Health inspection·November 19, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure resident rights were maintained related to not providing transportation to an outside appointment for one resident (Resident #50) out of the sampled forty residents. Findings included: A review of the admission Record for Resident #50 revealed that the resident was initially admitted into the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease (COPD). A review of the quarterly Minimum Data Set (MDS) dated [DATE] found that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. A review of the Order Recap Report with a date of 11/01/20 to 11/30/20 found that the resident had an order for a stress test on 11/11/20 at 7:40 a.m. with pick up at 7:15 a.m. one time a day for cardiac clearance. A review of the calendar provided by the facility, however, revealed that Resident #50 had an appointment scheduled for November 16. During an interview on 11/18/20 at 10:59 a.m., Resident #50 reported that she missed a scheduled appointment to see her cardiologist. She reported that the purpose of the visit was for a follow up on test results from a chemical stress test. The results of the test would indicate if she could have surgery on her leg. She had fallen and needed surgery on her hip, but the cardiologists would not approve. The test that was done would indicate if she could have the surgery or not. Resident #50 stated that she could not get to the appointment because the staff member that drives the van for appointments was out sick. She reported that he was out sick two days prior to her appointment, and no one told her that he was out and that she needed to reschedule her appointment. Resident #50 reported that she found out she couldn't go to the appointment on the day of the appointment. She stated that they have a backup driver, but he is a Certified Nursing Assistant (CNA). Resident #50 reported that she rescheduled the appointment for 11/30 and she hopes that she can go. She reported that if the staff had told her in time that the driver was out sick, she had a friend that could have taken her to the appointment. Resident #50 stated, Here, you have to schedule your own appointments. On 11/18/20 at 4:10 p.m., the DON reported that they did not have a policy for scheduling appointments and no policy on transportation to and from appointments. They have a scheduler that takes Page 1 of 27 105320 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents to appointments and schedules the appointment, but he was out sick. They have a backup who was a CNA that was available to take residents to appointments. Some appointments had to be rescheduled because the driver was out sick. On 11/19/20 at 10:35 a.m., the Director of Nursing (DON) reported that the appointment was not in the scheduling book, but it was on the calendar that's probably how it got missed. The DON stated that this was concerning. On 11/19/20 at 11:06 a.m., the Social Services Director (SSD) reported that her driver was responsible for scheduling appointments. She stated that she spent time on the phone getting appointments rescheduled on yesterday. The SSD reported that Resident #50 missed an appointment on Monday because she came to her after the fact. Nursing told her what appointments were missed and brought down documents yesterday to get appointments rescheduled. Admissions also assisted with getting appointments scheduled. On 11/19/20 at 10:56 a.m., Staff Q, Licensed Practical Nurse (LPN), reported that Resident #50 had an appointment on Monday. The van driver called in sick. Resident #50 rescheduled the appointment. Staff Q reported that once in a while, they would use an outside transportation service, but sometimes they can't come last minute. Found out too late that the van driver called in. On 11/19/20 at 2:31 p.m., the Administrator reported that they had a van driver who schedules and takes residents to their appointments. They have another van driver available, but he came in later that day. They sometimes used two outside transportation services as a contract service to take residents to their appointments. The van driver schedules the appointment and logs it into PCC (Point Click Care) so that the nurses can see the appointment. The Administrator stated that he assumed because it was short notice, Resident #50 did not get to her appointment. 105320 Page 2 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review, and interviews the facility failed to ensure one (#92) of two residents reviewed was able to visit with a family member(s) in privacy and without a staff presence during the visit. Residents Affected - Few Findings included: On the afternoon of 11/17/20 an outdoor visitation, which included three (3) persons, was observed ongoing on the front porch. The persons were assembled in a social distancing fashion, with the participants six (6) feet from each other. On 11/18/20 at approximately 11:00 a.m., another observation indicated one of the participants from 11/17/20 sitting on the front porch during an ongoing family/resident visitation. The participants were socially distanced in a triangular formation and within hearing distance of each other. On 11/18/20, Resident #92 was interviewed regarding concerns of lack of visitation privacy voiced during the facility task of Resident Council. At 1:42 p.m., the resident was observed in her room, sitting in a wheelchair between the two beds. She stated she had a visitation with her daughter and grandson on Monday, 11/16/20. She reported that the Activity Director moved amongst multiple ongoing visitations and would sit down next to the resident's daughter. When asked if the family had said anything to the Activity Director about her sitting with them, she stated they just thought it was part of the procedure. Resident #92 was admitted on [DATE]. The admission Record included diagnoses not limited to paroxysmal atrial fibrillation and unspecified chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) indicated a Brief Interview of Mental Status score of 15 out of 15, cognitively intact. The MDS identified the resident had adequate hearing without the assistance of devices, had clear speech, and had the ability to understand others and to make herself understood. At 11/18/20 at 12:00 p.m., Staff Member A, activity aide, was asked if she sat with residents and families during visitation, she stated yes. She stated they were told they had to monitor the visitation to make sure they stayed six (6) foot away from each other and did not touch. The Activity Director provided a copy of the corporation's policy, Safe and Limited Re-opening of Visitation: COVID-19. At 2:02 p.m., on 11/18/20, the Director of Nursing (DON) stated that the policy given to this writer by the Activity Director was not the right one and it had been recalled. She stated, she