Health inspection·March 18, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review the facility failed to ensure that one (#20) of 21 sampled residents was provided with linens to cover a mattress. Findings included: On 03/15/21 at 10:58 AM, Resident#20 was observed to have four covers/blankets; however, the mattress was bare and had no sheet over it. The resident was alert but confused and unable to understand the surveyor's questions when asked about his missing linens. A review of Resident #20's clinical record revealed he had resided in the facility since 2018 and had a Brief Interview of Mental Status (BIMS) score of 10 (moderate cognitive impairment) according to the quarterly Minimum Data Set (MDS) assessment dated [DATE]. On 03/15/21 at 11:31 AM, a second observation was conducted. The resident was lying in bed with covers on but again, no linens were on the mattress. On 03/17/21 at 10:10 AM, an interview was conducted with the resident's Certified Nursing Assistant (CNA), Staff C, who was shaving the resident. She stated that Resident #20 had a specialized mattress and the air pressure would not allow for a fitted sheet to work. An interview was held with the Director of Nursing, DON, on 03/17/21 at 10:13 AM. The DON observed that Resident #20 was laying on a bare mattress. The DON reported that he should at least have a flat sheet on his bed. The DON stated I wasn't aware that sheets were not placed on his bed. I would expect at least a flat sheet on the mattress. Page 1 of 23 105292 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interviews, policies and resident council minutes review, the facility failed to act upon resident's concerns and grievances as evidenced by: (1) same grievances reported and documented without resolution for 6 out of 6 resident council meeting minutes. (2) Facility not having social services personnel available. (3) Nursing home administrator (NHA) failure to attend resident council meetings per the request of council participants. (4) NHA failure to respond to grievances and complaints. Findings included: A review of resident council meeting minutes was conducted with the following items marked as unresolved and action needed for the following dates: 2/10/21: 1/13/21: 11/18/20: 12/2/20: 10/4/20: 9/9/20. Grievances are not always being resolved satisfactorily and or resolution is not relayed to residents. Communication from NHA and Director of Nurses (DON) is not satisfactory to the residents. DON sends unit manager, NHA is very difficult to access. Residents concerned with use of agency staff stating that meds are not given correctly at times and treatments are not always completed. Dietary concerns related to snacks not being distributed, failure to follow meal tickets and dietary preferences, late meal tray deliveries. Staff not checking residents every 2 hours. Staff not knocking on resident's doors prior to entering. Maintenance work orders not completed in a timely fashion. In a resident council meeting held on 3/17/21 at 10:30 a.m., attended by council President and three other regular members, the residents confirmed the stated concerns adding that the facility has no leadership and the NHA won't attend meetings when requested. Residents stated that they have no one to talk to. When asked if the facility responds to their concerns, it was reiterated that the NHA does not attend meetings, does not to give feedback and is not accessible to residents. When asked if they had discussed this in Resident council meetings, council members stated that they had spoken to the Activities staff but, they have no power. A review of nursing home key staffing form revealed that the facility has no Social service director. The position is noted vacant. In an interview with the residents during resident council addressing the question of how the facility is handling grievances, it was reported that the Social worker used to file the grievances. Residents reported that they went without one for a long time. The facility hired one and then she quit. In an interview with NHA on 3/17/21 at 2.09 p.m., the NHA confirmed that they did not have a full-time social worker but, a part time social worker, Staff N who used to work here and just started. 105292 Page 2 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of an undated job description titled, Social Services Director under essential duties and responsibilities states that, the social services director coordinates grievance complaint process. A review of the facility grievance logs from December 2020 to March 2021 was conducted. The NHA stated the other records may be filed somewhere by the previous social worker. The December log showed one entry made on 12/1/20 with a follow- up dated 12/8/20. The January grievance log was marked no grievances received. The February log revealed a list of resident council concerns added on the same date 2/12/21, with all items marked as resolved satisfactorily, inconsistent with resident council meeting feedback. An interview was conducted with the NHA on 03/17/21 at 2.09 p.m. When asked how long it had been since the social worker position was vacated, the NHA stated that it has been since the first part of January and that they are still looking to fill the position. When asked who was filling in when Staff N was not in the building, the NHA answered, we are all pitching in. When asked how that was affecting the facility, the NHA stated she did not think the residents were affected. When asked how they are addressing grievances, the NHA stated that they have morning meetings where every department head reports if they are any grievances in their areas. The NHA was asked how she responds to the resident council concerns and if she meets with the residents. The NHA confirmed that she did not meet with the residents. The NHA explained that they have talked about that and are changing the process next month. When asked about the concern documented in resident council and discussed at the meeting about being inaccessible to residents, the NHA stated that she had an open-door policy but had a problem with some residents who just want to complain. A review of the resident handbook titled, Resident information and Reference guide, dated June 1, 2016, page 14 subject: Grievances and Complaints confirmed that the facility was not implementing their own policies and procedure. The policy states: it is the policy of the facility to support each resident's rights to voice grievances and to ensure that after a grievance has been received, the facility actively resolves the issue and communicates the resolution's progress to the resident and or resident's family in a timely manner. The administrator is ultimately responsible for the resolution of all grievances and /or complaints. Number #9 of the grievance section states that the resident council or family council are additional forums for voicing complaints and grievances and that these grievances will be acted upon in accordance with this policy. The facility's policy titled, Filing grievances/complaints revised August 2008 revealed that the NHA will review the (complaint) findings with the person filing the grievance and will make such reports orally within 10 working days of filing the grievance or complaint. The facility did not provide evidence of the review process or a written summary of the investigations as stated in their policy. A review of resident council meeting minutes, dated 12/2/20, under old business confirmed that the NHA did not follow through with a plan to meet with the residents monthly. Under old business, resolution to improve communication from NHA and DON states that; DON and NHA will meet with residents monthly on the third Thursday at 2:30 p.m. In a follow- up interview with the NHA on 03/17/121 at 2:09 p.m., the NHA stated that she tried to schedule a meeting with the residents and DON, but it did not work out. NHA said, it wasn't a positive experience. 