Health inspection·October 13, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and an interview with the Business Office Manager, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for two (Resident #42 and Resident #22) of three residents sampled for review of Beneficiary Protection Notifications, from a total sample of 40 residents. Residents Affected - Few The findings include: A review of Resident #42's medical record revealed an admission date of 5/26/2022. His last covered day for Medicare Part A services was 7/19/2022. The resident was discharged from Medicare A and remained in the facility. A review of Resident #22's medical record revealed an admission dated of 7/25/2022. Her last covered day of Medicare Part A services was 8/17/2022. The resident was discharged from Medicare A and remained in the facility. A record review of Beneficiary Protection Notifications for three randomly selected residents, including Residents #42 and #22, who were discharged from a Medicare A covered stay with benefit days remaining in the past 6 months revealed the facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices of Noncoverage (SNF ABN) when required. During an interview with the Business Office Manager (BOM) on 10/13/2022 at 11:37 a.m., she acknowledged that the notifications were not given to Residents #42 or #22. She stated she was new and was told not to give the SNF ABN forms to residents who were flipping to Medicaid. When asked who told her that, she stated she generally spoke with Social Services staff or the Minimum Data Set (MDS) nurse about these things. She further stated there was no documentation about when they spoke with the residents regarding possible liability, and she again stated the facility didn't use the SNF ABN forms. When asked about the break in coverage between Medicare A ending and Medicaid beginning, she stated residents could be liable for that charge. When asked how they would have been informed of that, she stated again that she was told not to use the SNF ABN and that there was no additional documentation. She stated the facility pre-screened residents and pretty much knew which residents would be eligible for Medicaid, but again there was no documentation or communication about possible charges due to a coverage lapse. . Page 1 of 7 105315 105315 10/13/2022 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure assessments accurately reflected residents' status for two (Resident #82 and Resident #93) of 40 residents sampled. Failure to accurately assess residents' care needs and medical status could result in a failure to provide needed care and services, resulting in complications and/or functional decline. Residents Affected - Few The findings include: On 10/10/2022 at 2:45 p.m., Resident #82 was observed in his room lying in bed under the covers. He was greeted and he responded with garbled speech. At this time it was determined that the resident was not interviewable. Upon leaving Resident #82's room, Resident #93 was observed being escorted back to her room on a shower bed by two staff members. She was greeted and asked if she would agree to an interview once she returned to her room and got settled. She responded with grunts and giggles, reaching her hand out to make contact, and continuing to grunt, giggle, and motion for the surveyor's hand. At this time it was determined that the resident was not interviewable. During an interview with the Social Services Director (SSD) on 10/13/2022 at 11:38 a.m, she stated she had been employed with the facility since 3/7/2022. She added that she was responsible for completing section C of the Minimum Data Set (MDS) assessment. She stated she conducted the Brief Interview for Mental Status (BIMS) assessment for residents. She explained the process of how she completed the assessment, and stated she went in to see the resident and made an introduction. She asked the resident if they could hear/see her and if she could speak with them. She then asked the resident to repeat the three words and told them to remember the words. She asked the resident to repeat the three words. She stated at times she would give them cues to help them remember the words. She stated she then documented how many words they repeated on the first attempt, then she moved on to the day, year, month, week, then went back to the three words they were previously asked to repeat. She stated the cues were given if the resident couldn't repeat the three words. She was asked how the BIMS score was assessed for nonverbal residents. She stated staff who had worked with and/or were familiar with the resident did the assessment. She stated some of the nonverbal residents could nod, point or make a noise/sound in order to answer assessment questions. She stated the assessment was performed the same way for residents who were cognitively impaired, adding that what they could answer was used to determine their BIMS score. She stated there were times in an assessment that a dash (-) was documented in the answer section, indicating the resident's response was nonsensical or the resident failed to give an answer/response. She stated at times she referred to the MDS staff if she was unsure about an assessment, and there were times when multiple staff members would complete an assessment. When asked how Resident #82 was assessed, she stated he spoke very softly, very minimally, and does more pointing than verbal communication. He has a hard time talking, so I write the 12 months out and he points to the right month; I write the years out and he points to the correct year. She was asked if she could demonstrate this and she agreed. At 12:08 p.m., she went to the resident's room. She re-introduced herself, asked the resident if she could ask him a few questions, and then began the BIMS assessment. The resident responded to all questions asked with moaning and grunting. There were no intelligible words spoken, the resident did not make a pointing motion to communicate, nor did he nod or shake his head in response. The SSD stated she understood the resident's responses. The surveyor advised the SSD that she could not determine what the resident was saying. The SSD continued the assessment. When asked the current month, the resident grunted. The