Health inspection·November 30, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, and facility policy review, it was determined that the facility failed to provide the resident group with a private space for 8 out of 12 residents sampled. A resident group is defined as a group of residents that meets regularly to: Residents Affected - Some Discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life; Support each other; Plan resident and family activities; Participate in educational activities; or For any other purpose. The findings include: On 11/27/23 at 11:30 am, the Activity Director was asked when the next scheduled Resident Council Meeting would be held. She stated it was scheduled for that day at 2:00 pm. She was asked if she could confirm if Resident #13 was the Resident Council President. She stated yes. She stated Resident #8 was the [NAME] President, and had previously been the President. On 11/27/23 at 11:45 am, Resident #13 was asked if she was the Resident Council Present. She stated yes. She was asked how long she had been President. She stated she was not sure exactly, but it had been a few months. When asked if the council would be meeting today at 2:00 pm, she stated yes. When asked she gave permission for the surveyor to attend the meeting today. She was asked where they hold their meetings and she stated in the TV room where they eat meals. On 11/27/23 at 2:00 pm, eight residents were observed in the open area which serves as the facility dining room and activity room. This area was observed to have 3 walls with no fourth wall or door to enclose the area for privacy. The open area led to the nurses' station straight ahead, the 100 hallway to the right and the 200 hallway to the left. The meeting was called to order at 2:00 pm with the President leading the group with the Pledge of Allegiance. There were 2-3 staff observed in the nurses' station for the duration of the meeting. Staff were observed to come into the meeting area throughout the meeting included housekeeping sweeping the floor and kitchen staff speaking to other residents who were not attending the meeting. The meeting area was observed to be noisy and chaotic. The President was asked if it's always this noisy during their Council meetings. She stated, Yes, and just wait until 3:00, it gets even louder. She was asked if she wished to have the meetings in a private area. She stated yes. The Activity Director stated, We used to have the meetings in the therapy room, but that stopped with the new owners. At 2:39 pm Resident #3 yelled out, If people would be quiet, we could hear! to the residents in the back of the area who were not attending the meeting. At 2:46 pm, the noise level escalated due to Page 1 of 11 105261 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff scooping ice into cups and other staff and residents not in the meeting speaking loudly. The Council President and one resident yelled loudly to staff and other residents to quiet down by yelling, We're trying to have a meeting here. The Activity Director then said, We're trying to have a resident council meeting. At 3:18 pm, three staff members were observed coming in and out the locked side door beside where the meeting was being held, talking loudly among themselves. Furniture was observed being moved loudly across the floor at this time. At 3:23 pm in an interview with Resident #8, she was asked if the council meetings are always held in the common area. She stated, When I was the president we used to have the meetings in the gym, but they've been held out here for at least a few months now. She was asked if she would prefer the meeting be held in a quieter and/or private area. She stated, I like it out here but it's too noisy. I like it because it's a big area but it's too noisy. Sometimes it should be more private of an area, because anyone could be walking through and listening. We might be discussing something we don't want some staff to hear. On 11/29/23 at 4:00 pm in an interview was conducted with the Administrator. She was asked if she had attended any Resident Council Meetings and stated, No, I haven't yet and to be honest, I haven't reviewed the past meeting minutes, but I am going to review them and I am going to ask the president of the council if I can have permission to attend the next meeting. When asked if she was aware where the Resident Council meetings are held she stated, Out in the dining and activity room area. She was asked if that area affords privacy for the residents and she stated no. On 11/30/23 at 12:40 pm in an interview with Employee F she was asked if she had ever attended a Resident Council Meeting. She stated, No, but I was here when they had it on Monday. When asked how often the meetings are held she stated they were monthly and confirmed they were held in the common area. Regarding residents having privacy for their meetings she stated, I would say privacy is difficult because there are no doors to close in that area. She was asked if she can hear what is being discussed at the meetings. She stated, Yes I can hear what's being said. I think the area could be more private so we can't hear what they are saying. A review of the facility policy titled Resident Council (revised 8/22) revealed: (The Facility) supports a resident council. Department leaders including the Administrator and Director of Nursing will attend only if an invitation is extended. . 