Health inspection·January 26, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on record review and interview, the facility failed to obtain physician's orders and a diagnosis for a urinary catheter for one (Resident #12) of two residents sampled for a review of urinary catheters, from a total of 19 residents in the sample. The findings include: A review of the facility's Resident Matrix, printed on 1/23/23, revealed that Resident #12 had an indwelling urinary catheter. A record review was conducted for Resident #12, revealing an admission date of 10/26/22. The resident's diagnoses included cardiomyopathy, interstitial pulmonary disease, heart failure, hypertension, and atherosclerotic heart disease. A review of the resident's active Physician's Order Sheets for January 2023, revealed no diagnosis or physician's orders for a urinary catheter or catheter care. (Photographic evidence obtained) A review of the resident's care plan, dated 11/15/22, revealed that Resident #12 was admitted with an indwelling urinary catheter. He received extensive assistance to meet his toileting needs with interventions that included administration of medications as ordered; monitor catheter every shift for blockage, leakage, if present document and notify doctor; monitor for signs and symptoms of discomfort during urination and frequency. Monitor/document for pain/discomfort due to catheter. Perform catheter care every shift and position catheter bag and tubing below the level of the bladder and away from entrance room door. (Photographic evidence obtained) An interview was conducted with the Director of Nursing (DON) on 1/26/23 at 10:31 a.m. She stated the facility's protocol for catheter care should be based on a physician's order and diagnosis. She stated, Orders should state when a resident's catheter should be changed and how long the catheter should be place. She was asked to identify the diagnosis for Resident #12's catheter placement. She stated I don't see one. She was asked to find the physician's order for Resident #12's catheter. She stated there was no diagnosis or order for the resident's catheter in the electronic medical record. The DON reviewed the hard (paper) chart, and was unable to find a physician's order for a urinary catheter in either the hard chart or the hospice care plan. She stated, I see what your saying. She agreed that there was no diagnosis in the hard chart. The DON was asked how the nurse would know what to do with the catheter if there was no order. She replied, They wouldn't. The facility's policy for Foley (urinary catheter) Catheters (revised 8/19/2015), did not reference obtaining a physican's order or a diagnosis for the use of a urinary catheter. Page 1 of 5 105210 105210 01/26/2023 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0690 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105210 Page 2 of 5 105210 01/26/2023 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's policy and staff interview, the facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. Residents Affected - Many The findings include: During the Quality Assurance Performance Improvement (QAPI) review with the Administrator and the Director of Nursing, conducted on 1/26/23 at 11:30 a.m., there was no current documentation to demonstrate evidence that the facility had an active QAPI program. On 1/26/23 at 11:50 a.m., an interview was conducted with the Administrator and the Director of Nursing. Both confirmed they were unable to provide documentation of any recent ongoing QAPI initiatives. The facility provided a sheet that read 2018 QAPI Plan. (Copy provided) The facility had no specific policy related to maintaining documentation for their QAPI program. . 105210 Page 3 of 5 105210 01/26/2023 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on policy review and staff interviews, the facility failed to effectively maintain a system to identify, collect and use data and information from all departments, including, but not limited to the facility assessment, adverse event monitoring, and feedback from direct care staff, including how such information would be used to develop and monitor performance indicators. The findings include: During the Quality Assurance Performance Improvement review with the Administrator and the Director of Nursing, conducted on 1/26/23, there was no evidence that the facility had any active Performance Improvement Projects. On 1/26/23 at 11:50 a.m., an interview was conducted with the Administrator and the Director of Nursing. They both confirmed that there was no evidence that the facility had any Performance Improvement Projects at the time of the survey. A review of the facility's policy titled QAPI Plan, with an effective date of 11/2017, read as follows: Page 1, #6, stated a program of operation with quality concerns will be described and the choosing of performance improvement projects will be developed as prescribed by the Centers for Medicare and Medicaid Services (CMS). . 105210 Page 4 of 5 105210 01/26/2023 W Frank Wells Nursing Home 210 N 2nd St MacClenny, FL 32063

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, policy review, and staff interview, the facility failed to follow appropriate infection control guidelines for urinary catheter bags for two (Residents #2 and #12) of seven residents with urinary catheters, from a total of 19 residents sampled. Residents Affected - Few The findings include: 1. On 1/23/23 at 10:22 a.m., Resident #2 was observed self-propelling in his wheelchair down the hallway on the west wing near the nursing station. His urinary catheter bag was dragging on the floor under his wheelchair. (Photographic evidence obtained) On 1/23/23 at 1:46 p.m., during an interview with Resident #2 in his room, he stated his urinary catheter got in his way. At this time, the catheter bag observed to be connected to the underside of his wheelchair. The bag and tubing were touching the floor. Also, as the resident moved back and forth in his wheelchair, his catheter bag dragged on the floor. (Photographic evidence obtained) On 1/24/23 at 10:35 a.m., Resident #2 was observed in the hallway of the west wing, self-propelling toward the nursing station in his wheelchair. His urinary catheter bag was dragging on the floor. (Photographic evidence obtained) 2. On 1/23/23 at 10:25 a.m., Resident #12 was observed self-propelling in his wheelchair down the hallway on the west wing between the nursing stations. His urinary catheter bag was dragging on the floor under his wheelchair. (Photographic evidence obtained) On 1/24/23 at 10:20 a.m., Resident #12's urinary catheter bag was observed to be attached to the underside of his wheelchair. His catheter bag was touching the floor and dragged on the floor as the resident moved back and forth in his wheelchair. (Photographic evidence obtained) On 1/24/23 at 10:40 a.m., an interview was conducted with the Infection Control nurse. She confirmed that urinary catheter bags and tubing were not permitted to touch the floor. She stated the cateter bag and tubing should always be off the floor. A review of the facility's policy titled Foley Catheters with a last revised date of 08/19/2015, revealed the following: Page 1, #10, read, Do not let the bag drag on the floor. (Photographic evidence obtained) . 105210 Page 5 of 5