Resident #194's primary physician, he said he was covering for Resident #194's primary physician on 8/24/2023 through 9/4/2023, however, he was never present at the facility during those times, and he was not made aware of the Resident #194's refusal to receive dialysis or her medicine. He stated, Maybe the facility notified the ARNP during those times when [Resident #194] refused her medication. During an interview on 9/6/2023 at 5:06 p.m. with the Advanced Registered Nurse Practitioner (ARNP), he said he was not notified when Resident #194 was sent out to the hospital, refused dialysis or her medications. The ARNP said he was on the phone with the Director of Nursing, and she never told him about Resident #194's refusals of medication or being sent out to the hospital. During an interview on 9/7/2023 at 11:31 a.m. with Staff G an On Call physician, she confirmed she was on call for the facility on Friday, 8/25/2023 from 5:00 p.m. to 7:00 p.m. and she did not remember receiving any calls from the facility about any residents at the facility. During an interview on 9/7/2023 at 11:46 a.m. with Staff H, a second On Call physician he said he worked on call from Sunday 8/27/2023, 7:00 p.m. to Monday 8/28/2023 7: 00 a.m. and he did not recall getting a call from the facility about Resident #194 refusing her medication or dialysis services. The on- call physician said if he received a call about the resident refusing dialysis or her medication, he would have instructed the facility to send the resident to the emergency room. During an interview on 9/7/2023 at 3:30 p.m. with Staff E, License Practical Nurse (LPN), she said she notified the ARNP on 9/5/2023 when Resident #194 was sent out to the hospital, but she did not notify the provider of the ARNP about the resident refusing dialysis or her medication. Staff E said when Resident #194 refused dialysis she notified a nurse at the dialysis center to let them know the resident refused dialysis. During an interview on 09/07/23 at 3:20 p.m. with the Director of Nursing, she said she was not made aware the resident was refusing. She stated, I was made aware [Resident #194] was refusing meds probably Tues, Wed (5th and the 6th). She was taking her meds on 7:00 p.m.-7:00 a.m. on 08/25/23. I was not made aware that the resident refused dialysis until after the fact. I don't see anywhere where the doctor was notified. They [the nurses] may document in the EMAR, or a progress note, they can document either place. I would expect them to document doctor notification after any missed medication. I looked everywhere in the EMAR and progress note and did not see any notification to the 105149 Page 4 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doctors. All entries under EMAR show blank with nothing about doctor being notified. I would expect my nurses to let me know when a resident stop taking meds. I would then ensure they contact the doctor. There are some meds that we asked to get liquid form but [Resident #194] not taking any meds were not brought to my attention and I would expect to see it care planned for refusal of medications. If it had been brought to my attention earlier that she had not taken her meds, I probably would have recommended that [mental health services] see her. The DON said the Resident was currently refusing all her medications at the hospital right now. She refused dialysis for the night nurse, and I got report. I talked to her, and she refused. The resident said she got a note from transportation stating that they weren't picking her up. The resident refused to go to dialysis they said it was too late to see her that day. I let the night nurse know she was refusing meds and dialysis. The resident was aware of the decision she was making and how serious it was. Her daughter would come visit her and I told her daughter about her refusing meds and she responded, 'I know how she is'. When the ARNP came in on Friday we made him aware when he was in the building. Review of the facility policy titled, Change in a Resident's Condition or Status, Revised date February 2021. Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/ or status ( e.g., changes in level of care, billing/ payments, resident rights, etc. ) Policy Interpretation and Implementation 1. The nurse will notify the resident; s attending physician or physician on call when there has been a( an) d. : significant change in the resident's physical/ emotional/mental condition. F refusal of treatment or medications two (2) or more consecutive times); 105149 Page 5 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

