Health inspection·February 17, 2022

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews and record review, the facility failed to treat residents with respect and dignity as evidenced by five staff members (A, B, D, E, F) failing to knock or announce themselves prior to entering occupied resident rooms in two halls (300 and 400) of four halls for four of four days observed (2/14/2022, 2/15/2022, 2/16/2022, and 2/17/2022). Findings include: During the days from 2/14/2022 to 2/17/2022 staff were observed to not consistently knock, announce or identify themselves prior to entering occupied resident rooms. The observations were as follows: - On 2/14/2022 at 10:08 a.m., Staff A, Certified Nursing Assistant (CNA) was observed to walk in resident room [ROOM NUMBER] and did not first knock and or announce herself. There were two residents in the room at the time. - On 2/14/2022 at 10:14 a.m. Staff B, CNA was observed to walk in resident room [ROOM NUMBER] without first knocking or announcing herself. There were two residents in the room at the time. - On 2/14/2022 at 10:16 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident in the room at the time. - On 2/15/2022 at 6:33 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There were two resident in the room at the time. - On 2/15/2022 at 6:37 a.m. Staff D, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There was one resident observed in the room at the time. - On 2/15/2022 at 6:42 a.m. Staff E, CNA was observed to walk into resident room [ROOM NUMBER] without first knocking and or announcing herself. There were two residents in the room at the time. - On 2/16/2022 at 7:50 a.m. Staff F, Licensed Practical Nurse (LPN) was observed to carry medications into resident room [ROOM NUMBER] and did not first knock or announce herself prior to entering. There was one resident in the room at the time. - On 2/17/2022 7:34 a.m. Staff B, CNA was observed to walk into resident room [ROOM NUMBER] and did not first knock and or announce herself prior to entering. There was one resident in the room at Page 1 of 30 105271 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0550 the time. Level of Harm - Minimal harm or potential for actual harm - On 2/17/2022 8:22 a.m. Staff F, LPN was observed to walk into resident room [ROOM NUMBER] and did not knock or announce herself prior to entering. There was one resident in the room at the time. Residents Affected - Some Random resident interviews revealed: On 2/14/2022 at 11:45 a.m. Resident #87 revealed staff always and continually walk into his room at all times of the day and most do not knock or announce themselves. He indicated he does like his privacy and would like for them to knock. He spoke to management before with no resolution. He has stopped complaining because nothing ever gets better. On 2/14/2022 at 2:00 p.m. Resident #53 confirmed staff routinely just walk in the room and don't knock before answering. While interviewing her, an aide was observed to walk in the room and only motioned to knock on the door as she was walking in. The resident indicated this happens at times and she does not like it. She further revealed she does not like confrontation, so she has not verbally complained to anyone about it. On 2/15/2022 at 2:15 p.m. Resident #62 revealed he has had it with staff just walking in the room and they don't say anything or knock before coming in. He has complained in the past but nothing ever gets better. He would like his privacy. On 2/14/2022 at 1:30 p.m. Resident #76 confirmed staff walk in her room all the time and don't say anything or knock. She felt staff should at least announce themselves before coming in the room. Sometimes she does not even know why staff come in her room, and they don't tell her why. She has reported it to management in the past but did not remember when or who she spoke with. On 2/17/2022 at 1:30 p.m. an interview with Staff T, Registered Nurse (RN)/300/400 Unit Manager revealed it is the facility's policy for all staff to either knock or announce themselves prior to going into resident rooms, no matter what. She did not have any documented information to show she audits staff knocking and announcing prior to going in rooms. She was also unaware that residents were not comfortable with staff just walking into the rooms unannounced. On 2/17/2022 at 2:00 p.m. an interview with the Director of Nursing (DON) confirmed staff should always knock and/or announce themselves prior to going into occupied rooms and they (staff) are trained and inserviced on that matter. There was no documented evidence to show staff were trained on this area. A review of the policy and procedure titled, Personnel Policies & Employee Conduct, with an effective date of April 2017, documented the policy as: To provide guidelines and standards pertaining to Environmental Management Services Sanitation Section job-related issues. The Manner section of the policy read: Be alert, courteous, helpful and brief. Employees should report any problems or issues to their immediate supervisor. Avoid showing irritation with residents and staff members. Show job interest and willingness to learn. Take pride in job. Be considerate of residents and the staff responsible for their care. Always knock, Announce, Identify, Duration, Engage, and Thank when entering and working in a Resident's room. 105271 Page 2 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure a change in condition was identified and addressed in a timely manner for one resident (#83) of fifty sampled residents. Residents Affected - Few Findings include: During a facility tour on 02/14/22 at 9: 53 a.m., Resident #83 was observed in his room laying on the bed. His roommates were observed eating their breakfast meal. Resident #83's breakfast tray was noted untouched. Resident #83 did not eat anything from his tray, and staff assistance, supervision or cueing was not observed. On 02/14/22 at 10:05 a.m., Resident #83 was observed from the doorway, noted to be throwing up. Emesis was observed on his gown and bed linens. Staff O, Certified Nursing Assistant (CNA) and Staff P, Registered Nurse (RN) were notified. An immediate interview was conducted on 02/14/22 at 10:08 a.m. with Staff O, after responding to Resident #83. Staff O stated, He makes himself throw up and then hides it. Staff O said this had been going on since the resident was admitted to the facility. Review of an admission Record for Resident #83 showed an admission date of 01/20/22, and diagnoses to include, muscle wasting and atrophy, Schizophrenia, hypothyroidism, adult failure to thrive, unspecified protein calorie malnutrition, difficulty walking, need for assistance with personal care, respiratory care, iron deficiency and underweight. An admission Minimum Data Set (MDS) dated [DATE] showed under Section C Cognitive Patterns that Resident #83's Brief Interview for Mental Status (BIMS) could not be assessed, indicating severe mental impairment. Section D related to mood, showed the total severity score was not assessed. Section G Functional Status showed Resident #83 required supervision for eating with one-person physical assist. Section K indicated no swallowing disorders and no complaints of loss of fluids, holding food in the mouth, no coughing or choking and no complaints of pain when swallowing. Section K also showed Resident #83 was admitted with a weight of 123 pounds and had no indication of weight loss or weight gain. Review of the electronic medical record (EMR) showed Resident #83 had a current weight of 119.4 pounds, indicating current weight loss. Review of a lunch meal ticket for Resident #83 dated 02/14/22 showed the resident was on a regular diet, thin liquids and an SB6 mechanical diet, meaning Resident #83 should be receiving a soft, tender, and moist diet. Under preferences, the ticket showed to add fortified food, magic cup, and whole milk. A care plan for Resident #83 showed a Nutritional focus initiated on 01/31/22 indicating Resident #83 had a potential nutritional problem due to schizophrenia diagnosis, underweight body mass index (BMI) category. The goal indicated Resident #83 will maintain CBW (current body weight) without weight loss and maintain nutritional intake through the next review. The interventions included to receive fortified foods with meals, weights as indicated, allow adequate time to eat, diet as ordered, fluids as ordered, offer substitute if refusal, obtain and review labs, observe and document meal consumption, amount assistance needed with meal, tolerance to diet / fluids, administer meds as ordered and to notify physician as needed. 