noise he made sounded nothing like a word. The surveyor observed that after each answer the SSD would reply yes, then say the correct answer indicating that the resident got it right. When asked to repeat bed, the resident did not answer. The SSD said to him, It's a piece of furniture. Then the resident pointed to the 105315 Page 2 of 7 105315 10/13/2022 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dresser. The SSD replied, Dresser? No, that's not correct. It was bed. You got that one wrong. The SSD thanked the resident for his time and exited the resident's room. The interview with the SSD continued upon leaving the resident's room. She was shown the previous MDS assessment where the resident was assessed with a BIMS score of 99 (Four or more items were coded 0 because the individual chose not to answer or gave a nonsensical response.) She stated she understood the resident and maybe the previous SSDs could not. She stated the resident would grunt out words or whisper them softly, but she was able to understand him. During an interview with MDS Coordinator C on 10/3/2022 at 2:03 p.m., he was asked if there was a review for accuracy of the MDS assessments. He stated no. He further stated the MDS Coordinators reviewed each section of the assessment to ensure each section was complete however, they did not go back to determine whether the assessments were accurate. During an interview with MDS Coordinator D on 10/13/2022 at 2:31 p.m., she was asked if the MDS assessments were reviewed for accuracy. She stated she reviewed the assessments, but didn't question anything and assumed the MDS was correct unless there is something major. She stated she knew the residents and could usually determine if something was accurate. She confirmed that she knew Residents #82 and #93. She stated both of the residents were rarely understood and added that she could not determine whether the employee conducting the assessment documented accurately, as she was not in the room when the assessment was done. She was shown and asked about the variance in the BIMS score for both Residents #82 and #93. She stated she could not determine whether the assessment was accurate. She stated she didn't recall having any questions about the assessments, adding that ultimately the MDS Coordinators reviewed the assessments to ensure that they were complete but not necessarily accurate. She stated the MDS Coordinators just have to trust that each section was being completed correctly. During an interview with Licensed Practical Nurse (LPN) E on 10/13/2022 at 3:07 p.m., she stated she had been employed by the facility for seven years, six of which she worked as a Certified Nursing Assistant (CNA). She further stated she was familiar with Residents #82 and #93, and had worked with them extensively as a CNA. She stated neither resident could communicate verbally. She stated both residents were limited to yes or no answers, adding that both residents could also nod or shake their heads when asked yes or no questions. During an interview with CNA F on 10/13/2022 at 3:24 p.m., she stated she had been employed by the facility for approximately six months. She further stated she was familiar with and had worked with both Resident #82 and #93. Both residents required total assistance with their Activities of Daily Living (ADL's), and both residents could say some words, but were rarely understood. She stated the words are grumbled and that she called the nurse when she didn't understand. A review of the 1/26/2022 annual MDS assessment for Resident #82 revealed the resident rarely/never understood, and the BIMS score was not assessed due to the resident being rarely/never understood. A review of the 6/29/2022 quarterly MDS assessment for Resident #82 revealed unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation and scored a 13/15 on the BIMS assessment, indicating intact cognition. A review of the 9/14/2022 quarterly MDS assessment for Resident #82 revealed adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct 105315 Page 3 of 7 105315 10/13/2022 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 12/15 on the BIMS assessment, indicating minimally impaired to intact cognition. A review of the most recent Care Plan for Resident #82 included a Focus on: Impaired communication related to aphasia with a Goal to continue to make needs known and Interventions including: Ask simple yes/no questions and give resident time to answer/respond and ask family for alternate means of communication A review of the 4/20/2022 quarterly MDS assessment revealed that Resident #93 had adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 3/15 on the BIMS assessment, indicating severe cognitive impairment. A review of the 7/6/2022 quarterly MDS assessment revealed Resident #93 had adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 3/15 on the BIMS assessment, indicating severed cognitive impairment. A review of the 9/21/2022 quarterly MDS assessment revealed Resident #93 had adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 10/15 on the BIMS assessment, indicating moderately impaired cognition. A review of the most recent Care Plan for Resident #93 included a Focus on: Impaired communication related to aphasia secondary to cerebrovascular accident (CVA) and Traumatic Brain Injury (TBI), uses non-verbal cues with a Goal to continue to make needs known and Interventions including: Ask simple yes/no questions and give resident time to answer or respond, ask family about alternative communication methods, use short simple sentences repeat, rephrase and adjust tones as needed. . 105315 Page 4 of 7 105315 10/13/2022 St Augustine Health and Rehabilitation Center 51 Sunrise Blvd Saint Augustine, FL 32084

