Health inspection·November 3, 2021

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 ensure a resident was assessed to self-administer oral pain/sleep medication and topical pain relief cream medications for 1 of 50 total sampled residents (#88). Residents Affected - Few Findings: Resident #88 was admitted to the facility on [DATE] with diagnoses including-unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, and muscle weakness. The resident's quarterly Minimum Data Set assessment, with reference date of 10/08/21, revealed the resident's cognition was moderately impaired and a brief interview mental status score of 12/15. On 10/31/2021 at 11:09 AM, the medication Tylenol PM 500 milligrams, a 3 ounce tube of Aspercream, and a 3 ounce jar of Biofreeze was in a pink wash basin on the resident's tray table in her room. Resident #88 stated that the creams are for the pain in her right shoulder. She also stated her son brought the Tylenol PM because He knows I have trouble sleeping. On 11/01/2021 at 10:54 AM, the medications were again observed in the pink basin on the tray table. On 11/02/2021 at 1:35 PM, the medications were observed in the pink wash basin on the tray table. On 11/03/2021 at 12:12 PM, Registered Nurse (RN) D was informed of the medications at the resident's bedside. RN D went to resident #88's room and informed her that she would have to keep the medications locked in a secure location for her son to collect. RN D stated resident #88 was not assessed to self-administer medications. RN D stated that a resident who wants to self-administer medications must be evaluated to determine if they are safe to do so, physician orders and care plan must then be in place, and the medication would be kept in the medication cart. On 11/03/2021 at 6:56 PM, the Director of Nursing (DON) confirmed that the resident was not assessed as a resident to self-administer her medications. Resident #88's medical record did not contain documented sleep issues or assessment to self-administer medications. There were no recommendations and no order for self-administration for oral or topical medications. Review of the most recent plan of care completed on 10/02/2021 did not reveal a plan of care for self-administration of medication. Page 1 of 5 105251 105251 11/03/2021 Rockledge Healthcare & Rehabilitation Center 587 Barton Blvd Rockledge, FL 32955

F 0554 Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure Self-Administration of Medications, dated December 2021, read, As part of their overall evaluation, the staff and practioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident self-administered medications must be stored in a safe and secure place, which is not accessible by other residents Residents Affected - Few 105251 Page 2 of 5 105251 11/03/2021 Rockledge Healthcare & Rehabilitation Center 587 Barton Blvd Rockledge, FL 32955

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #644 was readmitted to the facility on [DATE] with diagnoses that included stroke, dysphagia, protein calorie malnutrition, type 2 diabetes, and adult failure to thrive. Review of the quarterly MDS assessment dated [DATE] revealed resident #644 is rarely/never understood and needed extensive assistance with eating. On 10/31/2021 at 12:15 PM during lunch trays distribution, CNA B took the untouched tray off of resident #644's overbed table. In the resident's room, CNA B said she was taking the tray back to the food cart to stay warm because the resident is a feeder and we do them last. CNA A, who was also in the room, did not try to correct CNA B for calling resident #644 a feeder. On 10/31/2021 at 12:36 PM, resident #644 was in bed with the head of bed raised for lunch and CNA A was standing on the resident's left side of the bed feeding her a mechanical soft diet of fried chicken, mashed potatoes, broccoli and apple pie. CNA A did not talk to the resident and did not sit next to her during the meal. Instead, she stood by the resident and could easily be seen from the doorway leading out into the hall. Based on observation, interview and record review, the facility failed to promote the dignity for 3 of 3 residents in a total sample of 50 residents (#92, #644 & #16). Findings: 1. Resident #92 was admitted to the facility on [DATE] with diagnoses that included dysphagia, malnutrition, type 2 diabetes, and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 10/14/2021, revealed resident #92's Brief Interview for Mental Status score of 3, which indicated severely impaired cognition. The MDS also showed resident #92 needed extensive assistance with eating. On 11/02/2021 at 1:47 PM and 2:05 PM, during lunch trays distribution, Certified Nursing Assistant (CNA) G explained she was used to getting the feeders' trays from the kitchen, but the process was done differently at this facility. CNA G indicated staff first passed all trays out to residents who are independent or need set up with meals and then helped the feeders. CNA G asked CNA H the whereabouts of resident #92's lunch tray, and said, He is a feeder, to which CNA H replied, No, he is not. When asked why she referred to resident #92 as a feeder 3 times, CNA G explained she meant the resident needed assistance eating. CNA G indicated her new hire orientation covered resident rights but did not remember if using labels to refer to the residents was mentioned during her training. CNA G stated they used the word feeder in the facility at times when referring to the residents and added, It's not a good thing. CNA G stated it was her mistake to call him that, I apologize, my mistake. On 11/02/2021 at 6:23 PM, the Human Resources Director (HRD) and the Assistant Director of Nursing/Staff Development Coordinator (ADON) explained all new hires, agency staff included, received a New Hire Education Packet. The ADON indicated the New Hire Education Packet was to be reviewed and signed by the new employee on his/her first day at the facility. 105251 Page 3 of 5 105251 11/03/2021 Rockledge Healthcare & Rehabilitation Center 587 Barton Blvd Rockledge, FL 32955