105261 Page 2 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, observations, review of the resident council minutes and the Resident Handbook, the facility failed to ensure packages and mail were unopened when received for 1 of 13 sampled residents (Resident #32). Residents have the right to receive mail and packages unopened. The privacy of the residents are affected. Residents Affected - Few The findings include: An interview was conducted with Resident #32 in his room on 11/28/23 at 10:45 a.m. He reported having concerns that his mail and packages are being brought to him opened at times. His packages have to be opened in front of staff, usually the activity director. The resident was alert and oriented, and spoke clearly. He reported discussing this in Resident Council meetings. A record review was conducted for Resident #32 which noted an admission date of 3/1/23 and re-entry date on 7/14/23. Diagnoses included non-traumatic subarachnoid hemorrhage and mood disorder. A review of the Minimum Data Set on 9/4/23 noted resident has a BIMS of 14, indicating intact cognition. Resident #32 was observed receiving an Amazon package unopened at 2:45 p.m. on 11/29/23. The resident was speaking to the Clinical Nurse Supervisor, Licensed Practical Nurse (LPN) and was told he had to open it in front of the Activity Director. After the LPN walked off, the resident reported he is waiting for the Activity Director to return. The resident also reported telling the LPN supervisor and stated it was a federal offense to open the resident's mail. An interview was conducted with the Activity Director and Administrator on 11/29/23 at 3:55 p.m. The Resident council meetings were discussed. The Activity Director reported she delivers the mail and packages to the residents. An inventory form is taken with her and the resident opens the package in front of her. She was not sure there is a policy concerning opening mail and packages in front of staff. The inventory form is filled out when packages are opened. She reported only opening mail if asked, and the opening of packages in front of staff started 6 months ago. The Administrator reported it is not required for residents to open packages in front of staff. The Activity Director works Monday through Friday and there is no one to deliver packages on the weekend. The Administrator reported a plan would be put in place for a weekend receptionist to sort mail and disperse with education provided for staff concerning mail or packages being documented for inventory. The Activity Director confirmed that 3 of the 4 last resident council meetings noted opened mail and packages. The Administrator reported the mail should not be opened. An interview was conducted with Resident #32 in the hallway on 11/30/23 at 10:15 a.m. He reported he opened the package received on 11/29/23 in front of a staff member. A review of Resident Council Meetings dated 9/21/23 and 10/15/23 noted mail does not arrive unopened. (photographic evidence obtained) A review of the Resident Handbook noted under Consent Regarding Mail Correspondence revealed residents have the right to send and receive unopened mail. . 105261 Page 3 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

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 Based on observations, staff and resident interviews, medical record review, and facility policy review, it was determined that the facility failed to provide activities of daily living services to maintain grooming and personal hygiene, specifically fingernail care, for one resident (Resident #23) out of 12 residents sampled. Residents Affected - Few The findings include: On 11/27/23 at 12:15 pm, Resident #23 was observed in his room and had fingernails elongated on each finger. He was asked if he prefers his fingernails to be that long. He stated, NO! I don't. The interview was stopped at that time due to resident's display of anger. On 11/28/23 at 10:10 am, Resident #23 was observed up and dressed in day clothes in the milieu. His fingernails were observed to be elongated. He was asked if he prefers his fingernails to be that long. He stated, No, I gotta get these nails cut. The resident was asked if he would allow his fingernail lengths to be measured. He stated yes. The following measurements were taken from tip of finger to end of nail: Left hand thumb: 1 centimeter Left hand first finger: 1 centimeter Left hand second finger: 3/4 centimeter Left third finger: 3/4 centimeter Left fourth finger: 3/4 centimeter Right hand thumb: 1 centimeter Right hand first finger:1 centimeter Right hand second finger: 1 centimeter Right third finger: 3/4 centimeter Right fourth finger: 3/4 centimeter On 11/29/23 at 10:22 am, Resident #23 was observed sitting in a chair in the TV/dining room. He was observed to have both hands inside his sweat shirt pockets. He was asked if his nails were still long. He stated, Yeah, I need to get them trimmed. He took his hands out of his pockets and showed both hands. All nails were observed to elongated with the exception of the left pinky fingernail which was the same length as the fingertip. A medical record review for Resident #23 revealed a quarterly MDS (Minimum Data Set) evaluation dated 8/26/23 which showed a BIMS (Brief Interview for Mental Status) score of 08 (indicative of moderate cognitive impairment). Diagnoses included unspecified dementia, major depressive disorder, and cognitive communication deficit. 