Health inspection·February 7, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observations, resident interview, and staff interviews, the facility failed to ensure residents had a comfortable and dignified dining experience during four of four days observed (2/4/2020, 2/5/2020, 2/6/2020, and 2/7/2020), in one of four dining rooms (the café restorative room). It was observed that residents were 1. Cramped and in the room with staff constantly carrying items over their heads, 2. Residents positioned close to the wall with hand sanitizer stations right at or just above their heads and 3. Residents seated at tables in a manner not able to receive and take bites of food comfortably. Findings included: On 2/4/2020 at 12:10 p.m. the main dining room and back Café restorative room were observed during the lunch meal service. During this time Staff were observed assisting with hydration pass and awaiting the tray cart to pass out and set up meals. The back restorative room was observed with seven tables and with seventeen residents positioned at them. The tray cart arrived at 12:16 p.m. and staff started service immediately. Further observation revealed the tables were positioned in such a way, residents and staff were cramped in. Staff were observed to walk discarded trays and other items while they held them over the heads of residents, who were seated. Some tables were observed with approximately less than two feet of space between each other. Staff were observed at least eight times to pass or walk trays, while carrying them over resident's heads. Also, the room was observed with three hand sanitizer stations hanging on the wall on three of the four walls in the room. There was one resident (#49), who was seated directly next to a hand sanitizer station, which was no more than seven inches from the left side of his head. Various staff were observed to use this station at least twelve times while resident #49 was being assisted with his meal. Resident #49 could not be interviewed related to his dining service. There was also a table in the room that was directly next to another hand sanitizer station, and with two residents seated at it. Staff were observed at least ten times to go directly behind the resident to use the station, which was directly back and over the residents' heads. The lunch meal dining service lasted about one hour and ten minutes. On 2/5/2020 at 12:20 p.m. the small restorative dining room was again observed for the lunch meal service. There were eighteen residents in the room seated at the same seven tables. There were seven staff members observed in the room assisting and interacting with residents. At 12:32 p.m. the meal tray cart arrived for this dining room. The right side of the room and to the back wall was observed with a table used to place empty trays and other various used items. Upon placing/setting up meal trays, staff had to maneuver their way between three tables. Upon doing this, staff had to lift and carry empty trays and various other items directly over the heads of three residents. One resident was seated in a Geri chair. The Geri chair was reclined and positioned in a manner where staff had to squeeze their way by between that resident and another. It was observed that tables needed more Page 1 of 8 105248 105248 02/07/2020 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some spacing so staff would not have to squeeze between residents and carry items over their heads. Further, this was observed to happen over ten times. On 2/6/2020 at 8:10 a.m. the small restorative dining room was observed for the breakfast meal service. There were continued observations of the hand sanitizer stations on the walls, being utilized by staff, with residents seated directly next to and below them. It was observed that Resident #49 was again seated no more than seven inches with his head next to one of the stations. Staff were also observed to maneuver themselves at least ten times between resident #49's head and the wall sanitizer station. On 2/7/2020 at 8:30 a.m. the small restorative dining room was again observed during the breakfast meal service and with the same seven tables positioned tightly throughout the room. There were thirteen residents seated at these tables. Resident #44 still positioned at a table with the hand sanitizer station next to his head. Staff were observed to use the sanitizer station over twelve times as residents were being served meals. The station was seven to nine inches away from the resident's head. Further, while setting up and passing meal trays, staff were still observed to carry discarded/used trays and other items over the heads of several residents, who were in process of eating. The space and walk through area between two tables were tightly cramped. Observations during all four days in the