Health inspection·April 8, 2021

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 observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care for 1 of 4 dependent residents of a total sample of 35 residents, (#28). Residents Affected - Few Findings: Resident #28 was re-admitted to the facility from an acute care hospital on [DATE]. Her diagnoses included tracheostomy status (artificial opening in the neck), hemiplegia post stroke, muscle weakness and traumatic brain injury. The resident's quarterly Minimum Data Set (MDS) assessment with assessment reference date 2/4/21 revealed no history of rejection of care. Her Brief Interview for Mental Status (BIMS) score was 15/15 which indicated she was cognitively intact. The resident required extensive assistance of 1- 2 staff with her personal hygiene and was totally dependent on staff for bathing. The resident's care plan for ADL self-care performance deficit revised on 7/6/20 noted interventions that included, Bathing/showering: The resident is totally dependent on 1 staff for personal hygiene . On 4/5/21 at 9:15 AM, resident #28 was lying in bed. Her fingernails were approximately 1/2 to 3/4 inches long with brownish colored debris under the nails. The resident was oriented to person, place, and time. She was able to speak when she placed her finger over the tracheostomy tube. She said she wanted her fingernails trimmed shorter and cleaned. Registered Nurse (RN) E was present in the resident's room and acknowledged the resident's nails were long and dirty. On 4/5/21 at 12:06 PM, the resident was lying in bed. She was awake and alert. She showed her nails and they remained the same, long and dirty. On 4/5/21 at 1:59 PM, the resident's assigned Certified Nursing Assistant (CNA) D said, when I am not busy, I do the nail care and I have no free time. On 4/6/21 at 10:15 AM, the resident was lying in bed and showed her fingernails. Her fingernails were cut sideways, jagged with brownish residue under the nails. The resident nodded yes that staff had only trimmed her fingernails but not cleaned nor filed them. On 4/7/21 at 12 PM, the resident was lying in bed. She again showed her fingernails that were jagged and dirty. The nails had brownish/orange residue under the nails. The resident indicated staff had not cleaned or filed them. Page 1 of 9 105250 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/7/21 at 12:02 PM, RN E acknowledged the resident's nails were cut jagged, approximately 1/4 inch long and dirty. RN E said, I told the CNA yesterday about 3:00 PM to do the nail care. She said she could not remember the name of the CNA. The facility's policy for Providing Nail Care dated 2020 read, The purpose of this procedure is to provide guidelines for provision of care to resident's nails for good grooming and health .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing. Nail care will be provided as the need arises. Principles of nail care: Nails should be kept smooth to avoid skin injury . 105250 Page 2 of 9 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services to identify, monitor and treat pressure injuries for 1 of 3 residents reviewed for pressure ulcers, of a total sample of 35 residents, (#48). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments timely resulted in actual harm. Residents Affected - Few Resident #48 was identified with 2 new facility acquired unstageable pressure ulcer/injury by the surveyor from 4/6-4/7/21. The resident had 1 unstageable pressure ulcer/injury to his left heel and 1 on left inner ankle. The facility failed to identify wounds at an early stage and failed to initiate timely treatment and preventive measures. Findings: The National Pressure Injury Advisory Panel (NPIAP) redefined the definition of a pressure injury (formerly pressure ulcer) in 2016. The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence . The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear .Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin . which may appear differently in darkly pigmented skin.Stage 2 Pressure Injury: Partial-thickness skin loss with .Stage 3 Pressure Injury: Full-thickness skin loss .Stage 4 Pressure Injury: Full-thickness skin and tissue loss . If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar .Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration intact or non-intact skin .Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure . (The National Pressure Injury Advisory Panel website at www.npiap.com accessed on 4/9/21). Resident # 48 was a [AGE] year-old African American male admitted to the facility on [DATE] from an acute care hospital with diagnoses that included paraplegia, stage 4 pressure ulcers to both hips, muscle weakness, lack of coordination, and abnormal posture. The residents' significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted he required limited to extensive assistance of 1 person with bed mobility, dressing, and personal hygiene. He was bed/chair bound, had indwelling urinary catheter and was always incontinent of bowel. He was at risk for developing pressure ulcers/injuries. He was admitted to facility with 1 stage 4 pressure ulcer, 1 stage 3 facility acquired pressure ulcer and 1 unstageable-deep tissue injury that was also not present upon admission/entry or re-entry. He had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. The MDS assessment showed resident #48 did not .reject evaluation or care necessary to achieve the resident's goals for health and wellbeing . Review of resident #48's medical record revealed a care plan initiated on 12/3/20 and revised