105271 Page 3 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0637 Resident #83 was further observed as follows: Level of Harm - Minimal harm or potential for actual harm -On 02/14/22 at 1:23 p.m., Resident #83 was observed in his room during lunch, his tray was noted untouched as his roommates were finishing their meal. Residents Affected - Few -On 02/14/22 at 1:44 p.m., Staff O was observed removing the tray from the room. Staff O said the resident refuses to eat, and stated, He never asks for anything. I will offer him yogurt or something. -On 02/15/22 at 8:53 a.m., Resident #83 was observed with his breakfast tray and did not eat his breakfast meal. -On 02/16/22 at 8:38 a.m., Resident #83 was observed in his room without a tray. Resident #83's roommates were observed eating their breakfast. A follow -up interview was conducted with Staff Q, CNA on 02/16/22 at 8:59 a.m Staff Q confirmed Resident #83 did not eat his meal. Staff Q said, He never eats. He drank a little juice and spit it out. An interview was conducted on 02/16/22 at 8:59 a.m. with Staff P, RN. Staff P said, Everyone knows he [Resident #83] does not eat. Staff P stated they had notified the doctor. On 02/16/22 at 1:29 p.m. Resident #83 was observed in his room with his lunch tray noted untouched. Resident #83 was observed spitting out a pink colored liquid. Review of physician orders for Resident #83 printed on 02/17/22 showed: -Diet orders dated 01/21/22, regular texture diet, regular thin consistency, fortified foods with meals and a health shake BID (twice daily) with lunch and dinner. -Medpass (nutritional supplement) three times a day for poor intake give 240 ml (milliliters), dated 02/16/22 -Speech Therapy, Resident to be seen 5 times per week for dysphagia management for dysphagia management, dated 02/10/22. -Mirtazapine daily for appetite, dated 01/21/22. -Send to ED (emergency department) for evaluation dated 02/16/22. Review of Resident #83's Medication Administration Record (MAR) dated 02/01/22 to 02/28/22, printed on 02/17/22, showed Resident #83 had been refusing his medications for 6 days (02/11/22 to 02/16/22). The MAR showed an order for KUB (Kidney, Ureter and Bladder) X-ray was ordered STAT (immediately) on 02/15/22. Review of Resident #83's progress notes did not show any documented reports related to on-going refusal to eat, reports of daily emesis and on-going medication refusals. Request for IDT (inter-disciplinary team) meeting notes presented by the facility showed the 105271 Page 4 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0637 Level of Harm - Minimal harm or potential for actual harm facility did not identify concerns of refusal to eat, daily emesis and medication refusals. The notes showed unrelated documented concerns of weights and showers. On 02/16/22 at 4:03 p.m., an interview was conducted with Staff R, CNA. Staff R stated Resident #83 has been refusing food from day one. Staff R said, He should be checked out. He does not eat or drink. Residents Affected - Few Review of the CNA Task Log dated 01/21/22 to 02/16/22 showed Resident #83 ate less than 25% of his meal or refused entire meal consistently for the entire 30-day period reviewed. An interview was conducted on 02/16/22 at 1:33 p.m. with the Certified Dietary Manager (CDM) and the Registered Dietician (RD). The RD stated Resident #83 was admitted with a diagnosis of schizophrenia and did not express any food preferences, nor eating concerns on admission. The RD stated Resident #83 answered yes and no questions and did not express himself. The RD said Resident #83 was eating about 50% when he came in and fortified foods were included in his diet, and she had just added a high nutrient treat twice a day. The RD and CDM confirmed they did not know Resident #83 was not eating and was throwing up his meals. The RD said, I was not notified that he was eating any differently; the nurses should have notified me that he was spitting out his drinks. An interview was conducted with the Director of Nursing (DON) on 02/16/22 at 1:58 p.m The DON said, I was notified yesterday that he was not eating and is spitting out fluids. The DON stated she called the doctor and ordered a KUB (abdominal x-ray). The DON confirmed she had just become aware of the concern with not eating, emesis and refusing medications. The DON said, They [nurses] should have notified me and the doctor. A follow-up interview was conducted with the DON on 02/16/22 at 4:00 p.m The DON stated Resident #83 had some GI (gastrointestinal) issues and that was why she had called the doctor. The DON stated Resident #83 had refused the KUB x-ray and she had let the doctor know, and was sending him out to the ED (emergency department). The DON confirmed notification should not wait 2-3 weeks, and stated, If a resident has GI issues, nurses should call the doctor right away. On 02/17/22 at 1:45 p.m. Resident #83 was observed in his room with Staff S, Speech Therapist and the CDM. The CDM reported Resident #83 did not eat lunch, and stated, He threw up the med pass, we are attempting to give him water. An interview was conducted on 02/17/22 at 1:12 p.m. with Staff L, RN Unit Manager. Staff L said she did not do anything about the medication refusals because she thought the doctor knew about it. Staff L stated she had contacted the family today and was updated on his meal preferences. Staff L confirmed she did not know Resident #83 had any concerns prior to this week. An interview was conducted with Resident #83's doctor on 02/17/22 at 10:31 a.m The physician stated he had been notified Resident #83 refused his medication but could not recall when he was notified. The physician stated he comes to the facility on Thursdays, and he would follow-up. Review of the facility's policy titled, Physician Notification, dated October 2021, showed that Licensed Nurses will ensure physicians are notified of changes or diagnostic results that occur between visits. Changes may include but are not limited to: -A change in condition, mental or physical. 105271 Page 5 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0637 -Resident's refusal to take medication. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled, Notification of Resident / Patient Change in Condition, dated October 2021, showed: Residents Affected - Few (1.) Notify the physician/resident representative and case management when indicated, if there is a significant change in condition, regardless of the time of the day. (2.) Document the nurses' notes, the time notification was made and the names of the person(s) to whom you spoke to. Review of an undated facility policy titled, Medication Administration, showed under page 6 of 6: (2.) If a dose of regularly scheduled medication is refused, an explanation note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. 105271 Page 6 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to identify and develop a care plan with problem areas, goals, and interventions to include the use of an antibiotic and diagnosis of a Urinary Tract Infection (UTI), timely, for one (#62) of fifty sampled residents. Findings include: On 2/15/2022 at 1:45 p.m. Resident #62 was observed in his room. The side of the bed was observed with a properly placed urinary catheter drain bag, and catheter tubing. In a subsequent interview, Resident #62 revealed he currently had a Urinary Tract Infection and was receiving antibiotics; he could not remember how long he had been on antibiotics. On 2/15/2022 at 2:00 p.m. an interview with Staff I, Unit Nurse confirmed Resident #62 was recently readmitted from the hospital and is being treated with an antibiotic for a UTI. On 2/16/2022 at 10:00 a.m. an interview with the Staff T, 300/400-Unit Manager also confirmed Resident #62 had a UTI and is receiving antibiotics. Review of Resident #62's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the current Minimum Data Set (MDS) admission assessment, dated 1/10/2022, revealed: Cognition/Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating he had intact cognition; Under Active Diagnosis, UTI was not checked. Review of the current Physician's Order Sheet dated for the month 2/2022 revealed: - Cipro 500 mg (milligrams) 1 PO (orally) BID (twice daily) for 7 days (original order date 2/12/2022 and end date 2/19/2022) for a UTI. - Schedule transport for Urology appt. (appointment) on 2/22 at 1:45 p.m. Review of the progress notes/assessments revealed: -2/11/2022 - Reviewed labs and indication of UTI. -2/12/2022 - Orders to start Cipro for UTI. -2/14/2022 - Continues Antibiotic for UTI. -2/16/2022 - Antibiotic/UTI continues PO fluids encouraged and accepted this shift. On 2/16/2022 at 1:00 p.m. and again on 2/17/2022 at 10:00 a.m., review of the current care plans with next review date 5/2/2022 revealed: -Use of catheter with history of infection and or complication with interventions in place. The care plan did not indicate problem areas, goals and interventions related to a UTI, nor use of 105271 Page 7 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0656 an antibiotic. Level of Harm - Minimal harm or potential for actual harm On 2/16/2022 at 1:35 p.m. and 2/17/2022 at 10:00 a.m., an interview with the Care Plan Coordinator revealed the resident was receiving an antibiotic for a UTI. She confirmed this problem area should have been care planned with goals and interventions. She indicated Resident #62 had been utilizing the antibiotic since 2/12/2022 (five days) and confirmed a change in condition such as UTI or use of an antibiotic should be reflective in the care plan as soon as possible, and not to exceed two days. Residents Affected - Few Review of a facility-provided policy titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting dated March 2017 showed: -The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -The facility shall assess and address care issues that are relevant to individual resident, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. -The overall care plan should be oriented towards: 2. Preventing avoidable declines in function or functional levels or otherwise clarifying why another goal takes precedence. 3. Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. 4. Applying current standard of practice in the care planning process. 5. Evaluating treatments of measurable objectives, timetables, and outcomes of care. 6. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. The procedure section of the policy, revealed: #2. Daily Updates to Care Plan (a) Daily updates to care plans are added by a member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. 105271 Page 8 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to update and revise a care plan to reflect non-use of an antidepressant for one (#81) of fifty sampled residents. Findings include: On 2/16/2022 at 7:30 a.m. Resident #81 was observed in her room. She did not present with any behaviors, pain, or discomfort. Resident #81 was pleasant to speak with and had no immediate concerns. Review of Resident #81's medical record revealed she was admitted to the facility on [DATE], with diagnoses to include but not limited to: Adult Failure to Thrive, Need for assistance with personal care, Abnormality of gait, Depression, Insomnia. Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 1/21/2022 revealed: -Cognition/Brief Interview for Mental Status (BIMS) score - 15 of 15, indicating intact cognition, -Behaviors - None exhibited, -Mood - None exhibited, ADL (activities of daily living) - Extensive to total care with most to all ADLs to include Toilet use Total dependence with one person assist, Personal Hygiene Total dependence with one person assist, Bathing with total dependence, -Active Diagnosis - Depression. Review of the current care plan revealed: 7. Psychotropic med - The resident uses psychotropic meds related to antidepressant and to manage depression with interventions to include: Administer medications as ordered/document for side effects and effectiveness; Anti-Depressant: Observe/document for potential side effects may include dizziness, drowsiness, diarrhea, dry mouth, urinary retention, suicidal ideation, orthostatic hypotension; Psychological services per order and PRN [as needed]; Use of psychotropic medications will be reviewed at least quarterly with the IDT/MD to review continued need for the medication and ensure lowest dose. The care plan was developed and initiated on 4/26/2021. Review of the current Physician Order Summary for the month of 2/2022 revealed no active orders for antidepressant use. Review of the 2/2022 Medication Administration Record (MAR), and Treatment Administration Record (TAR) did not indicate use of an antidepressant, or any psychotropic medications. On 2/16/2022 at 1:10 p.m. an interview with Staff T, 300/400-unit manager confirmed Resident #81 does not receive any psychotropic medications to include any antidepressants. The unit manager provided the following information: 105271 Page 9 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0657 Level of Harm - Minimal harm or potential for actual harm 1. Original order date 9/15/2021; Remeron 15 mg (milligrams) 1 PO (orally) QD (daily) for appetite supplement and under the category of Antidepressant use. 2. Discontinue order date 1/17/2022; Remeron 7.5 mg 1 PO QD for appetite supplement and under the category of Antidepressant. Residents Affected - Few The unit manager confirmed as of 1/17/2022, the antidepressant was discontinued, and the care plan should have been revised to reflect current non-use of this medication. On 2/16/2022 at 1:33 p.m. an interview with the MDS/Care Plan Coordinator revealed Resident #81 was no longer ordered for an antidepressant. She confirmed the care plan should have been revised and updated to reflect the discontinued use of the medication. Review of a facility-provided policy titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting dated March 2017 showed: -The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. -The facility shall assess and address care issues that are relevant to individual resident, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. -The overall care plan should be oriented towards: 2. Preventing avoidable declines in function or functional levels or otherwise clarifying why another goal takes precedence. 3. Addressing ways to try to preserve and build upon a resident's strengths, needs, personal and cultural preferences. 4. Applying current standard of practice in the care planning process. 5. Evaluating treatments of measurable objectives, timetables, and outcomes of care. 6. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. The procedure section of the policy, revealed: #2. Daily Updates to Care Plan (a) Daily updates to care plans are added by a member of the IDT at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. 105271 Page 10 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

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 observations, staff and resident interviews, and medical record review, the facility failed to ensure nail care was provided for one resident (#87) of five sampled residents reviewed for assistance with activities of daily living (ADLs). Residents Affected - Few Findings include: On 2/14/2022 at 9:55 a.m., and 1:00 p.m. Resident #87 was in his room in bed and all fingernails, on both his left and right hands, were observed to be elongated approximately three quarters of an inch to one inch in length past the tips of the fingers. Further observation revealed built up brown matter beneath all ten of the fingernails and some of the nails appeared cracked, peeling, and with sharp edges. Resident #87 explained he could pretty much do everything on his own to include showering, dressing, moving out of bed, eating, and personal hygiene. However, when asked about his fingernails, he explained, I would cut them myself but they won't give me scissors to cut my hair and won't give me clippers to cut my nails because they think I will hurt myself. He confirmed he did not like them long and he wanted them cut. He further explained he spoke to his nurse and various aides in the past week or so, but they never came back to cut his nails. The resident's left thumbnail was observed to be longer than all the others and was cracked and peeling. Resident #87 took his right hand and peeled the fingernail off to the fingertip. He confirmed his fingernails were too long for him. On 2/14/2022 at 11:00 a.m. both Staff G, Certified Nursing Assistant (CNA) and Staff N, Licensed Practical Nurse (LPN) confirmed Resident #87 was able to complete most of his activities of daily living (ADLs) tasks on his own with supervision, and was not able to do fingernail care on his own. They both indicated they would follow up with him and did not at this time offer that he refuses nail care. On 2/16/2022 at 10:05 a.m. Resident #87's was noted in bed and lying on his side, with the covers only covering his lower half of his body. Further observations revealed both his hands were visible and only his left thumbnail was observed trimmed/peeled to the fingertip. All others were still observed elongated, not clipped and with brown matter beneath the fingernail beds. On 2/17/2022 at 8:20 a.m. Staff G, CNA revealed Resident #87 routinely refuses nail clipping care and she had reported this to the nurses. Staff G also revealed she documented in the CNA daily progress notes when and what Resident #87 refuses, to include refusing nail care. On 2/17/2022 at 8:30 a.m. Resident #87 was observed lying in bed holding a cup of coffee with his left hand. His hand was observed with four of the five fingernails elongated approximately three quarters of an inch to one inch long from the tips of the fingers. Further observation revealed brown matter stuck under the nails. Resident #87 explained, Nobody has still offered to cut my fingernails, and they were supposed to come and clip my nails last night (2/16/2022). He said they (staff) know about his nails and told him they would provide him with nail care but never showed up back to his room after his initial conversation with two aides (names unknown). He again explained he was constantly told he was not allowed to clip his own fingernails, and that he does not like his nails long and dirty. He stated again, I have asked repetitively for clippers so I can clip the nails on my own but keep being told that I can't have clippers and do nail care on 105271 Page 11 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0677 my own because they think I will hurt myself. Level of Harm - Minimal harm or potential for actual harm On 2/17/2022 at 9:35 a.m. Staff G, CNA noted, I was able to complete nail care and clip all the fingernails for [Resident #87]. She further noted he did not refuse the nail care and did not present with any behaviors. She revealed he was thankful. Residents Affected - Few On 2/17/22 at 9:50 a.m. all of Resident #87's fingernails were observed to be clipped and well groomed. He exclaimed, It's about time and my hands feel a lot better. Review of the admission Record revealed Resident #87 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include cerebral infarction, dementia, bipolar, depression, adult failure to thrive, and cognitive functions nontraumatic. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed: Section C - Cognitive Patterns a Brief Interview for Mental Status score of 8 indicating moderate impairment. Section G - Functional Status revealed ADLs Personal Hygiene with Supervision and with one person physical assist. Review of the nurse progress notes dating from his recent admission 1/17/2022 to 2/17/2022, did not indicate any documentation of Resident #87 refusing fingernail care, nor presenting with any behaviors with relation to personal hygiene. Review of the current care plans with the next review date 5/3/2022, revealed the following areas: 14. Activities of Daily Living (ADL) - [Resident #87] has an ADL self care performance deficit as evidence by weakness, impaired cognition, with interventions in place to include but not limited to: Personal hygiene independent; Bathing - Check all nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. (This care plan area was originally dated 7/27/2020). 15. Behaviors - [Resident #87] noted with the following behaviors may be angry outbursts at times: confabulation, may mix past and present at times, may call 911 thinking a truck was stolen or other items and he has not had one here since admission or other things mixing up when he lived in an apartment years ago, may prefer not to ask staff for assistance and or use the call light, may become confused to time and place, may become forgetful about when his last meal was, does not have a wallet in facility, may refuse care, labs, showers, meals, supplements, and clothing changes, prefers to wear shoes in bed. Prefers not to shave his beard, may throw items may prefer to not have supplement drink, may remove call light from bed and clip to the curtain, with interventions in place. Review of the current care plan problem area did not reflect Resident #87 had any behaviors of refusal specific to assistance with fingernail care, nor did it specify Resident #87 presented with any type of behaviors related to fingernail care. On 2/16/2022 at 1:33 p.m. the Care Plan Coordinator revealed she was fairly new to the MDS and Care Planning position and was not fully aware of the resident and his nail care. She revealed that he was able to perform most of his ADLs with supervision and does not know if there was any concerns with him clipping his fingernails on his own. She reviewed his care plans and nurse progress notes and confirmed there was no documentation to support the resident was not able to conduct clipping his fingernails on his own. She further confirmed there was no assessment or documentation that would indicate he specifically refused or has a history of refusing nail care. 105271 Page 12 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/17/2022 at 9:07 a.m. an interview with Staff T, RN revealed she was aware of Resident #87 actively and historically refusing bathing, personal hygiene care and nail care. She revealed, with his cognition level, they will not allow for him to have his own scissors and clippers. She revealed he continues to ask for them but they offer him assistance instead; and he refuses. Review of the CNA ADL daily flow sheets for the months 1/2022 and 2/2022 included documentation that personal hygiene was completed and nail care as a PRN (as needed) task for the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts. The flow sheet for February 2022 did not show Resident #87 refused nail care. It showed: -Dates of 2/1, 2/2, 2/9, 2/12, 2/14, 2/15 and 2/16 NN was documented during the 7:00 a.m. to 3:00 p.m. and 2/5 and 2/7 for the 3:00 p.m. to 11:00 p.m.; indicating Resident Not Available. -Dates of 2/4 NA: was documented during the 3:00 p.m. to 11:00 p.m. indicating Not Applicable. -Dates of 2/3, 2/6, 2/8, 2/10, 2/11, and 2/13 there was no documentation of nail care. The CNA ADL daily flow sheet for January 2022 showed a RR for the dates of 1/1, 1/22 an 1/29 during the 7:00 a.m. - 3:00 p.m. shift, indicating the resident refused nail care. The other dates indicated the following: - Dates of 1/3-1/10, 1/18-1/19, 1/26-1/28, and 1/30 NN was documented during the 7:00 a.m. to 3:00 p.m. and 1/1, 1/3-1/8, 1/10-1/11, 1/18-1/22 and 1/29 - 1/30 for the 3:00 p.m. to 11:00 p.m.; indicating Resident Not Available. -Dates of 1/ 2 and 1/27 NA: was documented during the 3:00 p.m. to 11:00 p.m. indicating Not Applicable. Dates of 1/12 and 1/31 were noted with a NC during the 7:00 a.m. - 3:00 p.m. shift indicating Nail Care was completed. Review of the admission Record showed the most recent hospital stay for the resident was 1/12/22 - 1/17/22. -Dates of the remaining 15 opportunities between both shifts either showed an X or no documentation of nail care. On 2/17/2022 at 8:30 a.m. the Director of Nursing revealed the facility did not have a specific policy and procedure related to fingernail care. The Nursing Home Administrator confirmed this at 3:30 p.m. 105271 Page 13 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure activities were provided for seven dependent residents (#64, #83, #10, #39, #72, #66, and #75) on one hall (Hall 200) of three halls out of a total of twenty one sampled residents. Residents Affected - Some Findings include: On 02/14/22 at 10:19 a.m. and 1:21 p.m., Resident #64 was observed in her room, lying on the bed. Resident #64 was non-verbal and dependent on staff for all activities of daily living (ADLs). Resident #64 was observed not engaged in any activities or receiving interaction from staff. On 02/14/22 at 2:28 p.m. seven dependent residents on Hall 200 (Resident #64, #10, #75, #72, #39, #66 and #83) were observed to be in bed, without staff interaction. Review of the electronic medical records (EMR) for the residents showed the following: An admission Record for Resident #64 showed she was admitted to the facility on [DATE] with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery. The Minimum data set (MDS), 1/10/2022, for Resident #64 showed under Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Section F - Preferences for Customary Routine and Activities was noted as blank, and Section G Functional Status indicated Resident #64 was totally dependent on staff for ADLs. An admission Record for Resident #83 showed he was admitted to the facility on [DATE] with diagnoses to include muscle wasting and atrophy, schizophrenia and adult failure to thrive. The MDS for Resident #83, dated 01/27/22, showed in Section C-Cognitive Patterns a BIMS score of 00, indicating severe cognitive impairment. Section F - Preferences for Customary Routine and Activities was noted as blank, and Section G Functional Status indicated Resident #83 required staff supervision for ADLs and requires a wheelchair for mobility. An admission Record for Resident #10 showed the resident was admitted to the facility on [DATE] with a diagnosis of senile degeneration of brain, not elsewhere specified. A MDS for Resident #10, dated 05/24/21, showed in Section C-Cognitive Patterns a BIMS score of 09, indicating moderate impairment. Section F - Preferences for Customary Routine and Activities participation was somewhat important. Section G Functional Status indicated Resident #10 required extensive assistance from staff for ADLs. An admission Record for Resident #39 showed she was admitted to the facility on [DATE] with diagnoses to include Parkinson's, muscle wasting and atrophy. A MDS for Resident #39, dated 12/22/21, showed in Section C-Cognitive Patterns a BIMS score of 07, indicating severe cognitive impairment. Section F Preferences for Customary Routine and Activities was noted as blank. Section G - Functional Status indicated Resident #39 required extensive assistance for ADLs. An admission Record for Resident #72 showed she was admitted to the facility on [DATE] with diagnoses to include heart failure, multiple sclerosis, muscle wasting and atrophy and obesity. A MDS for Resident #72, dated 10/14/21, showed in Section C-Cognitive Patterns a BIMS score of 07, indicating 105271 Page 