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission, and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting appropriate to their needs for one (Resident #67) of 40 sampled residents. Residents Affected - Few The findings include: A review of Resident #67's medical record on 10/10/22 at 2:36 p.m. and on 10/11/22 at 2:00 p.m. revealed no Pre-admission Screening and Resident Review Process (PASARR) present. On 10/11/22 at 2:50 p.m., the Director of Nursing (DON) stated, I could not find the PASARR. We are going to do a new one now. A record review was conducted for Resident #67 noting an admission date of 8/18/22. His diagnoses included pathological fracture, humerus, subs for fixture for routine heal; malignant neoplasm of unspecific part of unspecific bronchus or lung; type II diabetes mellitus, heart disease, bipolar disorder, major depressive disorder, and anxiety disorder. Resident #67 had physician's orders that included Xanax for anxiety every 8 hours, started on 9/29/22; Hydroxyzine HCL (hydrochloride) 25 mg (milligrams) every 8 hours as needed for 14 days, starting on 10/7/22; Trazodone, once daily for depression, started on 9/2/22, and Duloxetine HCL two times a day for diabetic peripheral neuropathy. A review of the Minimum Data Set (MDS) assessment, dated 8/24/22, revealed that the resident entered from hospice and had a Brief Interview for Mental status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. He was expected to remain in the facility. An interview was conducted with the Admissions Coordinator at 11:25 a.m. on 10/13/22. She reported that part of the admission process was to acquire the 3008 transfer form, the PASARR, a face sheet, and the History and Physical upon admission. She reiterated that the PASARR should be received on the day the resident was admitted . She was asked whether a resident could be admitted without a PASARR, and she replied, I don't know. I would say no. An interview was conducted with Social Services Director (SSD) on 10/13/22 at 12:00 p.m. She stated her job was to make sure the PASARRs were in the residents' records. She stated the Director of Nursing (DON) would do the PASARR if facility did not get it on admission. She further stated she thought the PASARR was to be received on the day of admission. A review of the facility's policy titled Pre-admission Screening for Mental Retardation and Mental Illness (Effective July 15, 2009), revealed under Process Level I Determinations must be signed and dated by a Registered Nurse (RN) at the admitting nursing facility on or before the date of admission. The nursing facility is responsible for ensuring that a Level I screening is completed, submitted and has a Level I Determination and/or a Level II if indicated, on or before nursing home admission and regardless of payment source. The original documents for the Level I and/or Level II determinations will be retained in the medical chart behind the Social Services tab. . 105315 Page 5 of 7 105315 10/13/2022 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, and facility record review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for food storage and proper sanitation practices in the kitchen. Specific instruction on food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted with Dietary Manager (DM) G on 10/10/2022 at 10:25 a.m. During the tour, the bread cart in the dry storage pantry had three open bundles of bread that were not dated/labeled. The fryer was covered with grease buildup and food debris. The floor underneath the fryer had soiled grease and a buildup of food debris covering the drainage area. During an interview at the time of the observations, DM G stated, The cook or person working in the area is responsible for cleaning the fryer. A weekly cleaning schedule dated 10/8/2022 thru 10/9/2022 was obtained on 10/10/22, indicating the fryer and floor had been cleaned. The same observations previously mentioned were made again on 10/12/2022 at 11:10 a.m. and on 10/13/2022 at 3:30 p.m. (Photographic evidence obtained) Interviews were conducted with [NAME] I on 10/13/22 at 3:40 p.m. [NAME] I stated the policy for food storage, including leftovers was to wrap and date food items. She stated each staff member was designated to complete a cleaning task. Dietary Aides 1 and 2 were responsible for cleaning the floor. When asked who monitored the cleaning schedule for the kitchen and food service equipment, [NAME] I stated, the Dietary Manager. The Dietary Manager (DM), who was also present, stated the policy for food storage, including leftovers was to date the food item and discard it after three days. She stated, The weekly cleaning schedule is posted every Friday, and each position is assigned a cleaning task. The evening aides clean the floor daily and the DM walks through and checks the kitchen daily to ensure tasks are complete. A second copy of the weekly cleaning schedule, with a date that appeared to be marked through to read 10/8/2022 thru 10/14/2022 was obtained on 10/13/22 at 4:00 p.m. A review of the facility's policy and procedure entitled Sanitation Principles (dated 2/1/2022), revealed: Food service areas should be maintained in a clean and sanitary manner. The current USDA Food Code should be utilized as guidelines for the Department. a. Kitchens and dining areas should be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. (Copy obtained) A review of the facility's policy and procedure entitled Safety Principles (dated 8/15/2009) revealed: To prevent injury to food service employees through exposure to heat, cold, chemicals and other workplace hazards. 10. Be sure ovens and stoves are free from grease at all times. Grease is a fire hazard. According to the United States Food and Drug Administration Food Code 2017. 3. Public Health and Consumer Expectations. Clean environment. Page 10. https://www.fda.gov (Accessed 0n 10/18/2022): It is a shared responsibility of the food industry and the government to ensure that food provided to the consumer is safe and does not become a vehicle in a disease outbreak or in the transmission of 105315 Page 6 of 7 105315 10/13/2022 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 - Few communicable disease. This shared responsibility extends to ensuring that consumer expectations are met, and that food is unadulterated, prepared in a clean environment, and honestly presented. According to the United States Food and Drug Administration Food Code 2017. 4.602.12. Cooking and Baking Equipment. Page 568. https://www.fda.gov (Accessed 0n 10/18/2022): Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. Because of the nature of the equipment, it may not be necessary to clean cooking equipment as frequently as the equipment specified in § 4-602.11. . 105315 Page 7 of 7