on 4/5/21 for actual skin breakdown related to stage 4 pressure ulcers to both hips. Interventions included pressure reducing mattress and wound care as ordered. The resident's Activities of Daily Living 105250 Page 3 of 9 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0686 Level of Harm - Actual harm Residents Affected - Few (ADL) self-care performance deficit plan was initiated on 12/4/20. Interventions were for 1 staff to provide extensive assistance with bathing/showering, turning and repositioning in bed. The care plan initiated on 11/24/20 for skin breakdown related to impaired mobility secondary to paraplegia included interventions for nurses to complete weekly skin assessment, Certified Nursing Assistants (CNA) to monitor skin during bathing, especially over bony prominences, and report abnormalities to nurse, nursing staff to monitor skin for signs and symptoms of skin breakdown, related to cracking, blistering and offload heels while in bed as resident allows. The goal of the skin care plan was the resident will remain free of skin breakdown throughout next review date 6/2/21. On 4/5/21 at 8:45 AM, resident #48 was in bed on a specialty mattress eating breakfast. He was alert and oriented to person, place, and time. He had a visible wound dressing on his right hip dated 4/4/21, which was soiled with dark brown/tan drainage. The resident said he got the wound on his hip while he was in quarantine on the other side of the facility. The resident had a urinary drainage bag present and said that he needed this because he was paralyzed from his waist down and had no feeling. His lower extremities were contracted, bent upward and covered with blanket. On 4/6/21 at 5:07 PM, the facility Wound Nurse was prepared to enter the resident's room and said the resident was on enhanced precautions as he had an infection in his wound. The resident was lying in bed wearing bilateral foam type boots that covered his feet and ankles. The resident was asked if he had any sores on his heels. He reached down and took off his left boot. There was a darkened area approximately the size of a small orange on his left heel. On 4/7/21 at 10:48 AM, an observation of wound care was conducted with the Wound Nurse and CNA A. The nurse gathered her supplies and performed wound care to resident #48's bilateral hip wounds and sacral area. The left lateral hip pressure wound measured 5.6 centimeters (cm.) by 6.4 cm. by 1.4 cm deep, 80% granulation (pink) tissue, 5% necrotic tissue. The wound to right lateral hip measured 7.25 cm by 6.6 cm. by 0.8 cm deep, 90% granulation tissue. The pressure wound to medial coccyx was resolved. The CNA held the resident's legs up off the bed so the Wound Nurse could remove the residents' foam boots and socks. He had no breakdown seen on the right heel or ankle area. The Wound Nurse looked at his left lower extremity and said, the left heel has 1/2-dollar size, dark necrotic eschar (dead tissue) and dime size dark necrotic area on the left medial (inner) ankle. She said the areas look like they have been there for awhile and should have been reported by the CNAs to the nurses. She added, the nurse doing the weekly skin sweeps missed it. CNA A said she was the Restorative CNA and applied his boots daily. She said she had not reported any changes in his left heel to the nurse because she thought the darkened necrotic areas to the left heel and left inner ankle were not new. CNA A said she helped his regular CNA with care, and the left heel and ankle looked worse than last week. The Wound Nurse acknowledged there was a dramatic difference in the appearance of the right foot which had no breakdown as compared to the left. On 4/7/21 at 12:51 PM, the Director of Nursing (DON) said, she looked at resident #48's pressure wounds to his left heel and inner ankle. She added, this did not happen overnight. The CNAs or the nurses doing the weekly skin sweeps should have caught this sooner, notified the doctor, obtained new treatment orders and notified the family. On 4/7/21 at 1:13 PM, Licensed Practical Nurse (LPN) B verified, she was assigned to resident #48 105250 Page 4 of 9 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0686 Level of Harm - Actual harm Residents Affected - Few on day shift 3 days last week and from 4/5 to 4/7 this week. LPN B said, she did the wound care to his hips and bottom and the restorative CNAs applied his boots. She said none of the CNAs mentioned he had skin breakdown on his left heel and inner ankle. The CNAs should be washing his feet and report any breakdown to the nurse, because the resident is paralyzed and would not be able to feel it. She added if the CNAs brought concerns to her attention she would have assessed the resident's skin, report any new breakdown to the Unit Manager (UM), do a change in condition note, notify the physician, get treatment orders, and notify the family. LPN B said she was not the nurse that did the resident's weekly skin checks. She said the standard of practice would be to look under his heels since this is a vulnerable area and he stays in bed, and does not move his lower extremities. On 4/7/21 at 1:26 PM, the resident's assigned CNA C said she was agency staff and had worked at the facility less than 1 month. She added that today was the first time she had cared for resident #48. CNA C said that part of giving a bath would be to check the resident from head to toe and notify the nurse of any concerns. On 4/7/21 at 2:38 PM, CNA F said she was assigned to resident #48 on the 3-11 shift last Friday 4/2/21. She knew the resident well and had been assigned