small restorative dining room revealed residents were not interviewable and were not able communicate related to their dining experience. On 2/7/2020 at 1:00 p.m. an interview with both the Director of Nursing (DON), and the Nursing Home Administrator (NHA) confirmed the small restorative dining room is a bit cramped and that the meal service in that room needs to be expanded to two meal services, for both lunch and dinner, so there is more room for residents and staff to move throughout. The NHA further confirmed that the hand sanitizer stations were positioned on the walls directly close to residents and that they need to be addressed as well. Observation on 02/06/2020 Resident #68 at 12:15 p.m., revealed she was seated in her low wheelchair at a table in the small restorative dining room. The Resident's head was turned downward resting in her hand, resulting in the edge of the table being level with her forehead. When the Resident #68 would slightly lift their head upward, the edge of the table was still above the Resident's mouth. An Aide sat in a high-level swivel chair next to Resident #68 and began to assist her with eating. The Aide's shoulder was level with the Resident's top of head. The Aide brought the utensils with food down below the edge of the table to reach the resident's mouth. At 12:19 p.m., another Aide sat next to the Resident #68 in a lower level chair, resulting in the Aide's shoulder being level with the Resident's shoulder and began assisting with eating. The observation during the entire meal service from at least 12:15 p.m. through to 1:00 p.m. revealed resident #68's face and mouth were at or too close to the table's edge, making it very difficult for her to take bites of food comfortably. Interview with Aides in the room revealed resident #68 is seated in a low wheelchair and she does not use a seat booster. None of the Aides had reasoning as to why she was being assisted with her meals at such a low position. Resident #68 was not able to be interviewed related to her positioning and meal service. 105248 Page 2 of 8 105248 02/07/2020 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interviews, observations, and record review, the facility did not ensure that one of sixty-one sampled residents (#44,) received adequate treatment and care in accordance with recognized practice standards. Specifically, this was related to the facility did not have orders for Resident #44's thumb splint, hand splint and brace during three of four days. Findings include: An observation was conducted on 2/06/20 at 10:55 a.m. Resident #44 was observed in her room sitting in her wheelchair. She was observed wearing a left leg orthotic brace. A left thumb splint was not observed. The Resident stated the thumb brace had fallen off. She stated they will replace it in therapy when they come get her. On 2/07/20 at 12:36 p.m., Resident #44 was observed in her room, seated in her wheelchair watching TV. Her left hand thumb brace was in place. A blue finger loop hand splint was also observed on top of the side table. Resident stated, The aides put it on when I go to therapy. Review of Resident #44's medical record revealed that Resident #44's initial admission was 8/10/19. The admission Record included medical diagnoses not limited to hemiplegia, hemiparesis, and muscle weakness. A review of Resident #44's Comprehensive Care plans, most recently revised on 10/17/19 revealed there were no focus areas or interventions pertaining to splints or braces. Review of the physician Order summary Report dated 2/7/2020 revealed there were no orders for Adaptive devices such as splints or braces or a Restorative Program. The MDS (minimum data set) dated 11/17/19 revealed: Cognitive Patterns: BIMS (Brief Interview for Mental Status) score of 09, which indicated she had moderate cognitive impairment. Section F Functional Status: resident requires 1-2 person extensive to total dependence assistance with most activities of daily living (ADL's). Under Specialized Treatments/Services: OT (Occupational Therapy): certification period 11/15/19-12/13/2019: use of an adaptive device was checked. On 2/04/20 at 10:37 a.m., Resident #44 was observed in her room seated in her wheelchair. Resident #44 stated she was waiting for therapy. She had a soft splint on her left thumb. Resident #44 stated the splint on the thumb is to straighten the thumb. Review of the OT Recert, Progress Report and Update Therapy Plan (certification period 12/13/19 3/11/2020) revealed: continue Short Term Goal (STG) # 3: Patient will increase time out of bed/out of room in her wheelchair with the use of adaptive equipment/devices for 6 hours, in order to improve skin integrity and hygiene, and facilitate weight distribution. Long Term Goal (LTG) #5.0: Patient will safely wear resting hand splint and a hand roll on left hand for up to 8 hours, with minimal S/S (signs and symptoms) of redness, swelling, discomfort or pain. Review of the Restorative Nursing Referral form dated 01/07/2020, revealed that Resident #44 had a resting hand splint with finger loops and a soft thumb extending splint. It was signed by the referring therapist on 01/12/20. 