105292 Page 3 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure it developed skin assessments for two residents (#5, and #45) of 21 sampled residents. Residents Affected - Few Findings included: 1. Resident#5 was admitted to the facility on [DATE] with a readmission date of 11/23/2020 and multiple diagnosis that included respiratory failure, pressure ulcers unstageable, Seborrhea capitis and dysphagia. On 03/15/21 at11:44 AM Resident#5 was observed with a skin rash on his right elbow, and a size approximately 3x3inches. In a subsequent interview, Resident#5 stated that it wasn't being treated, and no medication or ointment was applied to his rash on his elbow. He further said it has not been looked at or treated. An interview with staff member B, Licensed Practical Nurse (LPN) was conducted on 03/16/21 at 3:27 PM. She stated the resident's rash that was noted yesterday on his right elbow. She confirmed that she had not documented any skin assessments/notes regarding the rash on his elbow. The medical record revealed an order dated 2/7/2021 for ketoconazole cream 2% topical twice a day, apply to scalp and elbows or other inflamed areas. The medical record review also revealed that a medication was ordered 3/11/21; clotrimazole-betamethasone (cream topical) apply twice a day-apply cream to scalp and rash areas for 10 days. Staff member B, LPN confirmed that she has not documented anything regarding his elbow skin rash. A review of Resident #5's care plan approaches dated 12/12/2020 indicated: Shower daily and/or at resident request skin check by nurse. Conduct a systematic skin inspection weekly. Pay close attention to bony prominences. Report any signs of skin breakdown (sore, tender, or broken areas) to nurse or doctor. A further review of Resident #5's last observation documented on 2/7/21 at 9:49 a.m. revealed: Weeklyweekly skin checks: Skin. There were no further skin assessments or documented evidence that his rash on his right elbow had been addressed. An interview was conducted with the Director of Nursing (DON) regarding documentation for skin issues/treatments. She stated that it was the nurse's responsibility to conduct skin assessments for the residents. She was asked if she could provide documentation from the medical record that Resident #5's elbow rash had been assessed or treated. She reported that there was no documentation and her expectation was that any skin issue would be documented.2. Resident #45 was admitted on [DATE]. The Face Sheet included diagnoses not limited to Brain stem stroke syndrome, flaccid hemiplegia affecting right dominant side, and subsequent encounter for unspecified open wound to right lower leg. A review of Resident #45's clinical record indicated that a weekly skin observation/assessment had not been completed since November 2020, four months prior to this visit, nor did the record include a Wound Management Note was completed from 12/30/20 to 3/13/20. The progress notes for the resident included the following documentation regarding the resident's 105292 Page 4 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0641 trauma wound to his right lateral calf: Level of Harm - Minimal harm or potential for actual harm - 3/15/21 at 10:34 p.m., wound care completed on calf via orders. - 2/19/21 at 5:57 p.m., wound care was completed to right calf, dressing clean and intact. Residents Affected - Few - 2/18/21 at 9:49 p.m., refused leg treatments tonight, tried to redirect but unable to, will try again later for dressings. - 12/23/20 at 9:40 a.m., wound care of leg completed with wound nurse during rounds. No new orders received. - 12/11/20 at 7:39 p.m., (Resident #45) has a right lateral calf area of trauma. - 12/09/20 at 9:55 p.m., wound dressing (dsg) dry and intact, seen by wound nurse this am. - 12/06/20 at 7:00 p.m., Resident is skilled for (Wound Consultant) weekly wound care for area of trauma on right lateral calf. - 12/05/20 at 7:30 p.m., Resident is skilled for (Wound Consultant) weekly wound care for area of trauma on right lateral calf. - 12/03/21 at 4:58 p.m., Resident is skilled for (Wound Consultant) weekly wound care for area of trauma on right lateral calf. - 12/02/21 at 12:36 p.m., wound care during rounds. The review of the progress notes did not indicate any measurements or descriptions of the residents' right lateral calf wound. The latest Wound Care Consultant note, dated 12/30/20, indicated a Right lateral leg trauma wound measured 1.1 x 0.5 x 0.1 centimeters (cm). The area of the wound was 0.432 cm2 with moderate serosanguineous drainage, 90% granulation and 10% slough. The consultant described the progress of wound as stable and slightly smaller. A consultant's note, dated 12/23/20, indicated the residents wound #7 was a stage 2 sacral wound that was resolved. On 3/16/21 at 3:26 p.m., Staff B, Registered Nurse (RN), confirmed that Resident #45 had a wound to the right lower extremity that was scaly, crusty and dry. She stated she was trying to get him on the list to see wound care. The staff member stated that she always does do a skin assessment but does not document it unless it pops up (on computer) for her to do or if its prudent. Staff B had completed a wound management note, on 3/13/21, that indicated the right lateral calf wound measured 22 cm x 18 cm. At 5:14 p.m. on 3/16/21, the DON was asked if the resident had a Stage II pressure ulcer as indicated on the Facility Matrix. She stated she did not know unless she looked at the clinical record of Resident #45. When asked if the resident was seen by the Wound Care Consultant she stated she would have to check as the Unit Manager rounds with them but Staff G, RN had taken over that position last week and before that the floor nurses rounded with the consultant. The DON confirmed that the last consultant notes were from December 2020. She reviewed the wound management notes for Resident #45's 105292 Page 5 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lateral right leg wound and confirmed there was one from 12/16/20 that included measurements of 1.8 x 0.6 cm and one completed by Staff B, RN on 3/13/21 with measurements of 22 x 18 cm. The DON confirmed there were no weekly skin assessments or wound assessments for Resident #45. On 3/16/21 at 6:04 p.m., an observation of Resident #45's right leg wound care was conducted with Staff G and the DON. The observation revealed a large area lateral and posterior of the right leg covered with thick, grayish-brown crusty scabs from just below the knee to the ankle, with three open areas that were reddened, raw-looking, and without slough. The previous dressing, dated 3/15/21, did not appear to have any drainage on it. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had an open lesion other than ulcer, rash or cut and the activity of bed mobility only occurred once or twice, and the resident was assisted by two persons. The care plan for the resident included the problem of urinary incontinence and identified that he was at risk for infection, skin breakdown, loss of dignity due to total bowel and bladder (B&B) incontinence, had a diagnosis of neurogenic bladder and history of cerebrovascular accident (CVA), and as readmitted with a pressure area to the coccyx and area of trauma to the right calf. The approaches for this problem instructed nursing staff to report any signs of skin breakdown (sore, tender, red, or broken areas). The problem and all approaches of the residents' urinary incontinence was started on 12/6/2020, with a long-term goal target date of 2/18/2021. The care plan also identified that Resident #45 required extensive to total assistance of 1-2 staff for Activities of Daily Living (ADL's) other than eating, has decreased to Range of Motion (ROM) to affected right side, was non-ambulatory, and declined to spend any time out of bed, start date 12/6/2020. The approaches related to ADL care of the resident instructed nursing staff to provide extensive to total assistance for repositioning, transfers, bathing, and grooming as needed and to maintain body in functional alignment when at rest. The approaches started on 12/6/2020 and had the long-term goal target date of 2/18/2021. On 3/16/21 a request was made for copies of the Resident #45's Weekly Skin Assessments for December 2020, January, February, and March 2021 and for the Wound Management Note. The facility provided the Comprehensive Certified Nursing Assistant (CNA) Shower Reviews, dated 3/1, 3/11, and 3/15/21. The reviews dated 3/1 and 3/11/21 indicated a blister to the residents' anterior right lower extremity and an unidentified area on 3/15/21 to the anterior lower extremity. The shower reviews instructed the CNA to report any abnormal skin to the nurse immediately and forward any problems to the DON for review. The reviews did not indicate the nurse had assessed any noted areas or had signed the review. The facility did not provide the Wound Management Note. The policy titled, Wound and Skin Care Program Policy, and Procedure, revised May 2020, indicated that Residents with: history (hx) of current pressure sore(s), Hemiplegia, Quadriplegia, Peripheral vascular disease, desensitized skin, end stage diagnosis, Diabetes, or edema will be considered at high risk. The procedure indicated that on a weekly basis, all residents are to have a full body skin assessment completed, at bath/shower time, no less that one time per week, by the CNA and Nurse responsible for the resident that day. This is to be documented. If any new area(s) are found, appropriate orders are to be obtained for treatment of area(s). 105292 Page 6 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0655 Level of Harm - Minimal harm or potential for actual harm Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on observations, record reviews, and interviews the facility failed to develop and implement a baseline care plan for one (#99) of 21 residents sampled. Residents Affected - Few Findings included: A review of the policy titled Care Plans and Care Plan Meetings, dated 10/5/18, revealed: Baseline Care Plan- A preliminary plan of care that includes the minimum healthcare information necessary and instructions will be started and the facility will enable the resident to be informed of and participate in the development and implementation of the care and treatment regimen which will provide effective and person-centered care to properly care for the resident that meets professional standards of quality of care and meets the resident's immediate needs shall be developed for each resident. The baseline care plan summary must be provided to the resident and/or their representative between the 48th hour and completion of the comprehensive care plan . The policy identified that nursing staff will review the Attending Physician's orders (e.g. dietary needs, medications, and routine treatments, etc.) with the resident and representative, if applicable and collectively implement a care plan to meet the resident's immediate care needs. A review of Resident #99's Face Sheet revealed an admission date of 3/10/21. The Face Sheet included diagnoses of Acute Respiratory disease 2019-nCOV, unspecified Type 2 Diabetes Mellitus with diabetic neuropathy, unstageable pressure ulcer of sacral region, and acquired absence of left leg above knee. An observation of Resident #99 was made on the COVID-19 positive unit. The resident appeared to be frail and was laying in bed covered by a blanket. A review of the clinical record on 3/16/21 at 10:59 a.m. revealed the resident did not have a baseline care plan. Photo evidence was obtained. The physician orders for Resident #99 included the following: - dated 3/11/21: Resident under strict isolation precautions, services rendered in room. - dated 3/11/21: Clopidogrel 75 milligram (mg) orally once a day. (no diagnosis) Clopidogrel belongs to the medication class of blood thinners. - dated 3/11/21: Mirtazapine 7.5 mg orally at bedtime. (no diagnosis) Mirtazapine belongs to the medication class of antidepressant. - dated 3/11/21: Coccyx wound - cleanse with normal saline (ns), apply santyl and border/foam dressing daily. On 3/17/21 at 2:36 p.m., the Assistant Director of Nursing (ADON) was asked to assist with locating the baseline care plan. She stated that she did not know and would ask. On 3/17/21 at 2:37 p.m., the Director of Nursing (DON) stated that baseline care plans were located in the electronic medical record under the Observations tab. The DON proceeded to reviewed the Observations tab in Resident #99's electronic record. The DON verified that no baseline care plan had been developed. 105292 Page 7 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

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. Based on interview and record review, the facility did not ensure that the resident and resident representative were involved in care planning for one (Resident #3) of nine residents reviewed for care planning. Findings included: In an interview with Resident #3's Power of Attorney (POA) on 03/15/21 at 4:22 p.m., the POA stated that she had not participated in a care plan meeting in a long time. The POA reported that the facility did not have a social worker and that care planning and care coordination was lacking. The POA stated that before COVID-19, they would send a letter inviting the Resident Representative to the meeting. When asked if during COVID-19 she had participated in a conference call or video conference call care plan meeting, Resident #3's POA answered, No. It's been at least a year. An interview was conducted with the Nursing Home Administrator (NHA) on 03/17/21 at 2:52 p.m. The NHA stated that they started care plan meetings recently. The NHA said that they just got a conference call number probably a week ago. The NHA reported that the social worker had facilitated care plan meetings in the past, but now it was being done by the Minimum Data Set (MDS) Nurse or the Director of Nursing (DON). The NHA stated that family should be involved, and the care plan should be marked reviewed. On 03/17/21 at 2:57 p.m., an interview was conducted with the DON. The DON confirmed that up until two weeks ago, families were not being involved in the care planning process for the last year. The DON stated that she had realized that they were not following up, and they have started to make calls. A review of the facility's Resident information and reference guide with an effective date of June 1, 2016 revealed the following information related to Care Planning Conferences: Paragraph (2): The facility holds care planning conferences or meetings approximately 2 weeks after admission and then every 90 days thereafter. Paragraph (3) we invite you to attend your care planning conference and we will send reminders of any upcoming conferences. Paragraph (4) unless instructed otherwise we will invite your representative or other family member to attend your care planning conference each quarter. Your family member will be notified by mail in advance of the care planning conference. 105292 Page 8 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