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/03/2021 at 2:31 PM, the Director of Nursing (DON) explained residents who needed assistant while eating should be referred as Assisted Dinner and not feeders. The DON stated she did not know what was taught during the new hire orientation. On 11/03/2021 at 7:41 PM, the ADON indicated she always corrected CNAs if she heard them referring to the resident as feeder. The ADON explained the resident was to be referred as dependent or assisted dining because this was a dignity issue. The ADON explained resident rights was covered during new hire orientation. 3. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses including dementia, malnutrition, diabetes, and Parkinson's disease. The MDS Quarterly Assessment with assessment reference date of 7/30/2021 revealed resident #16 had adequate hearing, clear speech and was usually understood. The document indicated she required one person to assist with set up only for eating. Resident #16's care plan was initiated on 5/13/2021 and revised on 8/13/2021 for risk of weight loss, depression and loss of dignity related to her diagnosis of end stage dementia. The goal was for dignity and autonomy to be maintained at the highest level of capacity. On 11/03/2021 at 12:39 PM, resident #16 sat in the facility dining room for lunch. CNA C stood over resident #16 and asked nearby staff, Is she a feeder?, which she then repeated three additional times. No reply was made to CNA C by other nearby staff. Outside the dining room on 11/03/21 at 12:43 PM, CNA C stated she was an agency staff member. She stated that she did not know that residents should not be called feeders. She stated that the facility never educated her on what to call residents who required feeding assistance. Review of the Nursing Home Resident's Rights In Florida packet given to residents upon admission and New Hire Education Packet included The right to be treated courteously, fairly, and with the fullest measure of dignity The facility policy and procedure titled Dining Room, revised October 2017 read, Our facility audits the food and nutrition services department regularly to ensure that residents needs are met and that dining is a safe and pleasant experience for residents. 105251 Page 4 of 5 105251 11/03/2021 Rockledge Healthcare & Rehabilitation Center 587 Barton Blvd 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, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 2 of 2 nutrition rooms (East & [NAME] Wing). Residents Affected - Some Findings: 1. On 11/03/2021 at 1:07 PM, observation of the East Wing nutrition room with the Central Supply Manager revealed three cups of poured juice unlabeled and undated, and an individual container of cottage cheese past the expiration date inside the refrigerator. Food particles and a yellow substance were seen on the inside door of the refrigerator on the door shelves. No temperature log was found for the refrigerator. Food particles and trash were observed on the cabinet shelf, under the basket of snacks when it was lifted by the Central Supply Manager. She stated the kitchen was responsible for maintaining and cleaning the nutrition room. She was unsure who was responsible for the refrigerator temperature logs, but felt it was someone from the kitchen. She said the kitchen staff were supposed to clean the room and check the refrigerator when they came to replenish the nutrition room. The Central Supply Manager confirmed the unlabeled and expired items in the refrigerator and said the items should be discarded so they were not served to residents. Photographic evidence was obtained. 2. On 11/03/2021 at 1:14 PM, observation of the [NAME] Wing nutrition room refrigerator with the Central Supply Manager revealed three clear plastic bags with pizza inside labeled with a room number but not dated. One cup of nectar thick juice was inside the refrigerator unlabeled and undated. A wet paper towel was stuck to the back wall of the refrigerator. The Central Supply Manager confirmed the findings in the [NAME] Wing nutrition room and was unable to say where the refrigerator's temperature log was located. Photographic evidence was obtained. On 11/03/2021 at 4:45 PM, the Regional Certified Dietary Manager stated the managers were responsible for cleaning the nutrition rooms, but they didn't have a key, which was why it wasn't done. On 11/03/2021 at 6:45 PM, the Staff Development Coordinator (SDC) provided copies of refrigerator temperature logs for August 2021, September 2021 and October 2021, and stated the person from the kitchen who was responsible for the temperature log had been out sick. No logs for November 2021 were provided. On 11/03/2021 at 7:48 PM, tour of the East and [NAME] Wing nutrition rooms with the Staff Development Coordinator now revealed refrigerator temperature logs in both nutrition rooms. The SDC verified the East Wing Nutrition room Refrigeration Checklist temperature log for November 2021 had no entries logged for the month. Review of the policy Foods Brought by Family/Visitors, with revision date of October 2021, read, Food brought by family/visitors that is left with the resident to consume later will be labeled Containers will be labeled with the resident's name, the item and the 'use by' date Staff are directed to discard perishable foods on or before the 'use by' date. Review of the policy, Sanitization, with revision date of October 2008, revealed that all food service areas shall be maintained in a clean and sanitary manner. It further directed that, All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish counters, shelves and equipment shall be kept clean. 105251 Page 5 of 5