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 observation, interview, and record review, the facility failed to ensure a clean homelike environment on two out of two units and failed to ensure medical equipment was in good repair for two (Residents #11 and #26) of 21 sampled residents related to two out of six shower chairs and one out of two [brand name] positioning chairs not being in good condition. Findings included: An observation was made on 9/5/23 at 7:20 a.m. on the resident smoking patio of flower beds being overgrown with grass and weeds and trash around the area, including a medical glove in the middle of the patio on the ground. On 9/6/23 at 1:35 p.m. the patio remained in the same condition. An observation was made on 9/5/23 at 12:35 p.m. of the linen closet on a box on the floor that appeared to have a water stain on it. The box had yellow gowns spilling out on the floor with black marks on the sleeves. The linen closest also contained three pillows in a plastic bag stored on the floor. An observation was made on 9/5/23 at 12:37 p.m. of an approximate 4 by 2 area of a white dryed substance on the handrail in the hall outside of room [ROOM NUMBER]. This remained there throughout the survey on 9/6 and 9/7/23. An observation was made on 9/7/23 at 4:28 p.m. in room [ROOM NUMBER] of walls that were patched and not painted, wall board anchors in the wall where something used to hang, scratched up doors, and a dirty towel on the room floor. In the bathroom there were pieces of plastic pipe or pipe covers on the floor under the sink. There is also a missing tile in front of the toilet. An observation was made on 9/7/23 at 4:30 p.m. in room [ROOM NUMBER] of walls scratched down to the dry wall, dry wall anchors in the wall where something used to hang, dirty floor, and a used towel on the bathroom floor. An observation was made on 9/7/23 at 4:32 p.m. in room [ROOM NUMBER] of walls with what appeared to be dried liquid drips, walls that had been patched and not painted, and doors and wall scratched down to the wood. There was also a broken tile at the bathroom entrance. An observation was made on 9/7/23 at 4:36 p.m. in room [ROOM NUMBER] of two holes in the wall, baseboards peeling off, and a black stain on the ceiling. An observation was made on 9/7/23 at 5:08 p.m. in room [ROOM NUMBER] of dirty floors, chipped and scratched walls and doors. An observation was made on 9/7/23 at 5:10 p.m. in room [ROOM NUMBER] of dirty floors, paint peeling off the wall and the bathroom door scratched down to the wood. An observation was made on 9/7/23 at 5:12 p.m. in room [ROOM NUMBER] of a dirty towel on the floor behind the door. There was also a drywall patch on the wall that had not been sanded or painted and had a baseboard missing. The bathroom door and frame were observed to be scratched down to the wood. 105149 Page 6 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation was made on 9/7/23 at 5:13 p.m. in room [ROOM NUMBER] of marked up walls and dry wall anchors in the wall were items used to be hung. An observation was made on 9/7/23 at 5:15 p.m. in room [ROOM NUMBER] of the bedroom door chipped with missing paint. The door frame had gouges and black marks at the top. The floors in the room were also observed to be marked up and dirty. An observation was made on 9/7/23 at 5:16 p.m. in room [ROOM NUMBER] of drip stains on the wall under the window as well as marks along the wall. The floors in the room were also observed to be dirty. An observation was made on 9/7/23 at 5:18 p.m. of the bathroom door and bedroom door in room [ROOM NUMBER] being scratched up and missing paint. The floors were dirty. An observation was made on 9/7/23 at 5:20 p.m. of the wallpaper pealing and an unfinished patch on the wall above the double doors in the front hall near the nurses' station. An observation was made on 9/7/23 at 5:22 p.m. in room [ROOM NUMBER] of dirty floors and baseboards peeling off the wall. An observation was made on 9/7/23 at 6:56 p.m. of a used washcloth on the floor in room [ROOM NUMBER]. No staff were present, and no residents were moving around the room. An observation was made on 9/6 and 9/7/23 of the recreational room having boxes stacked in the corner and by the cabinets. This is an area residents use throughout the day. An observation was made on 9/7/23 at 4:38 p.m. in room [ROOM NUMBER] of paint chipping off the walls, walls having black marks on them, dry wall anchors in the wall where something use to be hung, walls had what appeared to be dried liquid drips, scratched up doors, and black marks on the floor in front of the cabinets. An interview was conducted on 9/7/23 at 7:01 p.m. with Staff J, Certified Nursing Assistant (CNA) Staff J, CNA said for maintenance items, he did not enter them in the computer tracking system, but let a nurse know so they could enter them. He said he regularly had residents complain to him about how long it took to get maintenance items done. He said one room had a broken sink and it took months to fix. Staff J, CNA also said a lot of residents did not have chairs in their rooms for residents or guests to sit. He said if a family member needed a chair, staff went to get one from the dining room. An interview was conducted on 9/7/23 at 4:05 p.m. with Staff B, Licensed Practical Nurse (LPN), She said for maintenance issues staff entered items into a computer tracking system. Staff B, LPN said there