105261 Page 4 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the person-centered care plan for Resident #23 revealed the following focus with goals/interventions: Focus (5/24/18, revised 11/29/22) Activities of Daily Living (ADLs): (Resident) is at risk for ADL self-care performance and mobility deficits related to diagnoses dementia, glaucoma, and muscle wasting of bilateral upper extremities. Goals: (revised 5/30/23) (Resident) will maintain current level of function through the review date Interventions: Check nail length and trim and clean on bath days and as necessary. Report any changes to the nurse. Progress notes were reviewed for Resident #23 from 8/1/23 through 11/29/23. There were no progress notes stating the resident refused nail care or any ADL care. On 11/30/23 at 8:30 am, an interview was conducted with Employee E, Certified Nursing Assistant (CNA). She was asked who provides fingernail care to the residents. She stated she was not for sure. She has washed under the nails, but has not clipped them. She was asked if a resident's nails are elongated, what is she trained to do. She stated, I'll let my nurse know. I know over at the sister facility the activities staff and the restorative lady do a lot of the fingernail care. They trim and clean. I'm not sure over here. She stated she was caring for Resident #23 today, but had never trimmed his fingernails. On 11/30/23 at 12:45 pm, in an interview was conducted with Employee F, Registered Nurse (RN). She was asked who provides fingernail care to the residents. She stated, On shower days it should be done by the nurses' aides; any other time any nursing staff and activities staff can provide that care. She was asked if she was caring for Resident #23 today and stated yes. When asked if she had ever trimmed his fingernails she stated, I have not. He can be difficult; he has his own preference for hygiene. She was asked if any nurses aide had reported to her that Resident #23 had refused fingernail care. She stated, No, not specifically. She was asked what she is trained to do if a resident refuses fingernail care and stated, We try to come back later and attempt again. We will have other staff try. When asked where is that refusal documented she stated, It should be in the regular progress note. A review of the facility policy titled, Activities of Daily Living; Quality of Life; Special Rehab Services (reviewed 11/2022) revealed: Policy statement: Each resident shall receive, and this facility will provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, consistent with the resident comprehensive assessment and care plan. Scope: Residents will be given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living, including hygiene, bathing, grooming, oral care, mobility, transfer, ambulation, elimination/toileting, eating, dining, and communication. . 105261 Page 5 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

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 Based on medical record review, observations, staff and resident interviews, and a review of the facility's dialysis policy, the facility failed to ensure shared communication between the facility and the dialysis center for one of one resident receiving hemodialysis services, from a total of 12 residents in the sample. (Resident #29) Residents Affected - Few The findings include: A medical record review for Resident #29 revealed no communication with the dialysis clinic he attended. A review of the resident's current physician's orders revealed an order for Dialysis Center Dialysis: M/W/F (Mondays, Wednesdays, and Fridays) at the named dialysis center, with a chair time of 11:40 AM. On 11/28/23 at 12:44 PM Resident #29 was observed in his room resting in bed and would only answer a few questions. He affirmed that the facility sends a bag meal/snack with him to dialysis. On 11/30/23 at 9:15 AM Employee C, Unit Manager, was interviewed. Employee C had been employed by the facility since 4/20/23. She was asked to explain the facility process for sending and receiving pertinent information about the resident to and from the dialysis center. She stated, We send information to the dialysis center with the resident in a binder or we call them if we need to. The dialysis center sends the binder back to the facility with the resident for us to review, or they call us. She was asked how the facility obtains post dialysis weights on the resident. She stated, We