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** 3. A review of Resident #20's most recent quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderately impaired cognition and total dependence on staff with the physical assistance of one person for personal hygiene and bathing. Residents Affected - Few On 03/17/21 at 12:53 PM, the Director of Nursing (DON) provided forms for Resident #20 titled Skin Monitoring: Comprehensive CNA Shower Review dated 3/1, 3/4, 3/8, 3/11 and 3/15/2021 which indicated that the resident needed his toe nails cut. Record review revealed no documentation for a podiatrist consult or that nursing had provided this service. A review of Resident #20's Plan of Care dated 2/21/21 revealed that the resident required total assistance with personal care due to decreased strength/coordination . An intervention dated 7/21/19 revealed the resident was to receive assistance with set up of items needed and performing oral hygiene, trimming nails, hair and facial hair (including shaving if appropriate). Observations were conducted 3/16/2021 at 11:56 AM, 3/17/21 at 12:53 PM, and 3/17/21 at 1:19 PM: Resident #20's bilateral toenails were approximately 2 inches longer than the nail bed and appeared dark under the nail bed. An interview was conducted with Staff A, CNA, on 03/17/21 at 1:19 PM. She reported that she can cut toe nails, but did not cut Resident#20's toe nails because, We are short staffed and very busy. Sometimes it's too much and we miss things. She was asked if she informed the nurse that the resident needed his toe nails trimmed, and she did not answer. The medical record was reviewed and found no documentation that the resident had refused to having his toe nails trimmed. Based on observations, interviews, and record reviews, the facility did not ensure three (#3, #14, #20) of four residents reviewed for Activities of Daily Living (ADL) received assistance with showers and nail care. Findings included: 1. Observation on 3/15/21 at 11:30 a.m., 3/15/21 at 4:22 p.m., and 3/16/21 at 3.39 p.m. revealed Resident #3 was laying in bed with hair that appeared unkept. A review of Resident #3's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. Continued review of the MDS revealed Resident #3 required extensive physical assistance with one person physical assistance for personal hygiene and total dependence with bathing with one person physical assistance. An interview was conducted with Resident #3's Power of Attorney (POA) on 03/15/21 at 4.22 p.m. revealed that Resident #3 had not a shower. The POA reported that, they wash her up, and her hair has not been washed in months. An interview was conducted on 03/17/21 at 4:48 p.m. with Staff O, Certified Nursing Assistant (CNA). Staff O was asked if Resident #3 had received a shower or bath. Staff O confirmed that that they gave Resident #3 a bed bath but did not wash her hair. Staff O was not able to offer an explanation 105292 Page 9 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0677 for why Resident #3's hair was not washed. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's care plan last reviewed on 01/06/21 for ADL functional rehabilitation revealed Resident #3 has a deficit and requires extensive total assist from staff with ADL's and transfers, she was non-ambulatory due to Parkinson's disease and a history of non-surgical fracture of Right Femur. A goal was listed for Resident #3 to be appropriately groomed and dressed by staff daily. The approaches listed included nursing staff to provide all ADL care to ensure daily needs were met. Residents Affected - Few On 03/17/21 at 1:25 p.m., Staff A, CNA was asked if she had given Resident #3 a shower or bath. Staff A stated that she had given Resident #3 a bed bath. Staff A reported that Resident #3 had not had a shower or had her hair washed recently. Staff A stated that it takes two staff get the resident up and sometimes they are short staffed. Staff A stated that she did not complete the shower review form as expected. A review of the shower log binder revealed no shower sheets were present for Resident #3. A statement on the binder noted: please put all shower sheets behind the assigned day. It also stated: each shower sheet is to be signed by the nurse, verifies shower, shave, nail care has been completed. If a resident refuses shower/hygiene, the nurse is to document on the 24-hour report in the nurse's notes. 2. During a facility tour on 03/15/21 at 11:30 a.m., Resident #17 reported not having had a shower in a month. Resident #17 stated that prior to that, it had been four months. When asked why she went that long without a shower, Resident #17 stated that they (facility) said it was because of COVID. Review of Resident #17's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. The MDS indicated that Resident #17 was dependent on staff for bathing and required one person physical assistance. An interview was conducted on 03/17/21 at 4.48 p.m. with Staff O, CNA. Staff O stated that she works fulltime and assisted residents with showers in the evenings. Staff O stated that Resident #17 got a bed bath the day before (3/16/21). Staff O said that Resident #17 loves showers, but since coming from the hospital she had not had one. When asked how often Resident #17 was showered, Staff O stated every two days in the evenings. Staff O reported it had been awhile since Resident #17 was last showered. She stated that prior to the bed bath on 3/16/21, it had been more than a month. A review of Resident #17's Care plan revised on 2/17/21; with a problem start date of 07/20/17 was reviewed. Resident #17 needed staff assist with ADLS and transfers due to impaired functional mobility, incontinence of Bowel and Bladder, impaired insight, and judgement. A listed goal stated that Resident #17 will continue to participate in ADL care as able through the next review date. The approach was for staff to assist with bed mobility, transfer ambulation, locomotion, dressing, toilet use, personal hygiene, and bathing. On 03/17/21 at 9:30 a.m., an interview with Staff C, CNA was conducted. Staff C stated that showers were supposed to be completed as scheduled. Shower sheets were to be completed after showers. Staff C stated that shower logs should be in the book. Staff C stated that the charge nurse was supposed to sign off after each shower and then the DON reviews and signs off. Following a review of the shower binder with Staff C, no shower sheets were noted. Staff C stated that DON might have them in her office. 105292 Page 10 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the DON on 03/17/21 at 9:45 a.m. The DON stated that the residents are receiving showers as scheduled. The DON stated that residents receive a shower or bath two times a week. A review of the shower log binder revealed no shower logs for Resident # 3 and Resident # 17. The DON stated that she had the shower logs in her office. On 3/17/21 at 2:15 p.m., a follow-up interview was conducted with the DON related to shower documentation. The DON sated there is a bunch of them (referring to shower sheets) in my office. The DON was again requested to provide the documentation. The shower log paperwork was not produced by time of exit on 3/18/21. A review of the facility's undated policy titled, Bath, Shower / Tub revealed that the purpose of this procedure was to promote cleanliness, provide comfort to the resident and to observe the skin condition. Documentation was to be completed at the date and time of shower or bath to include individual who assisted resident, skin assessment, if resident refuses and the interventions taken. 105292 Page 11 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