14 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some severe cognitive impairment. Section F - Preferences for Customary Routine and Activities indicated activity preference was somewhat important. Section G - Functional Status indicated Resident #72 required extensive assistance for ADLs. An admission Record for Resident #66 showed she was admitted to the facility on [DATE] with diagnoses to include muscle wasting and atrophy, unspecified dementia, schizophrenia and morbid obesity. A MDS for Resident #66 showed in Section C-Cognitive Patterns a BIMS score of 09, indicating moderate cognitive impairment. Section F - Preferences for Customary Routine and Activities indicated activity preference was somewhat important. Section G - Functional Status showed Resident #66 required extensive assistance for ADLs. An admission record for Resident #75 showed she was admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance. A MDS for Resident #75, dated 10/19/21, showed in Section C-Cognitive Patterns a BIMS score of 00, indicating severe cognitive impairment. Section F Preferences for Customary Routine and Activities indicated activity preference was somewhat important. Section G - Functional Status indicated Resident #75 required extensive assistance with ADLs. Review of the activity care plans in the EMRs for Residents #64, #10, #75, #72, #39, #66 and #83 showed each resident's care plan contained the same wording: at risk for psychosocial outcomes due to visitation limitations related to COVID-19. The care plans did not include individual activity preferences. Copies of the Care Plans were requested but not made available. On 02/15/22 at 11:27 a.m. and at 3:23 p.m. an observation was made of dependent residents in Hall 200 staying in beds in their rooms all day. Residents were noted without any activities. (Resident #64, #10, #75, #72, #39, #66 and #83.) An interview was conducted with an independent alert and oriented resident in Hall 200, Resident #79. Resident #79 stated she had not seen activities facilitated for dependent residents. Resident #79 said, There are no activities here for them. They don't have anyone to run the activities. On 02/16/22 at 9:15 a.m., dependent residents in Hall 200 were observed not engaging in any activities. (Resident #64, #10, #75, #72, #39, #66 and #83.) On 02/15/22 at 2:40 p.m., an interview was conducted with the Activities Director (AD). The AD stated she was the activities staff until about a month ago. The AD stated she was now in the role of the staffing coordinator. The AD stated the activities position had not been filled. When asked who was conducting activities, the AD stated she was filling in here and there, between being the receptionist and staffing. On 02/16/22 at 2:30 p.m. a Resident Council meeting was held. The meeting was attended by 16 residents. When asked about activities, the residents reported Staff Y, Certified Nursing Assistant (CNA) was the only one who does Bingo or any activities at least two times a week. The residents confirmed they had not seen activities provided for dependent residents. The residents confirmed earlier they had Bingo in the dining room, which was attended by residents who could ambulate. Review of an activities calendar posted in resident rooms on Hall 200 showed on each Wednesday 3pm One on One. 105271 Page 15 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 02/16/22 at 3:00 p.m. Residents #64, #10, #75, #72, #39, #66 and #83 were each observed to not be receiving the scheduled One on One activity. An interview was conducted on 02/15/22 at 3:00 p.m. with Resident #46 an independent resident in Hall 200. Resident #46 said, They don't do activities. Resident #46 stated independent residents engage themselves but not the dependent ones. On 02/17/22 at 12:50 p.m. on Hall 200 Residents #64, #10, #75, #72, #39, #66 and #83 were observed and they were not engaged in an activity. On 02/17/22 at 9:10 a.m. an interview was conducted with Staff Y and Staff H, CNA. Staff H said, They do not do activities. Staff H said the AD was covering other areas. Staff Y stated independent residents initiate their own activities. An interview was conducted on 02/17/22 at 9:14 a.m., with Staff Q, CNA. Staff Q stated they did not have enough staff to conduct activities. Staff Q stated the AD was now doing staffing. On 02/17/22 at 9:14 a.m., an interview was conducted with Staff P, Registered Nurse (RN). Staff P stated residents who are dependent stay in their rooms, mostly in bed. Staff P confirmed no one was providing activities for dependent residents. Staff P said, I know, it's hard for them [residents] and us. An interview was conducted on 02/17/22 at 9:19 a.m. with Staff O, CNA. Staff O stated sometimes they do activities like Bingo. When asked if they do activities in the resident rooms, Staff O said, I guess it is for those that can ambulate. On 02/17/22 at 9:21 a.m. an interview was conducted with Staff Z, CNA. Staff Z stated there had been no formal activities since the AD started doing staffing. Staff Z said, I know they are short staffed here. Staff Z stated the facility did not have enough staff for care, let alone activities. On 02/17/22 at 9:33 a.m. an interview was conducted with the AD. The AD said, I know we have not been going into the rooms for 1:1. I used to do it when I was in my position. The AD stated she had been pulled in many directions including screening. The AD said, It is not fair to them [dependent residents]. A interview was conducted on 02/17/22 at 9:53 a.m. with the Director of Nursing, (DON), the Nursing Home Administrator (NHA) and Regional Clinical. They were notified that activities were not observed to be provided for dependent residents and the care plans for the residents were not individualized. The Regional Clinical stated they would update the care plans. The NHA stated they are in the process of transitioning a new aide to the position. Review of a job description titled Director of Activities, dated January 2013, showed the Director of Activities is responsible for supervising and providing an activity program appropriate to meet the physical, social, cultural, spiritual, emotional and recreational needs and interests of each patient / resident. Under essential duties and responsibilities, the Director of Activities will assess individual / group resident / patient needs and develops related meaningful morning, afternoon, evening and special programs. The Director of Activities coordinates, directs and / or conducts all planned activities. 105271 Page 16 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0679 Level of Harm - Minimal harm or potential for actual harm Review of a facility policy titled, Activities Program, dated November 2013, showed the facility will develop and implement an on-going activities program, including individual and group activities. The procedure showed: 1. At the time of move-in, leisure interest information will be gathered. Residents Affected - Some 2. Scheduled activities shall be planned to include recreational, social and educational opportunities, offering no less than 12 hours weekly of activities, 6 days each week. 105271 Page 17 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure four (#4, #54, #69 and #93) of fifty sampled residents received comprehensive skin assessments weekly in accordance with professional standards, and facility policy. Residents Affected - Few Findings include: 1. An observation of Resident #4 on 2/15/22 at 11:28 a.m. revealed her left lower leg dry and flaky with multiple scabs observed. An observation of Resident #4 on 2/16/22 at 8:10 a.m. revealed her left lower leg dry and flaky with multiple scabs observed. During an interview and observation of Resident #4 on 2/16/22 at 1:40 p.m. with Staff L, Licensed Practical Nurse (LPN), the LPN stated the resident's leg had a lot of dryness and she had lotion ordered three times a day. The LPN said they document weekly skin checks on her condition. Review of physician orders for Resident #4 revealed: -Lac-Hydrin lotion 12% (ammonium lactate) apply to affected areas topically every shift for dry skin dated 4/23/21. Review of the treatment administration record (TAR) for February 2022, documented the resident receiving the lotion every shift. Review of the care plan for Resident #4 revealed a focus area of skin integrity risk and has potential/actual impairment to skin integrity, initiated 7/2/19. Interventions include observe for signs and symptoms swelling, tenderness, discoloration, or pain dated 7/9/19. Report changes in discoloration area dated 7/9/19. Review of the last four weekly skin checks for Resident #4 revealed: -2/16/22 Skin check weekly and as needed completed and checked as new areas of skin impairment found scabs on left and right front lower legs. -2/7/22 Skin check weekly and as needed completed and checked as no new areas of impairment. -1/31/22 Skin check weekly and as needed completed and checked as no new areas of impairment. -11/17/21 Skin check weekly and as needed completed and checked as no new areas of impairment. During an interview with Staff M, Unit Manager on 2/17/22 at 5:21 p.m. she confirmed skin assessments are completed weekly and on admission for each resident. 