to his care for approximately 6 months. She said he usually had his boots on when she arrived on duty and she removed them after dinner and applied lotion to his feet. She added she changed his brief, and informed the nurse when his hip dressings were soiled. CNA F recalled last Friday, 4/2/21, I think it was his left heel which had red spot brewing, and I reported this to the nurse, probably nurse (LPN) I. She did not know if the nurse checked his left heel. She acknowledged she was assigned to resident #48 last week on 3/29, 3/31 and 4/2/21. She noted the only day she had concerns with his foot/heel was on Friday 4/2/21. She said, I turn the resident side to side every 2 hours and because he is African American it's hard to tell with skin changes. Review of resident #48's medical record revealed the Wound Doctor documented on 3/15/21 that pressure wound on the right lateral buttock was resolved. Review of Registered Nurse (RN) G's documentation on the Weekly Skin Evaluations dated 3/20, 3/27 and 4/contradicted the doctor's assessment as she documented right lateral buttock area was still open. RN G had completed the 10 most recent Weekly Skin Evaluations on Saturdays. There wasn't any documentation by RN G regarding any skin breakdown to the left heel or ankle. On 4/7/21 at 4:17 PM, a telephone interview was conducted with RN G. She acknowledged she completed resident #48's skin evaluations the past 10 weeks with the most recent one done on Saturday 4/3/21. RN G said, she looked at everything including the resident's heels/ankles when doing the skin checks. She then stated, the left heel has always been softer than the right and she did not document the difference. I assumed they already documented the difference on his admit assessment and it is my fault for not looking at his admission assessment to see if they already documented it. Review of the Skin Assessment policy and procedure revealed, It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .Begin head to toe, thoroughly examining the skin for conditions. Pay close attention to pressure points, bony prominence and underneath medical devices .Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers and lesions .Consideration for resident with darkly pigmented skin: It is not always possible to identify redness on darkly pigmented skin. Indicators of early pressure damage: localized heat, 105250 Page 5 of 9 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0686 edema, bogginess, induration, temperature differences of surrounding tissue, skin discoloration . Level of Harm - Actual harm On 4/7/21 at 4:25 PM, the Advanced Practice Registered Nurse (APRN) H assessed resident #48's feet/ankles with the North Wing Unit Manager (UM). The resident was in bed, alert and talkative. The APRN said the left heel and inner ankle had discolored areas approximately the size of a [NAME]. The APRN said, both wounds were unstageable DTIs (Deep Tissue Injuries) and instructed the UM to obtain an x-ray of the left lower extremity to rule out osteomyelitis (bone infection). The APRN said, this has been here for at least a week. The UM said the CNA should have reported changes sooner to the nurse and the nurse doing the weekly skin evaluations missed this. Residents Affected - Few On 4/7/21 at 5:30 PM, LPN K who worked Monday to Friday on the 3-11 PM shift said that he did the initial skin assessment when resident #48 came back to the North Wing from the Coronavirus Disease 2019 (Covid) Unit. The resident was in the Covid unit from 1/19 to 1/29/21. LPN K said the resident did not have any discolorations on his heels when he returned. He added he had not looked at the residents' heels in over a month. LPN K stated, we have a lot of agency staff working here who don't know the residents and many of them no longer work at the facility. More than likely the breakdown on his left heel/ankle could have been due to agency nurses who would not have known better. On 4/8/21 at 9:32 AM, the Occupational Therapist (OT) said she obtained orders from the physician for foam boots for resident #48 on 3/2/21 because resident #48 had wounds on the outer ankles. The order was for foam boots to be applied for 6-8 hours daily in bed for pressure relief. She did not remember seeing any breakdown on the resident's heels or inner ankles at that time. She trained the CNAs on the application of the boots and he was taken off therapy caseload as of 3/2/21. The OT added the resident was completely numb from his waist down as he was paraplegic. The OT said that staff who donned and doffed the boots daily should have identified any new breakdown on the heels or inner ankles. She stated the resident's muscles were very atrophied and bony prominences were protruded which made his skin vulnerable to breakdown. On 4/8/21 at 10:47 AM, the DON said, the CNAs were responsible to inform the nurse immediately when there was a change in skin integrity so the nurse could assess the resident. The DON verbalized they did not have a process in place for CNAs to document any identified alterations in skin integrity. She stated the CNAs would verbally inform the nurse. The DON acknowledged that since the CNAs applied and removed resident #48's foam boots daily they should have identified and reported alterations in his left heel and ankle sooner. The Administrator said resident #48's regularly assigned day CNA was not available for interview by surveyor as she was on leave. On 4/8/21 at 11:58 AM, the Wound Nurse said he Wound Doctor would not have looked at resident's heels/ankles unless concerns were brought to her