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 interviews, observations, and records review, the facility failed to provide an on-going activities program to support the comprehensive assessment and care planned choices and preferences for one (#3) of three residents sampled for activities. Residents Affected - Few Findings included: Observations of Resident #3 were conducted on 03/15/21 at 11:23 a.m. and 12:21 p.m., 3/16/21 at 10:23 a.m., 11:30 a.m., and 3:31 p.m., and on 3/17/21 at 10:00 a.m. and 4:20 p.m. Resident #3 was observed sleeping or laying in her bed with her eyes closed. There was no evidence of either a radio, Television (TV) or mobile device being used or provided in Resident #3's room. Additionally, there were no observations of any one on one activities provided to Resident #3. Resident #3 was not noted to be assisted out of bed to attend any socially distanced group activities during the course of the survey conducted 03/15/21 to 03/18/21. On 03/16/21, 03/17/21 and 03/18/21, the Activities Director was observed sitting at the front desk screening incoming visitors and answering telephone calls. On 3/16/21 at 12:00 p.m., the Activities Director stated that she was helping at the front desk, covering some of the Social Services duties, and could not be on the floor all the time. The Activities Director stated that her Aide was doing rounds distributing snacks and offering residents coffee or tea. When asked who was providing group activities and 1:1 activities, the Activities Director stated that they were doing the best they can. A review of the Resident Face Sheet revealed that Resident #3 was admitted to the facility since 2017 and has a sister listed as her Power of Attorney (POA) and Responsible Party. In an interview with Resident #3's Power of Attorney (POA) on 03/15/21 at 4:22 p.m. it was revealed that Resident #3 used to like playing Bingo but because of COVID they're not doing it anymore. The POA added that the resident has a TV in her room, and she used to enjoy watching TV. Resident #3's POA stated, she just stares at the walls now because there is nothing to do. A review of Resident #3's MDS (minimum data set) quarterly assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 4, indicating severe cognitive impairment. Section G, functional status revealed that Resident #3 required extensive assistance for transfers requiring two + person physical assistance. A review of Resident #3's last annual MDS assessment dated [DATE] revealed the same BIMS score of 4 and indicated that the resident participated in the activity preferences interview. The resident indicated that it was very important to listen to music she liked, do things with groups of people, and do her favorite activities. The resident also indicated that is was somewhat important to go outside to get fresh air when the weather was good and to participate in religious services. On 03/17/21 at 4:.48 p.m., Staff O, Certified Nursing Assistant (CNA) was asked what activities Resident #3 liked to participate in. Staff O stated that Resident #3 liked to listen to music. She has her favorite music list, and she likes to watch TV. When asked what Resident #3 does in the evenings, Staff O stated that Resident #3 was typically watching TV and or listening to music. Staff O was asked if she had noticed Resident #3 watching TV or listening to music recently. Staff O answered, No. When asked if she was aware that there was no TV or radio in Resident #3's room, Staff O answered, 105292 Page 12 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0679 No. Level of Harm - Minimal harm or potential for actual harm On 03/16/21 at 4:51 p.m., a follow -up interview was conducted with Staff M, Activities Director. When asked what activities Resident #3 liked to do, Staff M stated that she loves music, country music, and Elvis [NAME]. Staff M stated that Resident #3 participated in small groups. Staff M explained that they do different things such as toss ball, YouTube games and dancing. Staff M confirmed that Resident # 3 engaged in these activities when offered, stating, She'll move to the dance. Staff M was asked when Resident #3 last participated in an activity. Staff M answered on 03/14/21 Sunday, she watched the sitcom MASH in her room using a tablet we have. We stay with her. When asked if Resident #3 was assisted out of bed for activities, Staff M stated that it was not every day and she had not been out of bed recently. Staff M stated that she did not notice that there was no TV or radio in the resident's room. When asked if she would expect a resident who enjoys music to have a TV or radio in her room, Staff M answered, Yes, I would expect she would have those. I did not notice. I try and stay on top of those kind of things. Staff M confirmed that the facility would usually provide a radio. Residents Affected - Few A Review of the Activities participation log for February and March 2021 was conducted. Resident #3 was offered activities 6 times out of 28 days, and 3 times thus far from 3/1/21 to 3/17/21. A review of Resident #3's care plan last reviewed 2/18/21 for activities revealed a goal to engage in 1:1 activities of interest. The care plan noted a problem of resident requires encouragement to actively participate in activities of interest. The approaches on the care plan included: provide 1:1 visits and offer 1:1 activities of interest such as music, chair dancing, and funny movie / TV clips was documented. A review of a Job description titled Activity Manager, with an effective date, 01/01/18, revealed that the essential duties and responsibilities included: Provides patients who are confined or choose to remain in their rooms with in-room activities in keeping with life-long interests. Assists with escorting patients to and from activities. 