2. An observation of Resident #54's feet on 2/14/22 at 11:30 a.m. revealed they were dry and flaky. An observation and interview on 2/16/22 at 10:25 a.m. with the Regional Nurse revealed the resident's feet were dry and flaky. The Regional Nurse confirmed the resident's were dry and flaky and said 105271 Page 18 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0684 she would get him some lotion. Level of Harm - Minimal harm or potential for actual harm An observation and interview with Staff L, LPN on 2/16/22 at 1:21 p.m. confirmed the resident's feet were dry and flaky. Residents Affected - Few A review of physician orders for Resident #54 did not reveal any lotions ordered. Review of the care plan for Resident #54 revealed a focus area for risk of developing a wound initiated on 6/10/21. Interventions included observe for any new areas of skin breakdown: redness, blisters, bruises. initiated on 6/10/21. Review of the last four weekly skin checks for Resident #54 revealed: -2/9/22 skin check weekly and as needed completed as no new areas of skin impairment. -2/2/22 skin check weekly and as needed completed as no new areas of skin impairment. -1/4/22 skin check weekly and as needed completed as new area of skin impairment found open area to bilateral buttocks measuring a stage II for each. -10/3/21 skin check weekly and as needed completed as no new areas of skin impairment. During an interview on 2/16/22 at 11:14 a.m. with Staff M, unit manager she confirmed skin checks are weekly and on admission. During an interview with the Director of Nursing (DON) on 2/16/22 at 4:55 p.m. she confirmed skin checks should be completed weekly on all residents. 3. An observation of Resident #69 was conducted on 2/15/22 at 9:01 a.m. The resident was sitting up in bed and eating with assistance. The resident's skin was observed clean and intact. Review of Resident #69's medical record revealed the last three weekly skin checks were completed on: -2/7/22 skin check weekly documented as no new areas of skin impairment. -1/31/22 skin check weekly documented as no new areas of skin impairment. -9/22/21 skin check weekly documented as no new areas of skin impairment. During an interview with the DON on 02/17/22 03:32 p.m., she stated the resident's skin assessments should be completed weekly. 4. An observation of Resident #93 was conducted on 2/14/22 at 12:28 p.m. The resident's hands were observed closed and without palm guards. An observation and interview of Resident #93 was conducted on 2/16/22 at 1:23 p.m. with Staff L, LPN. The LPN revealed the resident wears palm guards and skin assessments are completed weekly. 105271 Page 19 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0684 Level of Harm - Minimal harm or potential for actual harm During an interview and observation with the Director of Rehabilitation on 2/17/22 at 3:50 p.m., she confirmed palm guards do not need to be ordered or care planned, but confirmed the skin needs to be assessed. Review of the last four weekly skin checks for Resident #93 showed: Residents Affected - Few -2/3/22 skin check weekly completed and documented as no new areas of skin impairment. -1/3/22 skin check weekly completed and documented as no new areas of skin impairment. -10/5/21 skin check weekly completed and documented as no new areas of skin impairment. -10/3/21 skin check weekly completed and documented as no new areas of skin impairment. Review of the care plan for Resident #93 revealed a focus area of activity of daily living for self-care. Resident does not initiate or follow through due to impaired cognition initiated on 7/31/20. Interventions included, provide assistance as needed to perform activity of daily living functions. During an interview with the DON on 2/16/22 at 4:55 p.m. she confirmed skin checks should be completed weekly on all residents. Review of facility policy titled, Weekly and as needed skin check, from Clinical Programs Manual, effective 10/21, two pages, revealed: -The weekly and as needed skin check is used to document skin condition throughout the Resident's stay in the facility. The nurse will conduct weekly skin check and or as needed skin check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. -Procedure: 1. Once a week and when an area of skin impairment is reported the skin check should be documented on the Weekly and as needed skin check documentation tool. If a new area is identified the appropriate skin grid should be initiated within 8-hours. 105271 Page 20 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

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 observation, interview, and record review, the facility failed to ensure one resident (#67) received services to maintain or promote further range of motion of a contracture related to the application of hand, elbow, knee, and boot splints for four days (02/14/22, 02/15/22, 02/16/22 and 02/17/22) of four days observed of a total sample of 29 residents with contractures. Findings include: On 02/14/22 at 10:31 a.m. Resident #67 was observed in his room, lying in bed. Resident #67's left hand appeared contracted and was positioned on his chest area. Resident #67 was not wearing a splint on his left hand during the observation. Further observation revealed blue, gray and black splints on top of the dresser in Resident #67's room. On 02/14/22 at 11:23 a.m. another observation was made, and the splints were observed again, on top of the dresser. (Photographic Evidence Obtained) On 02/15/22 at 9:38 a.m. Resident #67 was observed in his room, lying in bed. Resident #67 stated the splints had not been applied at any time yesterday. The splints were observed again, on top of the dresser. On 02/16/22 at 9:05 a.m. Resident #67 was observed in his room, lying in bed. Resident #67's splints were observed again, on top of the dresser. (Photographic Evidence Obtained) On 02/16/22 at 9:58 a.m., an interview was conducted with Staff T, Registered Nurse (RN), Unit Manager. She stated Resident #67 received therapy while in bed. She believed there was an order for splint placement and therapy was supposed to apply them. She needed to double check the orders to make sure. On 02/16/22 at 1:32 p.m., an interview was conducted with Staff U, Certified Nursing Assistant (CNA). She stated Resident #67 was seen by therapy, they put his splints on for a few hours and remove them afterwards. The CNAs were not responsible for applying the splints. The facility has a restorative aide, but she was unable to recall her name. On 02/17/22 at 8:38 a.m., Resident #67 was observed in bed, after eating breakfast. Resident #67 stated he had not worn the splints at any time during the week. Resident #67 stated he was not sure exactly who was responsible to place the splints on him. He had previously asked a CNA about the splints and was told that therapy was responsible to put them on him. The splints were observed on top of the dresser. (Photographic Evidence Obtained) Review of Resident #67's medical record revealed an initial admission date of 08/13/18, with diagnoses to include quadriplegia, contractures, and unilateral primary osteoarthritis. Review of the Quarterly Minimum Data Set (MDS) assessment, Section G: Functional Status, dated 01/14/22, revealed Resident #67 required extensive to total care assistance with Activities of Daily Living (ADLs) and was impaired on both sides of the upper and lower extremities. Section C: Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #67 was cognitively intact. Section O for . indicated restorative nursing for splint or brace assistance was not provided. 