105248 Page 3 of 8 105248 02/07/2020 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 02/06/20 at 08:42 AM with Staff A, Registered Nurse (RN).Staff A reviewed the 3008 admission form, admission note for 8-24-19, Hard Copy Medical record and did not find information on splints. Staff A stated the resident may have received the splints in therapy because the admission was through Physical therapy/Occupational therapy. Staff A confirmed there were no orders for the Restorative program nor splints in the electronic or hard copy record. Nurse A then stated I'm familiar with the maintenance restorative program usually the devices are taken off at night and placed back on in the morning and residents also have routine skin checks. Restorative nurses take care of the braces. Unless it is maintenance ROM there would be a Restorative program order and I don't see it. An interview on 02/06/20 at 09:06 AM with the Restorative Nurse stated she was new in the position and is also the risk manager. Nurse confirmed the Restorative program referral was dated 1/7/20 and she stated she did not place the order for the resident to begin the restorative program. The Director of Nursing present at the time of interview, confirmed the date of the referral and added that there had been a CNA trained by PT to perform the resident's treatment recommended. The director also stated the restorative CNAs receive a special training. After the duration of the program is completed the resident is reevaluated by physical therapy for further recommendations. The CNAs are trained by PT/OT in the treatment that is recommended. An interview on 02/06/20 at 09:29 AM with the Rehabilitation Director and Staff D PTA (Physical Therapy Assistant). The Director stated the resident has a AFO (ankle foot orthotics) because she was able to stand but was rolling her ankle. The resident consulted with orthotics and they made a custom cast mold. The AFO was made for the resident. Physical Therapy recommended and ordered a hand brace but it was not here yet. The department provided the resident with a temporary one. When the resident transitions to restorative from Physical therapy the department assistants follow the Restorative CNA for a couple of visits to ensure the resident is comfortable and the treatment is being performed correctly. OT (Occupational therapy) gave the resident a finger splint. The Resident is able to put it on and take it off. Rehabilitation director reviewed the Restorative nursing referral form and stated she had been referred to the restorative program January 7, 2020 and that the CNA had been accompanied by Physical Therapy in three occasions to review treatment with the resident. An interview on 02/06/20 at 11:01 AM with staff B MDS RN. Staff B reviewed the care plan and confirmed there were no devices listed in the care plan. An orthotic device should be on the care plan under ADL's, if the resident was in the restorative program there would be a separate care plan for that. Staff B stated the other Restorative Nurse would write the restorative care plan. On 02/07/20 09:05 AM an interview with Rehabilitation Director, she stated an AFO is part of the resident's dressing it is placed in the morning before patient gets up from bed and taken off before going to bed, it is used for transfer. The AFO is one whole piece, shoe and brace with straps, there is really no wrong way to place an AFO, because it is a custom fit device, unless you place it on the wrong foot or the resident has recent edema you might tighten the strap too much. Unlike a hand splint which we have to determine amount of time tolerated the AFO is a dressing piece. 105248 Page 4 of 8 105248 02/07/2020 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interview, the facility failed to ensure proper storage of respiratory equipment, of a facemask for two (Resident #102 and Resident #309) of two residents sampled. Residents Affected - Few Findings included: A review of facility policy titled Equipment Storage-Respiratory (Disposable) (oxygen, tubing/cannula, nebulizer administration equipment) with effective date of March 2014, under Procedure, reads as follows: 3. Place respiratory equipment (e.g. excess tubing, cannula, nebulizer mouthpiece/mask, medication chamber) in plastic storage bag labeled with resident's name and store at bedside until next use. On 02/04/20 at 9:38 a.m. Resident #102 was observed to be sitting in a wheelchair wearing oxygen Nasal Cannula (NC) of 2 Liters (L). Respiratory equipment of a nebulizer facemask was observed to be on top of a night-stand table, located next to the resident's bed, and not properly stored in a labeled plastic storage bag. (Photographic Evidence Obtained.) A repeat observation of Resident #102's room was conducted on 02/05/20 at 11:45 a.m. The facemask was noted to be again improperly stored, and in the same spot, on top of the night-stand table. (Photographic Evidence Obtained.) During a subsequent observation of Resident #102's room on 02/06/20 at 10:20 a.m., the nebulizer facemask was again observed not to be stored properly. The facemask was in the same spot located on top of the night-stand next to the bed. (Photographic Evidence Obtained.) Clinical record review for Resident #102 indicated that he was admitted on [DATE] with multiple diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia and Asthma. Further clinical record review of Physician Order dated on 01/06/20 for Resident #102 revealed Albuterol Sulfate Nebulization Solution 2.5 MG/3ML) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for SOB/Wheezing. On 2/04/20 at 9:45 a.m., an observation of Resident # 309's room was conducted. The resident was not in her room at the time, and respiratory equipment of a facemask was observed to be on the night-stand next to the resident's bed. The facemask was next to a black nebulizer machine and was not be properly stored in a labeled plastic bag. On 2/05/20 at 9:54 a.m., a second observation was conducted of Resident #309's room. The resident's respiratory equipment of a facemask was observed to be on top of the night-stand next to the black respiratory nebulizer equipment. (Photographic Evidence Obtained.) An interview with Resident #309 was attempted, but she indicated she did not want to say anything to get the staff in trouble. Clinical record review for Resident #309 indicated that he was admitted on [DATE] with multiple 105248 Page 5 of 8 105248 02/07/2020 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses that included Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, and Dependence on Supplemental Oxygen. Further clinical record review of Physician Order dated on 01/25/20 for Resident # 309 revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 application inhale orally every 4 hours as needed for Wheezing. On 02/07/20 at 8:24 a.m., an interview was conducted with the Director of Nursing (DON). The [NAME] was informed of numerous observations made of both Resident #102's and Resident # 309's nebulizer facemask, not being stored properly per facility policy by staff. The DON was shown Photographic Evidence of both resident's rooms and their respiratory equipment and facemask not being stored appropriately in a labeled plastic bag. The DON stated, The nebulizer mask should be cleaned, placed and stored in a bag. 105248 Page 6 of 8 105248 02/07/2020 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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, facility policy review and staff interview, the facility failed to ensure one of five residents who receive Dialysis services, and out of sixty-one sampled total residents (#66), was evaluated for pre and post Dialysis visits. It was determined that the facility's Dialysis communication sheets were not documented with all the required information in order to closely evaluate the residents. Residents Affected - Few Findings included: Review of resident #66's medical record revealed he was admitted to the facility for long term care on 2/12/2017 and again more recently from the hospital on [DATE]. Review of the advance directives revealed resident #66 was his own responsible party and medical decision maker. Review of the diagnosis sheet revealed diagnoses to include but not limited to: ESRD (End Stage Renal Disease), Chronic Kidney Disease, Dependence on Renal Dialysis. On 2/06/20 5:04 p.m. an interview with Resident #66 revealed when he goes to Dialysis they give him a lunch but he doesn't remember what he ate. He feels safe when he is getting transported. When asked about why he was sent to the hospital from the dialysis center the resident said that blood pressure drops sometimes. It doesn't happen a lot but it generally does. He indicated that he doesn't feel pain around his stent. Review of the current POS (Physician's Order Sheet) for the month 2/2020 revealed resident #66 was ordered for: Dialysis schedule Tuesday's, Thursday's, and Saturdays; Diet order No Added Salt, regular consistency with thin liquids. Per review of the order sheet, observations during the survey from 2/4/2020 through to 2/7/2020, and interview with the resident and floor care staff, resident #66 is transported to a Dialysis center three times a week to receive services. Review of the facility's Dialysis Communication Forms, dated