is a chance it will get fixed. She added the facility did have angel rounds, but maintenance did not check the rooms for issues. An interview was conducted on 9/7/23 at 5:25 p.m. with the Maintenance Director. He said the facility did angel rounds and all the managers were assigned rooms to check. He said he had rooms [ROOM NUMBERS]. He said he checked everything in the room and bathroom such as toilets, lights, call lights, remote controls, oxygen signs. The Maintenance Director said most of the staff used the computer tracing system for maintenance issues, but some were not educated on it. He said if staff put things 105149 Page 7 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in the system, it would allow him to prioritize work orders. He said when he walked down the hall, ten people would tell him things, so he insisted on using the computer tracking system. He said if a resident asked for something to be fixed, he tried to get his tools and do it right away. He said he was the only maintenance person in the building and must do everything from air conditioners to water temperatures. He said the building was reconditioned about 10 years ago and had not been maintained since. The Maintenance Director said he had been in the facility for about 4 months and was trying to catch up. He said he understood the doors were chipped and things needed to be painted, but he had life safety things that need to be prioritized, like air conditioning and hot water. He said the cosmetic things had to wait until after the structural. As far as floors being dirty, he said housekeeping did the floors, and he did recently fix their floor buffer. An interview was conducted on 9/7/23 at 5:38 p.m. with the Housekeeping Director. She said there was no floor tech in the facility. She said they tried to pick two to three rooms to buff everyday and 3-5 rooms a week to strip and wax. She said she was the one currently doing floors, but it had to be done consistently. As for cleaning resident rooms, she said housekeeping should be cleaning high to low and doing the entire room. She said the spot on the ceiling in room [ROOM NUMBER], they had attempted to clean, and it would not come off so she let maintenance know so they could fix it. She looked at the black marks on the floor in room [ROOM NUMBER] and said it would not come up. She said they had tried, but the tiles needed replacing. An interview was conducted on 9/7/23 at 6:24 p.m. with the Director of Nursing (DON.) The DON stated she had noticed the issues with maintenance. She said she as well as her staff enter maintenance items into the computer tracking system. Regarding used towels and washcloths being left in residents' rooms and bathrooms, she said that should not happen and she would address it. An interview was conducted on 9/7/23 at 5:48 p.m. with the Nursing Home Administrator (NHA.) The NHA said they do angel rounds in the facility where managers look for odors, cleanliness, rooms that have concerns, holes in the wall, curtains, paint, walls, etc. The NHA said managers are assigned to certain rooms and they bring their findings to him in stand down and they review it. He said he had been in the facility a little over a month and he bought paint supplies so they could have a paint party. Discussing the condition of resident rooms in relation to the dirty floor, scratched up doors and walls he said no I don't consider it satisfactory. On 9/5/2023 at 12:20 p.m., Resident #11 was seen sitting upright in a [brand name] positioning chair, fully dressed, and well-groomed. Resident #11's ankles were seen resting against the metal leg bars of the chair, which was damaged and missing the footrest cushion support. On 9/5/2023 at 3:00 pm., On 9/5/2023 at 3:00 pm, Resident #11 was seen sitting erect in a [brand name] positioning Chair with his feet resting against the footrest's outer edge of the chair. A review of Resident # 11 admission Record showed, he was admitted to the facility on [DATE], with diagnoses to include but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Unspecified, Cognitive Communication Deficit, and Recurrent, Unspecified, Extrapyramidal and Movement Disorder. A review of the quarterly MDS dated [DATE], Section C, Cognitive Patterns, C0600, revealed Resident #11 was unable to complete the Brief Interview for Mental Status. Further review of the quarterly MDS, Section G, Functional Status, showed Resident #11 transferred with total staff dependence with two-person physical assistance. 