105271 Page 21 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current physician orders for the month of 02/2022 revealed Resident #67 had orders for: Left hand splint to resting hand splint on in am/pm removed before/after lunch as tolerated. May remove for skin sweep on 7-3. Right wrist stabilizer on in the am/pm removed before/after lunch or other as tolerated. May remove for skin sweep on 7-3. Left elbow splint on in the am/pm removed before/after lunch or other as tolerated. May remove for skin sweep on 7-3. Right knee extension on in am/pm removed before/after lunch or other as tolerated. May remove for skin sweep on 7-3, all ordered 08/20/21. On 02/17/22 at 9:25 a.m., an interview was conducted with Staff V, RN. She stated Resident #67 was seen by therapy very early in the morning. She has had to remove Resident #67's splints because he was too hot. Resident #67 was hot often, she had to remove the blanket from him yesterday because he was hot. She assumed that any staff member could have put the splints on him, as she had done so before. Staff V checked Resident #67's medical record and confirmed the CNAs were responsible to put the splints on him. On 02/17/22 at 9:45 a.m., an interview was conducted Staff W, Certified Occupational Therapy Assistant (COTA). She stated the resident was currently being screened by the Therapy Program Manager. When a resident completed therapy, nursing was provided with recommendations for the resident. From that point, nursing was responsible for the resident's care. She was not sure if there was a Restorative program at the facility because once a resident was removed from their caseload, they were no longer involved. On 02/17/22 at 11:08 a.m., an interview was conducted with the Therapy Program Manager. She stated Resident #67 was discharged from the therapy program on 01/12/22. He was discharged to the nursing staff. CNAs were responsible to apply his lower and upper splints. When a resident with splints was discharged to nursing, the CNAs were trained in how to apply the splints. Since she was informed the resident had not been wearing his splints, she planned to put him back onto the therapy caseload. The goal was to maintain his current level of functioning. On 02/17/22 at 1:18 p.m., an interview was conducted with the Director of Nursing (DON). She stated if Resident #67 had an order to wear splints she would expect staff to follow the order, according to the resident's desires. If the resident was refusing to wear the splint, it should have been documented. She was going to check the resident's medical record to confirm the specifics of the order and follow up with the surveyor. At the completion of the survey, the DON had not returned with any additional information. Review of the Restorative Nursing Progress Notes revealed the most recent notes as: 04/09/21- Resting hand splint donned to left hand and elbow splint donned to left arm. Both remained on for two hours. 04/16/21- Resting hand splint donned and left elbow splint for two hours. No redness or breakdown noted. 04/23/21- Resting hand splint and contracture splint donned to left hand and elbow for two hours. No redness or irritation noted. Review of the current care plan with initiation dates of 11/02/2020 and 04/13/21 revealed, a focus area for Range of Motion (ROM) and splint application related to a risk or actual limitations in ROM. Goals were to minimize the risk of complications related to splint application and maintain range of motion. Interventions included left wrist resting hand splint on after breakfast/off before breakfast, left anti-contracture splint (elbow) on after breakfast/off before lunch for approximately 2-3 hours daily as tolerated, left foot (boot) for approximately 3 hours daily as tolerated on after breakfast/off before lunch, right knee extension splint, apply to right knee for approximately 3 hours 105271 Page 22 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0688 daily as tolerated on after breakfast/off before lunch, removed for bathing or personal care activities. Level of Harm - Minimal harm or potential for actual harm Review of the CNA task documentation for splint application revealed not applicable, for the following dates, 02/01-02/15/22. Further review of the medical record revealed no documentation of refusals. Residents Affected - Few Review of the facility's policy titled Restorative Nursing Programs, revised October 2017 revealed: The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental, and psychological functioning. The IDT [interdisciplinary team], resident and, or family identify the needs of resident, and collaboratively determines appropriate Restorative Nursing Programs to achieve the resident's goals. The program includes- Contracture Management and Prevention- This program includes the provision of active and, or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity. 105271 Page 23 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (#4) received care and services to prevent a urinary tract infection of three residents sampled. Findings include: An observation of Resident #4's catheter on 2/15/22 at 11:41 a.m. revealed yellow urine draining into a patent catheter. An observation of Resident #4's catheter on 2/16/22 at 8:10 a.m. revealed the catheter draining yellow. An observation of Resident #4's catheter and interview with Staff L, Licensed Practical Nurse (LPN) on 2/16/22 at 1:45 p.m. confirmed the catheter bag and tubing turned deep purple. The urine was amber in color. During an interview and observation with the Director of Nursing (DON) on 2/16/22 at 4:41 p.m. she confirmed they were calling the doctor to get an order for a urinalysis and would change the catheter bag. The DON stated she would have expected documentation about the catheter changing to purple. The DON confirmed her expectation was the documentation would indicate the color of the urine and if the bag was purple and that should have been documented. During an interview with Staff K, Certified Nursing Assistant (CNA) on 2/17/22 at 9:10 a.m. she stated the resident's bag started turning purple and she told the nurses, but they did not do anything, and she has no where to document that. An observation of Resident #4's catheter on 2/17/22 at 9:28 a.m. revealed a newly inserted catheter was observed patent with yellow urine draining. During an observation of Resident #4's catheter on 2/17/22 at 1:28 p.m. the resident was observed sitting in her wheelchair and pulling at her catheter yelling that it hurt. The urine in the catheter was yellow at the bottom, cloudy and then the top of the tube was purple. The traveling DON confirmed on 2/17/22 at 1:29 p.m. the new catheter would come out and get changed again. They would call the doctor to get another order for urine and pain medication until the first urine sample comes back. A review of the admission Record revealed Resident #4 was admitted on [DATE] with a readmission on [DATE] with diagnoses to include neuromuscular dysfunction of bladder. Review of the physician orders as of 2/17/22 revealed: change catheter bag as needed, label with date as needed for urinary retention dated 9/11/20. [Indwelling] catheter care daily and as needed for preventative measure dated 11/2/21. [Indwelling] catheter: change [Indwelling] catheter as needed for leakage/blockage or dislodgement as needed document in resident's record dated 11/3/2020. [Indwelling] catheter to drainage bag for diagnoses of neurogenic bladder. [Indwelling] catheter size #20 with 10 cc (cubic centimeter) balloon. Observe every shift every shift for observation dated 11/3/20, 105271 Page 24 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0690 and Urinalysis culture and sensitivity every night shift for 2 days dated 2/16/22. Level of Harm - Minimal harm or potential for actual harm Review of the care plan for Resident #4 revealed a focus area of indwelling catheter: the resident uses the catheter with risk for infection and or complications, related to neurogenic bladder dated 8/29/19. Interventions included: change drainage bag routinely and as needed initiated on 8/29/19; Provide catheter care daily initiated on 8/29/19; Observe/document/report to physician for signs and symptoms of urinary tract infection: pain, burning blood tinged urine, cloudiness, no output, deepening of urine color initiated on 8/29/19; Irrigate catheter as ordered for blockage or sluggish output and notify physician, initiated on 8/29/19. Residents Affected - Few Review of the Treatment Administration Record for February 2022 documented: [Indwelling] catheter care daily and as needed every shift for preventative measures dated 9/11/20; [Indwelling] catheter to observe every shift dated 11/3/20 signed off daily; and [Indwelling] catheter to irrigate [Indwelling] catheter with 30 ml (milliliters) normal saline as needed for blockage/leakage or sluggishness dated 2/7/22. Review of facility policy, Notification of Resident/Patient Change in Condition, effective October 2021, revealed: Nurses will notify the resident/representative, if there is a crucial/significant change in the resident condition. A facility policy related to [Indwelling] catheters was requested on 2/17/22 at 5:00 p.m. and was not provided to the survey team at the time of the exit. 105271 Page 25 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure respiratory care was consistent with professional standards of practice for one resident (#9) of three sampled residents. Residents Affected - Few Findings include: An observation of Resident #9 on 2/15/22 at 10:08 a.m. revealed the resident was on 3 liters of oxygen via a nasal cannula. An observation of Resident #9 on 2/15/22 at 4:40 p.m. revealed the resident sitting up in bed with the head of bed at 45 degrees and revealed the resident was on oxygen via a nasal cannula infusing at 3 liters. An observation of Resident #9 on 2/16/22 at 8:49 a.m. revealed the resident using a nasal cannula with foam around the ears, infusing at 2 liters. An observation of Resident #9 on 2/16/22 at 10:37 