105292 Page 13 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the record for Resident #2 revealed an admission date of 4/12/15, and diagnoses that included COPD (Chronic Obstructive Airway Disease), muscle weakness, gait abnormalities, anxiety, and dysphagia. Resident#2 is a full code and legally blind. It was noted that Resident #2 had the following order: Durezol .05% three times a day; amount to administer 1gtt; ophthalmic (eye). A telephone interview was conducted with the Pharmacist on 3/18/2021 at 1:08 p.m. who acknowledged that the prescription should clearly indicate to which eye the drops would be administered. An interview was conducted with the DON on 3/18/2021 at 1:30 p.m. and asked if she had a clarification order for the above order. She reported that she should have obtained a clarification order but had not. Based on interviews, observations and record reviews, the facility did not ensure that 1) medications were available for 2 residents, (Resident #3 and Resident #17), and 2) did not ensure eye drops orders were clarified for 1 resident, (Resident # 2) of 21 sampled residents. Findings included: 1. An electronic medical record (EMR) review for Resident #3 on 03/18/21 revealed that Resident #3 missed a scheduled medication (Lorazepam 0.5 mg (milligram) schedule 1 tablet) from 3/1/21 to 3/6/21, missing 12 administration opportunities. A current prescription order revealed that Resident # 3 should receive the medication as follows: Lorazepam 0.5 mg; amount one tablet; oral; frequency twice a day at 06:00 a.m. and 06:00 p.m. Diagnosis: Generalized anxiety disorder. Resident #3 was admitted to the facility on [DATE], with a diagnosis to include; Parkinson's disease, neuroleptic parkinsonism, feeding difficulties, acute respiratory disease, muscle weakness, respiratory TB, Dysphagia, oral phase, insomnia unspecified, hyponatremia, hypokalemia, Edema, personal history of thrombosis and embolism, cough, major depressive disorder, chronic gastric ulcer, pain in right knee, paranoid schizophrenia, vascular dementia with behavioral disturbance, other epilepsy, congestive heart failure, hypothyroidism, chronic pulmonary disease. A review of Resident #3's quarterly minimum data set (MDS) dated [DATE], section C, cognitive status revealed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impact. On 03/18/21 12:11 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked why Resident #3's Lorazepam was not administered from 3/1/21 to 3/6/21. The DON was not sure if the medication was a routine order or PRN (as needed) order. The DON reviewed the order and confirmed that the medication was a routine order that should be administered twice daily. When asked if she was aware of any concerns with reordering the medication, DON stated that she was not aware of any concerns. The DON stated that she did not know the resident went that long without the medication. During a facility tour on 03/16/21 at 03:40 p.m., Resident #17 reported that she had not received her pain medication (Tramadol). Resident #17 stated that she was in a lot of pain and had requested the medication at 12:30 p.m. An electronic medical record (EMR) review for Resident #17 revealed an active order, dated 105292 Page 14 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 03/13/21. Tramadol - Schedule IV tablet 50mg, amount administer one tablet every 6 hours Level of Harm - Minimal harm or potential for actual harm Resident # 17 was admitted to the facility on [DATE] with a Diagnosis to include: non-displaced fracture, hemiplegia and hemiparesis, other specified disorders, muscle weakness, weakness, unspecified open wound, acute respiratory disease, hyperlipidemia, anxiety disorder, bipolar disorder, chronic bronchitis. A quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) of 15, indicating intact cognition. Residents Affected - Some An interview was conducted with Staff B, RN (Registered Nurse) on 03/16/21 at 03:45 p.m. Staff B was asked why Resident #17 had not received her pain medication. Staff B confirmed that the medication was not administered because it was not available. Staff B was asked what the protocol for refilling medications was. Staff B stated that in a perfect condition nursing staff would be notifying the physician to obtain a new script. Staff B said that she had made two calls but had been busy administering medications and had not been able to follow-up. Staff B confirmed that she was notified when she came in that Resident #17 was out of Tramadol. When asked if there was a system in place to track medication inventory, Staff B stated there was no tracking, and that the nurses use word of mouth. Staff B stated that the nurse who notices a medication is low should refill it. On 03/16/21 at 04:50 p.m. Staff G, RN confirmed that Tramadol and Lorazepam were available in the facility's EDK (emergency drug kit). Staff G stated that the pharmacy had authorized to open the EDK and offer Resident #17 pain medicine (Tramadol) On 03/18/21 12:11 PM, an interview was conducted with the DON. When asked what the expectation would be related to refilling prescriptions, DON stated that the nurse should have called the doctor. The DON stated that if there were any concerns with reordering the medications she would expect to be notified. The DON also stated that she would have called the doctor for a script, at which the pharmacy would authorized obtaining the medication from the EDK. The DON stated that the medication is available in the facility's EDK storage, and confirmed that the residents should not be going without medications. On 03/18/21 at 1:11 p.m., an interview was conducted with the facility's pharmacist. The pharmacist was notified that Resident #3 went without Lorazepam 0.5 mg for 6 days and Resident # 17 went without tramadol 50mg, missing one dose. The Pharmacist stated that he was surprised that Resident #3 went that many days without a routine medication. The Pharmacist stated that these are not drugs that a pharmacy would be out of. The Pharmacist explained that all the pharmacy needed was a current order given these are controlled substances. The order would authorize the EDK access, allowing a resident to receive the medication. The Pharmacist stated that he did not personally receive a call from the facility, and he could not see any notes related to the two issues. A follow - up interview was conducted with the Nursing Home Administrator (NHA) on 03/18/21 at 12:45 p.m. When asked what the expectation would be when a resident runs out of medication, the NHA stated, the nurse should reorder the medication. When asked if she was aware that Resident #3 went without Lorazepam for 6 days and Resident #17 missed a Tramadol dose the NHA answered, 'No.' The NHA added that this was the first time she was hearing about it, and stated that this is not the facility's protocol. A review of the facility's policy titled, Medication ordering and receiving from pharmacy dated, April 2018, revealed (H) Controlled substances are reordered when a 5-7 supply remains to allow for transmittal of the required written prescription to the pharmacist. 105292 Page 15 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and twenty-four errors were identified for four (#16, #7, #19, and #13) of five residents observed. These errors constituted a 64.86% medication error rate. Residents Affected - Some Findings included: 1. On 3/15/21 at 11:31 a.m., an observation of medication administration with Staff Member H, Licensed Practical Nurse (LPN), was conducted with Resident #16. The staff member reported the residents previous obtained blood glucose level of 347 and stated the resident was to receive 8 units of Novolog. She removed a Novolog Flexpen that was opened on 3/12/21 and dialed it to 8 units. Prior to entering the resident's room, when asked how she primed the Flexpen, she asked, you mean by 2 units?. She reported no I did not when asked if she had primed the Flexpen. The staff member entered Resident 16's room and interjected the Novolog insulin into administered 8 units into the resident's right arm, without priming the Flexpen. The manufacturer's Quick guide for each of the NovoLog FlexPen instructed users as follows: - Prime you pen - Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. - Select your dose - Turn the dose selector to select the number of units you need to inject. The pharmaceutical literature included instructions on how to prepare the Novolog Flexpen: - Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to select 2 units. - F. Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog FlexPen and contact Novo Nordisk. This information was obtained at https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen% The Consultant Pharmacist reported, at 1:11 p.m. on 3/18/21, that an insulin pen should be primed prior to use to extract air and to make sure the recipient received the correct dose of insulin. The policy titled, Insulin Administration identified the purpose of the policy was To provide guidelines for the safe administration of insulin to residents with diabetes. #5 of the preparation section of the policy indicated that The nursing staff will have access to specific instructions (from 105292 Page 16 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0759 the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Level of Harm - Minimal harm or potential for actual harm 2. On 3/16/21 at 8:51 a.m., an observation of medication administration with Staff Member B, Registered Nurse (RN), was conducted with Resident #7. Staff B was observed administering the following medications: Residents Affected - Some - Aspirin 81(milligram) mg chewable tablet orally - Bumetanide 1mg tab orally - Buspirone 5 mg tab orally - Docusate Sodium 100 mg softgel orally - Escitalopram 20 mg tab orally - Metoprolol Tartrate 25 mg tab orally - Risperidone 4 mg tab orally - Topiramate 50 mg tab orally - Ziprasidone 20 mg capsule orally - Fluticasone Propionate 50 microgram (mcg) nasal spray inhalation - Spiriva 18 mcg capsule inhalation Staff B stated the resident was to receive two medications, Amlodipine and Potassium, that was pending pharmacy delivery. When asked if the resident was a new admission, she identified that Resident #7 had been at the facility for a long time. The staff member stated she had ordered the medication (Amlodipine and Potassium) and would pass it on in report that the medication would need to be looked for. When asked why the medication was not available, she stated she did not want to point fingers, but some agency staff did a good job, but some came just for the paycheck. A review of the Medication Administration Record (MAR) for Resident #7 revealed the above medications were scheduled to be administered at 9:00 a.m. in addition to the above medications: - Amlodipine 5 milligram (mg) tablet orally daily; - Breo Ellipta (fluticasone furoate-vilanterol) blister with device 100-25 mcg/dose; 1 puff inhalation once a morning; - Potassium chloride extended release 20 milliequivalent (mEq) orally twice a day. Staff B documented on the MAR regarding the non-administration of Amlodipine and Potassium that each of the medication was pending pharm delivery and she documented that Breo-Ellipta had been administered. 105292 Page 17 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The policy titled Administering Medications indicated that Medications shall be administered in a safe and timely manner, and as prescribed. The Interpretation and Implementation of the policy identified that medications must be administered in accordance with the orders, including any required time frame. A review of Resident #7's progress notes, on 3/16/21 at 5:54 p.m., did not include documentation that the physician was notified that Amlodipine, Potassium, and Breo Ellipta was not administered as ordered. 3. On 3/17/21 at 10:54 a.m., an observation of medication administration with Staff Member B, Registered Nurse (RN), was conducted with Resident #19. Staff B was observed administering the following medications: - Aspirin 81 mg chewable orally (once a morning) - Lactulose solution 10 gram(g)/15 milliliter (mL) liquid - 45 mL orally (twice a day) - 4 capsules of Divaloproex 125 mg sprinkles (twice a day) - Benztropine 0.5 mg tablet (twice a day) - Ziprasidone 40 mg capsule (once a day) (Resident scheduled to be administered 80 mg at bedtime) - Levetiracetam 1000 mg tablet (twice a day) - Metformin 500 mg tablet (twice a day) A review of the Medication Administration Record (MAR) for Resident #76 revealed the above medications were scheduled to be administered at 9:00 a.m. The MAR for Resident #19 revealed the following unobserved medication was scheduled at 9:00 a.m. in addition to the above observed medications: - Namenda 10 mg tablet - twice a day. At 10:54 a.m., Staff B identified the reason Resident #19's and other resident's medications were late was that she had to call pharmacy and the physician. After the medication administration the staff member documented on 3/17/21 at 10:59 a.m. that the observed and unobserved medication was Late Administration: Charted Late, Comment: Charted Late. 4. On 3/17/21 at 11:25 a.m., an observation of medication administration with Staff Member B, Registered Nurse (RN), was conducted with Resident #13. Staff B was observed dispensing the following medications: - Docusate Sodium 100 mg capsule orally - Miralax 17g orally - MultiVitamin tablet orally 105292 Page 18 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0759 - 2 Senna-Plus 50-8.6 mg tablets orally Level of Harm - Minimal harm or potential for actual harm - Eliquis 2.5 mg orally - 2 Potassium 20 mEq caplets orally Residents Affected - Some - 2 Depakote capsules 125 mg orally - Amlodipine 5 mg tablet orally - Hydralazine 10 mg tablet orally - Lisinopril 20 mg orally - Pantoprazole 40 mg orally - Carbamazepine tablet 200 mg orally At 11:29 a.m., when Staff B was paged overhead to pick up a physician telephone call, she placed the medication cup into the top drawer, then the Director of Nursing stated from other end of hallway that she would take the call. Staff B passed this writer another blister packed card containing of Lisinopril 20 mg tablets, when asked if resident was receiving 2 Lisinopril tablets, she took the medication cup holding the oral medications and dumped them onto a plastic clipboard that she had been using to document resident notes, without a barrier, and reviewed the tablets to confirm that she had already dispensed the dosage of Lisinopril. Since the oral tablets/capsules were contaminated Staff B begun redispensing the medications, at which time the staff member changed the Docusate Sodium capsule for a tablet that was crushable. The review of the Medication Administration Record (MAR) indicated the above medications were scheduled to be administered at 9:00 a.m. The review of Resident #13's physician orders included the following medication orders: - Colace (docusate sodium) 100 mg capsule orally twice a day - Miralax 17 grams orally, dilute in 4-6 ounces in water - MultiVitamin with minerals tablet orally once day - 2 Senokot-S 8.6-50 mg orally twice a day - Eliquis 2.5 mg orally twice a day - 2 Potassium chloride 20 mEq extended release tablets orally once a day - 2 Divalproex (Depakote) 125 mg delayed release sprinkle capsule orally twice a day - Amlodipine 5 mg tablet once a day - Hydralazine 10 mg tablet orally three times a day 105292 Page 19 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0759 - Lisinopril 20 mg tablet orally once a day Level of Harm - Minimal harm or potential for actual harm - Pantoprazole delayed release 40 mg orally once a day - Tegretol (Carbamazepine) 200 mg tablet orally twice a day Residents Affected - Some The review revealed that in addition to Resident #13's 9:00 a.m. medications being administered at 12:22 p.m., Staff B administered a tablet of Colace instead of the ordered capsule and that the multivitamin did not contain minerals as ordered. The policy titled, Administering Medications, undated, identified that Medications shall be administered in a safe and timely manner, and as prescribed. The interpretation and implementation of the policy indicated Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During an interview with the Consultant Pharmacist on 3/18/21 at 1:11 p.m. he stated it is standard procedure to contact the Physician when medications are administered late. He further said, 'its OK to go past a little.' 