don't have to weigh him. Dialysis usually weighs him before and after dialysis, and the dialysis center usually puts that information in the communication binder. On 11/30/23 at 9:22 AM Employee L (CNA) was interviewed. Employee L had been employed by the facility for 20 years. She was asked to explain her role in caring for a resident who receives hemodialysis (HD). She stated, If I have the resident on that day, I make sure he is cleaned up and ready. I get his lunch bag from the kitchen, and I help make sure he has everything he needs in his bag, his blanket, his binder, whatever he needs to take with him. When transportation gets here, I go and let him know that they are here for him. She further stated, We only have one resident in the facility who gets dialysis. On 11/30/23 at 10:43 AM, the surveyor requested Resident #29's dialysis binder from the Director of Nursing (DON). She stated she would locate the binder. On 11/30/23 at 11:05 AM, the surveyor requested Resident #29's dialysis binder from Employee F, who was the nurse assigned to Resident #29. She stated she would locate the binder. On 11/30/23 at 11:46 AM, the surveyor requested Resident #29's dialysis binder from the administrator. She stated she would look into why the binder had not been located and presented. On 11/30/23 at 11:53 AM, surveyor again requested Resident #29's dialysis binder from Employee F who stated, They are printing it out now. At that time the surveyor requested the binder be presented immediately in whatever condition it was currently available. The binder was presented by Employee C who was accompanied by the DON. On 11/30/23 at 11:57 AM, Employee C presented the dialysis binder for Resident #29. She stated, 105261 Page 6 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

F 0698 There are no recent communication sheets in the binder. It looks like we haven't sent the binder in a while. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Dialysis, Care of the Resident Receiving Dialysis Treatments Policy, Issued September 1, 2022, Reviewed/Revised July 2, 2023, Standard of Practice, Special Care Monitoring for Residents on Dialysis, STEP 8 states: Arrange for dialysis as ordered. Send Dialysis Information Form with resident. STEP 12 states: Resident dialysis assessment will be maintained in the medical record. Residents Affected - Few . 105261 Page 7 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on staff interviews and facility job description review, it was determined that the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis. Residents Affected - Many The findings include: On 11/29/23 at 2:20 pm, an interview was conducted with the Director of Nursing who was asked how long she has worked for the facility. She stated, I started Monday, November 27 of this week. When asked what her title is she stated, I'm Director of Nursing. She was asked how many hours she works as the Director of Nursing. She stated, I work at least 40 hours. I'm also Director of Nursing at our other facility, (facility named). She was asked if she divides her time between the two facilities. She stated, I'm expected to be at each facility each day, for whatever hours are needed. She was asked what her duties are as Director of Nursing. She stated, I oversee the nursing process. I report to the administrator. I ensure the nursing staff are following the policies and the CMS regulations. I provide staff training for on-boarding and ongoing in-services. I'm also the infection preventionist. She was asked if their other facility has it's own Director of Nursing. She stated, Yes, me. On 11/29/23 at 4:00 pm, an interview was conducted with the Administrator and asked who is the Director of Nursing for this facility. She stated, That's (named DON). Her title is Executive Director of Nursing. When asked if this is a full time position, she stated yes. She was asked if the Director of Nursing at this facility also serves as Director of Nursing for another facility. She stated, Yes, for our sister facility, (Named facility). She was asked if the DON is a full time position. at the other facility and she stated yes. She was asked if the Director of Nursing serves as full time Director of Nursing at both facilities. She stated yes. On 11/30/23 at 9:10 am, in an interview with the Staffing Coordinator, Employee G, she was asked who is the Director of Nursing at this facility. She stated, She's new, she runs both facilities. Her name is (named DON). She was asked if she is at this facility full time. She stated, She works both facilities full time and divides her time as half days for each facility. A review of the job description for Director of Nursing revealed: General Purpose: The Director of Nursing services assume full time administrative responsibilities and accountability for the delivery of nursing services in the facility. . 