a.m. revealed the resident was sitting up in bed with a nasal cannula with foam around her ears and infusing 2 liters of oxygen. At this time, Staff K, Certified Nursing Assistant (CNA) confirmed the resident wore the nasal cannula with foam around her ears, an infusing the oxygen all the time. An observation and interview with Staff L, Licensed Practical Nurse (LPN) on 2/16/22 at 1:30 p.m. confirmed Resident #9 was wearing oxygen at 2 liters via a nasal cannula. Staff L, LPN confirmed the resident did not have physician orders for continuous oxygen and does not need the oxygen unless she is below 93% room air. Staff L, LPN confirmed the resident's oxygen was usually between 97% and 98% on room air. Staff L, LPN removed the resident's oxygen at 1:46 p.m. and confirmed her oxygen level was 100% at room air and removed the oxygen tubing, stating she did not need the oxygen with saturation of 100% on room air. A review of the physician orders as of 2/17/22 revealed: -Change oxygen tubing and set up weekly as needed, label tubing with date when changed, dated 2/4/22. -Change oxygen tubing and set up weekly every night shift every Sunday, label tubing with date when changed, dated 2/4/22. -Change oxygen filter weekly every night shift every Sunday for shortness of breath, dated 2/4/22. -Oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath every shift for shortness of breath, dated 2/7/22. A review of the Treatment Administration Record (TAR) for February 2022 revealed the resident was scheduled from 2/4/22 to 2/7/22 to receive oxygen at 3 liters via nasal cannula continuously for shortness of breath. A continued review of the TAR for February 2022 revealed the resident was scheduled from 2/7/22 to 105271 Page 26 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0695 Level of Harm - Minimal harm or potential for actual harm current for oxygen at 2 liters via nasal cannula as needed for shortness of breath. Documentation of oxygen levels for February 2022 ranged from 95% to 98%. Lung sounds were documented as clear. A review of the care plan revealed a focus area for oxygen therapy dated 11/22/21. The Interventions included: administering oxygen as ordered, and give the medications as ordered by the physician. Residents Affected - Few During an interview with the Director of Nursing (DON) on 2/16/22 at 4:51 p.m. she confirmed the resident should have oxygen levels checked and documented if on room air or oxygen. The DON confirmed the resident's oxygen levels did not require oxygen continuously and should not have been left on. A review of the facility policy titled, Oxygen Therapy and Devices, revealed: 1. Oxygen is a drug which must be ordered by a physician .7) Apply device to the patient with appropriate liter flow. 105271 Page 27 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure medical records were complete and accurate for one resident (#69) related to hospice care of fifty sampled resident records. Residents Affected - Few Findings include: Review of the Order Summary Report as of 2/17/22 revealed Resident #69 had an active physician order for: Resident followed by [Hospice Provider Name] for diagnosis of Adult Failure to Thrive, dated 10/20/21. Review of the care plan focus area initiated on 10/20/21 revealed the resident is diagnosed with a terminal condition and is at risk for loss of dignity during dying process related to the terminal diagnosis: adult failure to thrive. Interventions included: collaborate with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, initiated on 10/20/21; Hospice to provide supplemental services per order/ plan of care. (See hospice documentation for more detail.) initiated on 10/20/21; Notify physician/hospice for change in condition, initiated on 10/20/21. Review of progress notes dated 12/8/21 revealed Resident #69 would be discharged from hospice in two weeks and hospice was requesting family contact information. Review of the medical record for the Hospice Discharge/Transfer Summary showed it was absent at 10:00 a.m. on 2/17/22. The facility requested the Hospice Discharge/Transfer Summary and received it at 12:59 p.m. on 2/17/22. The Hospice Discharge/Transfer Summary, dated 12/23/21, stated the resident was discharged from hospice for no longer being terminally ill. During an interview with Staff L, Licensed Practical Nurse (LPN) on 2/17/22 at 3:22 p.m. he confirmed the resident had been discharged from hospice for several months. During an interview with the Director of Nursing (DON) on 2/17/22 at 3:32 p.m. she stated the resident was not on hospice and confirmed the progress note was from the previous unit manager in December (2021). The DON confirmed the record did not reflect the resident's current medical status. During an interview with the DON on 2/17/22 at 4:22 p.m. she confirmed the resident was discharged from hospice on 12/23/21. A facility policy was requested on 2/17/22 at 5:00 p.m. and was not provided to the survey team at the time of the exit. 105271 Page 28 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform representatives of five residents (#34, #9, #54, #93, & #69) of positive cases of COVID-19 in the facility on eight days (1/13/22, 1/17/22, 1/19/22, 1/20/22, 1/23/22, 1/24/22, 1/27/22 and 1/30/22) by 5 p.m. the next calendar day, out of five residents sampled for notification of COVID-19 status. Residents Affected - Some Findings include: Review of the facility's listings for COVID-19 positive staff and residents revealed positive COIVD-19 cases documented on 1/13/22, 1/17/22, 1/19/22, 1/20/22, 1/23/22, 1/24/22, 1/27/22 and 1/30/22. Review of five resident (#34, #9, #54, #93, & #69) medical records for notification of families or representatives by 5:00 p.m. the next calendar day for January 2022 did not show notification by mail was received by 5:00 p.m. the next day. Review of the medical records for notification of positive COVID-19 cases showed: Resident # 69's family member was notified last on 1/5/22 of a positive COVID-19 case. Resident #34's family member was notified last on 1/5/22 of a positive COVID-19 case. Resident #9's daughter was notified last on 1/5/22 of a positive COVID-19 case. Resident #54's friend was notified last on 1/5/22 of a positive COVID-19 case. Resident #93's responsible party was notified last on 1/4/22 of a positive COVID-19 case. An interview on 2/15/22 at 2:35 p.m. with a representative of one of the above residents, who requested to remain anonymous, confirmed they did not receive a phone call or a letter related to the COVID-19 positive cases following the last phone call received. A review of Resident #69's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 00, indicating severe impairment. A review of Resident #34's Annual MDS assessment, dated 12/11/21, revealed in Section C - Cognitive Patterns a BIMS score of 07, indicating severe impairment. A review of Resident #9's Quarterly MDS assessment, dated 11/12/21, revealed in Section C - Cognitive Patterns a BIMS a score not indicated, however in section C1000 for Cognitive Skills for Daily Decision Making the #3 was checked for severely impaired never/rarely made decisions. A review of Resident #54's 5- Day MDS assessment, dated 1/7/22, revealed in Section C - Cognitive Patterns a BIMS score of 08, indicating moderate impairment. A review of Resident #93's Annual MDS assessment, dated 1/15/22, revealed in Section C - Cognitive Patterns a BIMS score of 00, indicating severe impairment. 105271 Page 29 of 30 105271 02/17/2022 Boca Ciega Center 1414 59th St S Gulfport, FL 33707

F 0885 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the Social Service Director (SSD) on 2/17/22 at 9:00 a.m. he confirmed he was responsible for calling the families and responsible parties and confirmed he had others assist him with calls. He said the documentation was entered into the electronic medical record each time. The SSD stated he was unsure of the last time he contacted the families and responsible parties. During an interview with the Nursing Home Administrator (NHA) on 2/17/22 at 10:42 a.m. he confirmed the Social Service Director is responsible for notifying the families and representatives after a positive COVID-19 test. The NHA confirmed the facility calls and sends out letters with the updated website information. The NHA confirmed letters were sent out by regular mail, the website is updated daily, and the phone calls are documented in the electronic record by Social Services. The NHA could not provide documentation the families or representatives were notified by 5:00 p.m. the next calendar day. Review of the facility policy titled, COVID-19 - Guidance, effective 11/21, revealed: Letters of notification of COVID-19 initial cases will be mailed or given to the residents on admission and staff will be made aware. Letters are sent out by mail. The website is updated daily and addressed in the letter. The documentation should be in the [electronic medical record]. 105271 Page 30 of 30