from 1/1/2020 through to 2/7/2020, it was determined that six communication sheets were not filled out entirely, to include: a. Form dated 1/11/2020 revealed the section filled out by nurse prior to leaving the facility, revealed lacked vital signs, lack of when the resident had his last meal, and was not signed or dated by the nurse. Further, the section where the Dialysis center fills out, was not signed or dated by a nurse. Additionally, upon return from the Dialysis center, the section for the facility nurse did not document admitting vital signs, nor was it signed and dated by a nurse. b. Form dated 1/14/2020 revealed no section completed with vitals signs, etc., prior to leaving the facility. Further, the section to be completed by facility nurse, upon returning from the Dialysis center, lacked vitals signs and who and when that information was completed. c. Form dated 1/18/2020 revealed the section filled out by the nurse prior to leaving the facility, lacked vital signs, lacked when the resident had his last meal, and was not signed or dated by nurse. Further, the section completed by the Dialysis nurse, was not signed or dated. Additionally, the section to be completed by the facility nurse, upon resident returning from the Dialysis center, it was totally blank and not signed or dated. d. Form dated 1/23/2020 revealed the section filled out by the nurse prior to leaving the facility, 105248 Page 7 of 8 105248 02/07/2020 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lacked vital signs, lacked when the resident had his last meal, and was not signed and dated by the nurse. Additionally, the section to be completed by the facility nurse, upon resident returning from the Dialysis center, it was totally blank and not signed or dated. e. Form dated 1/28/2020 revealed the section filled out by the nurse prior to leaving the facility, lacked vital signs, lacked when the resident had his last meal, and was not signed and dated by the nurse. Additionally, the section to be completed by the facility nurse, upon resident returning from the Dialysis center, it was totally blank and not signed or dated. f. Form dated 2/1/2020 revealed the section filled out by the nurse prior to leaving the facility, lacked vital signs and was not signed or dated by the facility nurse. Additionally, the section to be completed by the facility nurse, upon resident returning from the Dialysis center, it was totally blank and not signed or dated. Interview with the Central Unit Manager on 2/7/2020 at 12:20 p.m. revealed that prior to leaving the facility, those who receive Dialysis are to have their vitals taken and to include Blood Pressure signs. She further indicated that the form goes to the Dialysis center with the resident and that center is responsible for filling out their section. She also indicated that upon return, the facility nurse is to take vitals and fill out the third section of the form to include vital signs. The Unit Manager confirmed that the above listed Dialysis Communication forms were not completed entirely and that they should have. The Unit Manager was asked if the information was documented elsewhere in the chart and she revealed that it was not. On 2/7/2020 at 3:10 p.m. the DON (Director of Nursing) indicated that for residents who go to Dialysis center, and to include resident #66, staff are to initiate every day and to do the following: Facility nurse is to fill out top portion of communication sheet with vitals, weights, med holds, and any other information prudent to Dialysis, and sign and date. The DON further indicated that the communication form goes to the Dialysis center and that nursing staff there are responsible for filling out their section with the same documenting of vitals, weights, med holds, etc. and that a nurse there is to sign and date as well. The DON also explained that the communication form is returned from Dialysis with the resident and upon arriving back, the nurse will again complete and document vitals, weights, med holds, etc. and then sign and date. She confirmed that out of sixteen communication sheets reviewed, six were not filled out completely with either weights not completed, and also staff not signing their section. She further confirmed that after checking the entire medical record and to include progress notes, none of the missing information on these communication sheets were documented and therefore nursing staff would not be able to make good assessment judgements from the lack of information. On 2/7/2020 at 2:45 p.m., review of the facility's Special Care - General Care of the Resident Receiving Dialysis policy and procedure, dated 6/7/2014, under the Procedure section, (I), and #12, revealed, Monitor the resident's blood pressure after the Dialysis treatment, or per Physician's orders. 105248 Page 8 of 8