105261 Page 8 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of medication administration, interviews with staff, and review of the Policies and Procedures for Infection Control/Medical Waste Handling, and Cleaning and Disinfection of Resident Care Items and Equipment, the facility failed to ensure the medication error rate was less than 5% with two errors out of 33 opportunities. The medication error rate was 6.06% due to the nurse discarding a sharps needle in the room trash can and using durable medical equipment without cleaning afterwards. Residents Affected - Few The findings include: On 11/28/23 at 10:33 a.m., Employee A, Registered Nurse (RN) was observed administering a blood glucose check in room [ROOM NUMBER]. The RN used a lancet to check the blood glucose, and after completion threw the lancet and test strip in the trash can at bedside. An interview was conducted with Employee A, on 11/28/23 at 10:40 a.m. He confirmed the lancet and test strip were thrown in the trash can and should have been disposed of in the sharps container. An observation was conducted with Employee A on 11/29/23 at 8:55 a.m. for medication administration. Employee A asked a nurse for a blood pressure machine and pulse oximeter (a device that measures the saturation of oxygen carried in the red blood cells) which were given to him. He did not clean the devices before use. After taking the blood pressure and blood oxygen level for the resident in room [ROOM NUMBER]C, the RN took the machine and set it back on cart without cleaning. An interview was conducted with Employee A on 11/29/23 at 10:40 a.m. He confirmed he did not clean the durable medical equipment before or after use. The RN reported it should have been cleaned with alcohol. He stated he usually cleans the blood pressure cuff and pulse ox equipment with alcohol. The Policy and Procedure for Infection Control/Medical Waste Handling reviewed November 2022 revealed under 3. All sharps must be handled as medical waste, placed in appropriate sharps container and sent for eventual incineration. The Policy and Procedure for Cleaning and Disinfection of Resident Care Items and Equipment reviewed November 29, 2022 noted under Standard of Practice reusable items are cleaned and disinfected or sterilized between residents (stethoscopes, durable medical equipment); #4 reusable care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions and #7 intermediate and low level disinfectants for non-critical items include: ethyl or isopropyl alcohol or three other cleaning agents. . 105261 Page 9 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

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 observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to properly store food with the potential to affect all residents who consumed foods from the facility. Opened bundles of bread stored on the bread rack were not sealed and date marked. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 11/27/2023 at 10:05 a.m. During the tour, no date markings were observed on two open bundles of bread located on the bread rack in the dry storage room. Another observation was made on 11/28/2023 at 9:20 a.m. At that time, eight open bundles of bread were observed on the bread rack in the dry storage room with no date marking. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 11/29/2023 at 10:35 a.m. Six open bundles of bread were observed on the bread rack in the dry storage room with no date marking. (Photographic evidence obtained) An interview was conducted on 11/30/2023 at 9:20 a.m. with Dietary Aide H, who confirmed that the facility policy for date marking leftover bread was to use First In, First Out (FIFO) and check for expiration dates. She stated the facility did not use and place back on the rack. Small portions are used for lunch and dinner. An interview was conducted on 11/30/2023 at 9:25 a.m. with [NAME] I, who confirmed the facility policy for date marking leftover bread was to date food when received. When bread is opened, used, and placed back on the bread rack a used first sticker is added and labeled with the date opened. Bread is discarded after 5 days. An interview was conducted on 11/30/2023 at 9:30 a.m. with [NAME] J, who confirmed that the facility policy for date marking leftover bread was to label open bread and discard after 3 days. She stated staff try not to have leftover bread. An interview was conducted on 11/30/2023 at 9:52 a.m. with the Certified Dietary Manager, who confirmed the facility policy for date marking leftover bread was to date food items when received and once the food item is opened, add use first sticker and date opened. Bread is discarded after 5 days. A review of the facility's policy and procedure entitled Sanitation (effective 9/2010), revealed: 4. Use the First In, First Out (FIFO) method when stocking and rotating product. 5. Ensure all food and chemical containers are labeled with name and date received. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023) Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code 105261 Page 10 of 11 105261 11/30/2023 Athens Post Acute LLC 545 West Euclid Avenue Deland, FL 32720

F 0812 Level of Harm - Minimal harm or potential for actual harm facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. . Residents Affected - Many 105261 Page 11 of 11