105149 Page 8 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with Resident #11 On 9/5/2023 at 3:00 pm., Resident # 11 said he had had the [brand name] positioning Chair for a year, and the chair had not had a cushion on the footrest. He said his ankle hurt sometimes when he was up in the chair. An interview was conducted with the Director of Nurses, DON, on 9/7/2023 at 6:47 pm. The DON said she was not aware of the broken footrest on Resident #11's [brand name] positioning chair. The DON said she expected staff to quickly report any damaged medical equipment so that a work order could be filed to get the chair fixed. On 9/5/2023 at 9:20 am., Resident # 26 was observed laying down in bed, fully dressed, well-groomed with his call light in reach with no signs of distress. Resident #26's bathroom was observed with a broken shower chair left in shower stall. On 9/5/2023 at 3:00 pm., Resident #26 was observed laying down in his bed with his call light within reach, with no signs of distress. The resident's bathroom was observed with a broken shower chair in the shower stall. Review of Resident #26 admission Record showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to HB-SS Disease with Cerebral Vascular Involvement, and Recurrent, Unspecified, Lower Back Pain. Review of the annual Minimum Data Set, dated [DATE], showed Section C, Cognitive Patterns, Brief Interview for Mental Status, BIMS score of 15, which indicated Resident # 26 was cognitively intact. An interview was conducted on 9/5/2023 at 9:20 am., and at 3:00 pm., with Resident # 26. Resident #26 said he almost fell in the shower today because his shower chair was broken and it had been that way for about a week. He said he spoke with the Maintenance Director this morning about his chair and was told his chair would be fixed today. Another interview was conducted on 9/5/2023 at 3:00 pm., with Resident #26. Resident # 26 said no one had come to his room to fix his shower chair, so he would hold off taking a shower until his chair is fixed. An interview was conducted on 9/7/2023 at 5:40 pm., with the Nursing Home Administrator (NHA). The NHA said he expected when a resident reported a concern to a member of his staff, such as a broken shower, it should be resolved right away for the resident's safety. The NHA said he would take the shower chair out of Resident # 26's room for repair. Review of the facility policy titled, Cleaning and Disinfection of Environmental Surfaces, revised on August 2019, showed 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis, when spills occur, and when surfaces are visible soiled. 11. walls, blinds, and windows curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Review of the facility policy titled, Standard and Guidelines: Training - Floor care, dated 12- 2018 showed, Housekeeping in-service Floor Care, One of the ways infections is spread in a facility is through air-borne particles settle on the floors, Sanitizing the floors is the key to a good infection Control Program. Occasional care: The area 1/4 along baseboards collect dust and debris left by the buffer and mop. it is necessary to scrub and scrape these areas to ensure a clean appearance. Daily care: All ceramic tile should be swept and mopped daily, this helps control odor and retains floor appearance. 105149 Page 9 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0584 Further facility policy review showed the facility did not have a policy for broken equipment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 105149 Page 10 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review, and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility did not label, date and/or cover food items stored in the refrigerator or freezer. Findings included: An observation, on 09/05/23 at 9:20 a.m., showed a reach-in refrigerator in the kitchen area that contained: Three (3) sandwiches not labeled or dated. A big bag of lettuce not labeled or dated. 1 package of lunch meat smoked ham not dated. An open package of orange square cheese slices with package ripped and left uncovered. (photographic evidence obtained) During an interview on 09/05/23 at 9:20 a.m., Staff A Dietary Manager (DM) stated food items stored in the refrigerator should be labeled and dated. Staff A stated the cheese should have been covered and stored appropriately. An observation, on 09/05/23 at 9:30 a.m., showed a reach-in freezer in the kitchen that contained: Two whole frozen chicken breasts not labeled or dated. Six frozen bags of broccoli (2 pounds and 8 ounces) each not labeled or dated. Four frozen sugar peas (2 pound) bags each not labeled or dated. 105149 Page 11 of 12 105149 09/07/2023 North Healthcare and Rehabilitation Center 1301 16th St N Saint Petersburg, FL 33705

F 0812 One catalina blend (3 pound) bag not labeled or dated. Level of Harm - Minimal harm or potential for actual harm 12 bags of frozen peas/carrots mix (2 pound and 8 ounces) bags each not labeled or dated. Residents Affected - Many (photographic evidence obtained) During an interview on 09/05/23 at 9:30 a.m., Dietary Manager (DM) stated that food in the freezer should be labeled and dated. DM stated the food truck came while he was not in the facility however, he would expect the dietary staff to label and date the food items before storing in the freezer. A review of the facility's policy titled, Food Receiving and Storage revised date October 2017. stated, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 105149 Page 12 of 12