attention. The Wound Nurse acknowledged that RN G failed to complete a thorough skin assessment as RN G continually documented for 3 weeks that the resident had an open area on the right buttock after the Wound Doctor had resolved the area on 3/15/21. On 4/8/21 at 12:29 PM a telephone interview was conducted with LPN I. She said she worked on the North Wing 3-11 shift on Friday 4/2/21. She said she was not aware that resident #48 had any new skin concerns. She said CNA F did not report any skin issues with the resident's heel or ankle. She stated if she was made aware of any new skin issues, she would have assessed the skin, then notified the physician to obtain treatment orders. On 4/8/21 at 4:08 PM, the DON reviewed the resident's weekly Braden Scale for Prediction Pressure Ulcer Risk forms from 3/2/21 to present. She noted the resident was erroneously scored at a lower 105250 Page 6 of 9 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0686 Level of Harm - Actual harm risk than he should have. The DON reviewed form dated 4/7/21 which had a score of 16 that indicated he was at risk for pressure injury. The DON said he should have scored 12 to 13, which would have put the resident at moderate to high risk. The areas that were not scored properly were weight loss, sensory perception, moisture, mobility and friction/shear. Residents Affected - Few On 4/8/21 at 4:29 PM, a telephone interview was conducted with the Wound Care Doctor. She said she had just observed resident #48's wounds via telemedicine. She stated, the left heel looks like a pressure ulcer with non-infected eschar and same with the inner ankle. They are both unstageable pressure ulcers and I do not know how long they have been present. The wound doctor was made aware that the surveyor identified discoloration left heel and inner ankle from 4/6 to 4/7/21 during survey. She was also made aware that RN G who did the last 10 weekly skin sweeps documented erroneous information and CNA F had reported to LPN I on 4/2/21 of red spots brewing on the resident's left heel. The Wound Doctor acknowledged the facility staff should have identified these pressure injuries when they noticed the redness. She verbalized the staff should have intervened, reported to the physician and repositioned the resident frequently. The Wound Doctor added, If we are aware that he has a stage 1 that would be the time to put in preventive measures to keep if from progressing. Review of the facility's Pressure Injury Prevention and Management policy and procedure, with no date revealed, To minimize the risk of formation of pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions .Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over bony prominence .Licensed nurses will conduct a full skin assessment on all residents upon admission/re-admission, weekly .Certified Nursing Assistant will inspect skin during the resident bath/shower and will report any concerns to the residents nurse . 105250 Page 7 of 9 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to follow proper thawing procedures to prevent the potential of food borne illness when preparing frozen chicken. Residents Affected - Few Findings: On 4/05/21 at 7:05 AM, the production sink noted a pan with wrapped chicken packages thawing under cold running water. The Certified Dietary Manager (CDM) had placed the chicken in the pan and had water flowing over the chicken. The water temperature was checked by the CDM with a calibrated thermometer and read 72.8 °F (Fahrenheit). She said she was not aware that water temperature for thawing under cold water had to be 70°F or below in accordance with the Food and Drug Administration 2017 Food code Chapter 3-501.1. 105250 Page 8 of 9 105250 04/08/2021 Sunrise Point Health and Rehabilitation Center 1775 Huntington Lane Rockledge, FL 32955

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the safe functioning of resident beds for 1 of 35 total sampled residents, (#4). Residents Affected - Few Findings: On 4/05/21 02:17 PM, Licensed Practical Nurse (LPN) B reached for resident #4's hand to check her pulse oxygen saturation. As she leaned forward, the bed slid away from her. The base of the bed foot wheels was in lock position. Resident #4 said, the bed had slipped before and it scared me. I thought they fixed it. On 4/07/21 at 10:15 AM, the Director of Maintenance (DOM) said he did not have a routine program in place to ensure beds were safe. He said an outside service company inspected beds annually for electrical functioning and safety. He stated the process was that when staff identified a problem with a bed, they contacted him, and he replaced the bed. He said he had new beds available and he changed the beds when staff identified a problem with the bed. On 4/07/21 at 12:06 PM, resident #4 said that was not the first time the bed rolled away. She said when staff leaned against the bed it would slide away. She added it had happened for quite some time. She said she had been in the same bed for 9 years. I asked someone to put in work orders to fix the break. It didn't last. On 4/08/21 at 4:30 PM, the DOM revealed that he received messages via his cell phone when staff entered a concern about equipment and repairs into the facility's electronic reporting system. He said he deleted the message after the repairs were completed. He acknowledged he did not have an ongoing reporting system in place. He noted he had a safety committee meeting and discussed equipment repairs. The DOM did not have any documentation that these meetings occurred to demonstrate what was discussed. 105250 Page 9 of 9