Health inspection·March 11, 2021

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide residents with private space to participate in resident groups and to ensure that staff, visitors or other guests attended resident group or family group meetings only with the respective group's invitation. This involved 10 residents participating in Resident Council on 3/10/2021 (Residents #78, #105, #66, #89, #359, #81, #12, #69, #18 and #59) out of 110 residents residing in the facility at the time of the investigation. Residents Affected - Some The findings include: On 3/9/2021, the Activities Director and Resident Council President scheduled a resident council meeting. The meeting was held on 3/10/2021 at 10:30 a.m. in the facility's dining room. The Activities Director advised all facility staff present in the area where the meeting was to be held to leave, as this was to be a resident-only meeting. The Activities Director provided a copy of the Resident Council Meeting minutes for December 2020, January 2021 and February 2021. The Activities Director placed a sign on the outside of the door which read: Ssshhh RESIDENT COUNCIL MEETING IN SESSION Please do not disturb! There were 10 residents in attendance, including the President and [NAME] President of the Resident Council. When asked, the residents present in the meeting stated they normally met in the facility's dining room. During the meeting multiple staff were observed entering and exiting the area of the meeting causing the meeting to be paused. The residents in attendance stated that they preferred to meet without staff present, however, staff still came in and out of their meetings without regard to the sign placed on the door. The residents stated that this was a violation of their privacy, and they had made reports to facility staff. The residents voiced concerns with staff obtaining information discussed during their meetings and reporting it to other facility staff possibly resulting in retaliation. A review of the meeting minutes provided by the Activities Director revealed no concerns from the Resident Council during the meetings. When asked about this, the Resident Council President stated that the minutes were not accurate and these were not the minutes that she had taken during the meetings provided. During an interview on 3/10/2021 at 12:14 p.m. with the Administrator and Activities Director, they were advised of the concerns raised during the Resident Council meeting held on 3/10/2021 at 10:30 a.m., and of the concern with the inaccuracy of the meeting minutes provided. They could not explain Page 1 of 6 105315 105315 03/11/2021 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some why staff would continuously come in and out of the meeting, but agreed that this should not have been happening. They acknowledged previous concerns from the council regarding fear of reprisal. The Activities Director stated that the minutes she provided were not taken by the Resident Council President. She provided the survey team with the actual minutes taken by the Resident Council President. A record review revealed inconsistencies between the meeting minutes taken by the Resident Council President and the minutes provided by the Activities Director for meetings held in January 2021 and February 2021. During the meeting held on January 27, 2021, the council documented concerns with being treated with respect and dignity from the staff. This information was not included in the meeting minutes for the same date provided by the Activities Director. During an interview on 3/10/2021 at 1:26 p.m. with the Administrator, she was provided the documentation revealing the discrepancies in the Resident Council Meeting minutes. She stated she was not aware of the concerns raised. When asked how the residents' concerns were reported to her, she stated the Activities Director would obtain the minutes and communicate them to her. During an interview on 3/10/2021 at 2:29 p.m. with the Activities Director in the presence of the Administrator, she was asked why there were separate copies of the meeting minutes and to explain the inconsistencies between the two. She stated she re-wrote the minutes sometimes when the president's writing was not legible. She did not address the inconsistencies of the information, and neither did the Administrator. The Administrator stated again that she was not aware of this issue. . 105315 Page 2 of 6 105315 03/11/2021 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

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, interviews and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for two resident (Residents #22 and #1) of three residents sampled for review of Activities of Daily Living (ADL) from a total of 38 residents in the sample. Residents Affected - Few The findings include: 1. During a tour of the facility on 3/8/21 at 2:17 p.m., Resident #22 was observed lying in bed with dried saliva observed between her lips as she tried to speak. Her hair was unkempt with dandruff visible over her loosely plaited cornrows. Attempts were made to interview the resident on 3/8/21 at 2:25 p.m. The resident only nodded yes or shook her head no to simple questions. When asked whether the staff were cleaning her, she shook her head no. In a phone interview on 3/9/21 at 2:41 p.m., the resident's mother stated she had concerns about her daughter's care. She stated when she visited her daughter about two weeks ago, her hair and teeth were not clean. She added that the facility was supposed withdraw money from her daughter's personal funds account for hair care and other ADLs as needed, but her monthly statement revealed that no funds had been removed. The resident's mother also stated she had raised these concerns during a care plan meeting. She said before the COVID-19 pandemic, she would visit her daughter and help her with mouth care and she would provide drinks, but she was not sure now whether staff were paying attention to her daughter. She couldn;t verify whether they were, because she was unable to visit frequently. A review of the clinical record indicated that Resident #22 was admitted to the facility on [DATE]. Her diagnoses included intracranial injury, encounter with gastrostomy, moderated protein calorie malnutrition, vitamin deficiency, major depressive disorder, transient paralysis, chronic pain due to trauma, dry mouth and generalized anxiety. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 1/13/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 points, indicating severe cognitive impairment. Resident #22 was also assessed to be totally dependent on staff for bed mobility, transfers, toileting and eating. Her current ADL care plan revealed the following interventions: Resident is unable to make choices at this time related to severe cognitive impairment, observe for inability to perform care, make bathing process pleasant by ensuring non-hurried atmosphere, give assistance as needed, assist with hair, assist with brushing teeth/oral care, bath per schedule. A review of the shower schedule revealed that the resident's shower days were Tuesdays, Thursdays and Saturdays. On 3/10/21 at 1:50 p.m., Employee A, Certified Nursing Assistant (CNA), stated residents were provided with showers/bed baths per the schedule and as needed (PRN). She further stated showers were documented in the electronic medical record software whe showers were provided or refused. If showers were refused, the nurses were notified. 