105292 Page 20 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and record review, the facility failed to maintain the reach in freezer at appropriate temperatures and ensure staff kept personal items separate from food storage on 2 of 2 days observed (3/15 and 3/17/21). Findings included: On 03/15/2021 at 9:39 AM, an initial kitchen tour was conducted with Staff P, Cook. The reach-in freezer at this time was found to be 2 degrees Fahrenheit. A review of the freezer's temperature log for the month of March revealed that the freezer was consistently above the 0 degree Fahrenheit threshold. Staff P was unaware of the freezers temperature. A review of the facility's temperature log revealed the logged temperature on the morning of 3/15/2021 was 4 degrees. On 03/17/2021 at 11:37 AM, during a tour with the Certified Dietary Manager (CDM), a staff member's personal jacket was found on a dry food storage shelf along with a staff member's N95 mask sealed in a plastic bag. The CDM stated that neither of those items were supposed to be there and that this was something that he had not seen before. In addition, a second observation of the reach-in freezer revealed the temperature gauge to be at 10 degrees Fahrenheit. The CDM stated that it was being open and closed a lot while preparing for lunch. On 03/18/2021 at 10:31 AM, the kitchen's policy for maintenance and personal property was requested from the CDM. The CDM stated that they do not have a written policy for either because these are covered in orientation. A written statement was provided and signed by the CDM regarding personal property, dated 3/18/2021. The statement read: It is the practice of [Facility Name] Dietary not to have personal items kept in the food production areas of the kitchen. Furthermore, a written statement was provided by the facility's Administrator regarding the facility's maintenance policy. The statement read: The practice of the building is that maintenance work orders be entered into the [Computerized] system. Photographic evidence was obtained. 105292 Page 21 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure one (#18) of 21 sampled residents had an accurately documented code status in the medical record. Findings included: On [DATE] at 11:16 AM, a review of Resident #18's Electronic Medical Record (EMR) revealed the resident was identified as a full code. Further review revealed the resident had a signed Do Not Resuscitate (DNR) Order. A review of the facility's nurses' stations Full Code and DNR books revealed Resident #18 was identified by the facility as both a full code and Do Not Resuscitate (DNR), despite the documentation of the DNR order. An interview on [DATE] at 11:25 AM with Staff B, Registered Nurse (RN), revealed that to check a resident's code status she would look at the resident's EMR or the Full Code/DNR books. When asked to look for Resident #18's Advance Directive, Staff B referenced the resident's face sheet on the EMR and stated that she would perform CPR. On [DATE] at approximately 11:30 AM the Director of Nursing (DON) was informed of the conflicting information. The DON confirmed that Resident #18 should be a DNR and that they would perform a sweep on the entire facility's population for proper documentation of code status. A review of the quarterly ([DATE]) Minimal Data Set (MDS) revealed that the resident was unable to be evaluated for by a Brief Interview for Mental Stats (BIMS) indicating cognitive decline. A review of Resident #18's care plan dated [DATE] revealed the resident had the DNR status included in the care plan as the chosen advanced directive. A review of the facility's Do Not Resuscitate Order policy revealed, A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State Law) and placed in the front of the resident's medical record. Resident #18 had a DNR form signed by the healthcare representative and physician. 105292 Page 22 of 23 105292 03/18/2021 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on record review and interview the facility failed to designate a healthcare professional with specialized training as the Infection Control Preventionist (ICP) for the facility. Residents Affected - Some Findings included: During an interview with the Director of Nursing (DON), on 3/18/21 at 2:11 p.m., she stated she does not have Infection Control Preventionist credentials. The DON further stated one of the nurses, Staff Member Q, Registered Nurse (RN) had a certificate, but 'was not technically the ICP.' The DON offered to obtain a copy of the certificate but was unable to provide it. When asked who did staff education related to infection control, she stated that the previous Assistant Director of Nursing (ADON) did but she left in December 2020 and the new ADON started at the facility one week ago. The DON stated she did spot-on education if she observed an issue. She further stated that the Nursing Home Administrator (NHA) was the Department of Health contact. During an interview, on 3/18/21 at 3:00 p.m., the NHA identified the facility's Infection Control Preventionist as the DON, stating I believe. The NHA also indicated that the COVID-19 line listings were completed by the Human Resources Director (HRD). At 3/18/21 at 1:49 p.m., during an interview with the HRD, she said she did the COVID-19 line listing for staff and the resident line listings were completed by the NHA. She stated she added positive staff to the line listing after the facility's morning meeting. During an interview on 3/18/21 at 3:56 p.m., with the facility Medical Director, he said he recognized the ADON as the facility's ICP. A review of a facility-provided job description titled 'Infection Preventionist' and undated revealed the IP was responsible for the facility's activities aimed at preventing healthcare-associated infections (HAIs) by ensuring that sources of infections are isolated to limit the spread of infectious organisms. The IP systematically collects, analyzes, and interprets health data in order to plan, implement, evaluate, and disseminate appropriate public health practices. The IP conducts educational and training activities for healthcare workers through instruction and dissemination of information on healthcare practices. The IP conducts rounds, discusses, and monitors infection prevention practices with staff members, collects infection data from departments, maintains records for each care of healthcare-associated infection, conducts outbreak investigation, trains staff members on implementation of infection prevention practices, investigates incidents of infections and reports such incidents to the appropriate person/department, and ensures availability of supplies required for infection prevention activities. 105292 Page 23 of 23