105315 Page 3 of 6 105315 03/11/2021 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the CNA task documentation revealed that Resident #22 had not received a shower or bed bath from 2/11/21 through 3/10/21. During an interview with Employee I, Registered Nurse (RN)/Unit Manager, on 3/11/21 at 10:30 a.m., she stated residents should receive showers/bed baths on their scheduled days and PRN. When asked whether she had conducted audits of the showers provided, she replied no. In an interview on 3/11/21 at 4:15 p.m. with the Director of nursing (DON), she was asked about the facility's provision of salon services. She stated during the pandemic salon services were not offered. Residents were receiving in-room services. She also stated residents were to receive hair care during their scheduled shower days. When asked if Resident #22 received hair care services, she confirmed that there was no documentation available to verify that she had. A review of the policy and procedure titled, Maintaining ADL skills NM.I.30, effective November 10, 2014, revealed: Purpose The facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with the comprehensive assessment and plan of care. 2. An observation of Resident #1, conducted on 3/8/21 at 11:12 a.m., found his fingernails on both hands unfiled and with jagged edges. Several nails were long, especially on the left hand, which was observed to be contracted (permanently shortened muscles or joints). The pointer finger on his right hand had a build-up of an unidentified dark substance under the nail. When asked if staff assisted him with nail care to his satisfaction, he looked at his nails but did not answer. In an interview with Employee E, Certified Nursing Assistant (CNA), on 3/10/21 at 9:34 a.m., she stated Resident #1 was alert and orientated and able to communicate using a communication board and finger spelling. He could assist with some activities of daily living (ADLs) using his good hand, the right. He needed assistance with handwashing. CNAs completed his nail care, and this was usually performed as needed and at shower time. An interview was conducted with Employee F, Registered Nurse (RN), on 3/10/21 at 9:59 a.m. She stated Resident #1 partially assisted with ADLs, depending on what you did with him. He had use of his right hand and could assist with handwashing. He didn't really let staff do his nails and he was care planned for that. He might allow it on a good day. Resident #1 was interviewed on 3/11/21 at 11:36 a.m. His fingernails were observed in the same condition during th einterview as they were during the 3/8/21 observation at 11:12 a.m. When asked if he was provided nail care by the aides, he did not respond. When asked if he had refused nail care, he shook his head no. When asked if he wanted his nails cleaned and trimmed, he nodded yes. Employee G, CNA, was interviewed on 3/11/21 at 11:38 a.m. He stated only nurses and someone from the outside did resident nail care. He said Resident #1 did not refuse care. In a second interview on 3/11/21 at 4:32 p.m., Employee G was asked to observe Resident #1's nails. He looked at the resident's nails, which remained in the originally observed state, and only said someone from the outside was supposed to do the residents' nails. 105315 Page 4 of 6 105315 03/11/2021 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the Wound Care Nurse on 3/11/21 at 5:55 p.m., she stated CNAs could trim resident's fingernails, but only if the residents were not diabetic. A record review for Resident #1 found a Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 3/3/21. On this assessment, the resident was assessed with no speech and the ability to sometimes make himself understood. He usually understood others. Resident #1 was assessed with long- and short-term memory problems and moderately impaired cognitive skills for daily decision making. He was dependent on staff for personal hygiene and bathing. Active diagnoses included cerebrovascular attack (CVA, or stroke), hemiplegia or hemiparesis (paralysis or muscle loss and weakness on one side of the body), seizure disorder, anxiety, psychotic disorder and schizophrenia. Resident #1 was care planned for behaviors including refusal of oral care. The care plan did not address any refusal of nail care. He was also care planned for total care with ADLs, however, interventions did not address nail care or when it should be performed. A review of nursing progress notes found nothing reflected about the provision or refusal of nail care. . 105315 Page 5 of 6 105315 03/11/2021 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews, the facility failed to store dishware, covered or inverted, in a location where it was not exposed to splash, dust and other contamination. The facility failed to maintain two of the three microwaves used for residents, in a safe and sanitary manner. This deficient practice potentially affected all residents in the facility who took their meals from the facility's kitchen and/or obtained any food/beverage items from the North or South Unit nourishment rooms. The findings include: An initial tour of the kitchen was conducted on 3/8/2021 at 9:55 a.m. with the Dietary Manager (DM). During the tour, a plate dispenser was observed with no cover and plates were stored face-up. A second tour of the kitchen and interview with the DM was conducted on 3/11/2021 at 3:40 p.m. The plate dispenser was full of plates and they were not inverted or covered. Food splatter was observed on the rim of the plate dispenser next to the plates. (Photographic evidence obtained) The Dietary Manager acknowledged the potential for splatters and contamination of the eating surface of the plates at the time of the observation. An initial tour of the North Unit Nourishment Room was conducted on 3/10/2021 at 9:44 a.m. with a second visit on 3/11/2021 at 11:20 a.m. The microwave was observed heavily soiled with dark food splatter on the top inside surface, sides and corners during both visits. A tour of the South Unit Nourishment Room was conducted on 3/11/2021 at 12:25 p.m. The microwave was observed with a brown substance resembling coffee splatter on the top inside surface and sides. The counter appeared to have water damage and dark areas behind the sink and along the backsplash that resembled biological growth. (Photographic evidence obtained) An interview was conducted with the Dietary Manager on 3/11/2021 at 3:40 p.m. During the interview, she stated the equipment in the nourishment rooms was to be cleaned daily. A follow-up tour of the North and South Unit nourishment rooms was conducted with the Dietary Manager at the time of this interview. She observed both nourishment rooms and stated she would have them cleaned right away. . 105315 Page 6 of 6