didn't know. The policy that was received from the DON, dated September 11, 2020, identified visitation could occur if the center was without positive patients and/or staff or at least 14 days. The policy indicated, in the section: Outdoor Visitation, spaces can be created outside of the center to allow for controlled, monitored visits to connect residents with their families. The policy, received from the DON, indicated visits would be controlled and monitored but did not identify staff were to deny privacy during the visitation. An interview on 11/19/20 at 11:42 a.m., was conducted with the Director of Nursing and the Regional Nurse. The DON stated activities were handling visitations and corresponding electronic visitation. She indicated visitations were conducted outside on the facility's front porch. The Regional stated the activity staff should not be on 1:1 during the visit, they should maintain distance to give them privacy and randomly monitor to make sure they are following policy. The Regional Nurse stated the facility was using the previous corporation's visitation policy, the policy that was obtained from 105320 Page 3 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0583 the DON. Level of Harm - Minimal harm or potential for actual harm The Centers for Medicare and Medicaid Services (CMS) memo, QSO-20-39-NH, dated September 17, 2020 addressed Nursing Home Visitation - COVID-19. The memo stated, visitation should be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life. The risk of transmission can be further reduced through the use of physical barriers (e.g., clear Plexiglas dividers, curtains). Also, nursing homes should enable visits to be conducted with an adequate degree of privacy. This guidance was effective immediately. Residents Affected - Few 105320 Page 4 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/16/20 at 11:26 a.m., Resident #46 reported, when asked how was the food at the facility, it _______ lately, they went to a new vendor. The resident stated the poached eggs served at breakfast, on 11/16/20, was like rubber. Resident #46 was admitted on [DATE]. The admission Record included diagnoses not limited to multiple sclerosis. The Quarterly Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, cognitively intact. 3. Resident #151 stated, on 11/17/20 at 8:40 a.m., she took the time to fill out the menus but they send whatever they think I should have. She reported that they got it right (this morning) probably because you're here. At 1:17 p.m. on 11/17/20, the resident was observed with her lunch tray in front of her on the over-the-bed table. She stated she received the food that was ordered but she did not get a fork with her lunch. She stated the aide informed her that no one had gotten a fork. The facility residents had been served lunch in foam to-go container with plastic utensils. Resident #151 was admitted on [DATE]. The admission Record included diagnoses not limited to End Stage Renal Disease and Type 2 Diabetes Mellitus with hypoglycemia without coma. The MDS completed on 7/30/20, indicated the resident was cognitively intact with a BIMS score of 15 out of 15. 4. A review of the admission Record for Resident #50 revealed that the resident was initially admitted into the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease (COPD). A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. On 11/16/20 at 10:36 a.m., Resident #50 reported that the kitchen was always out of milk. She never had milk to eat with her cereal. Resident #50 reported that you never get what was ordered on your tray for meals. Today she ordered a cheeseburger with slaw, but she did not get the slaw. On 11/17/20 at 1:30 p.m., Resident #50 reported that she ordered cottage cheese and fruit tray as an entrée for lunch. She received a cup of cottage cheese and a cup with 6 grapes. Resident #50 stated that it was supposed to be on a nice plate. She stated that that was not enough food for an entrée (photographic evidence obtained). On 11/18/20 at 1:23 p.m., Resident #50 reported that she ordered fried chicken for lunch but was served BBQ chicken and she couldn't eat that because of her esophagus. She reported that the Certified Nursing Assistant (CNA) had to go back to the kitchen to get the fried chicken. Resident #50 reported that the meals barely comes with condiments. If they put extra condiments on the tray, she keeps them in the case during meals they are out of condiments. Jelly was hard to come by stated the resident. Resident #50 reported for dinner last night, she ordered chicken strips and cole slaw but received chicken strips and fries. She stated, That's too many carbs for someone with diabetes. Resident #50 reported that she went to the Administrator about food concerns three or four months ago to straighten the situation out. 105320 Page 5 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Resident #74 was initially admitted into the facility on [DATE] with a primary diagnosis of diabetes mellitus without complications per the admission record. The quarterly MDS, dated [DATE] found that the resident had a BIMS score of 14 out of 15 indicating cognitively intact. On 11/16/20 at 11:26 a.m., Resident #74 reported they were not served cereal because there was no milk today. The kitchen had been out of bread, eggs, and milk. You never get what you request, they put whatever they want to put on the tray during mealtimes. On 11/17/20 at 1:20 p.m., Resident #74 reported that she received everything she ordered for lunch, but no butter or condiments. Resident #74 reported that she received no fork only a spoon. Margarine was listed on the menu but was not served. 6. A review of the Grievance Log from May 2020 to present revealed that there was not a grievance filed for Resident #50 and Resident #74. 7. On 11/18/20 at 1:33 p.m., Staff R, CNA, reported that residents voiced concerns about not getting the correct food on their trays all the time. She reported that residents always complain about not getting condiments. If they go to the kitchen to check for condiments, they were not always available. She has had to serve residents cereal with no milk the kitchen doesn't always serve silverware. Staff R reported that there was always a delay in meal service. Food was usually cold by the time it gets to the residents. Staff S, Personal Care Attendant (PCA), confirmed the allegations. On 11/18/20 at 2:35 p.m., the Certified Dietary Manager (CDM), reported that she completed the last order when the Dietary Director was out. She stated that she did not have an inventory list to follow to complete the order. They still do not have everything that they need. She worked Saturday and when she came in Monday morning the girls said that they were out of milk. Some of the residents did not have milk during breakfast. On 11/19/20 at 11:18 a.m., the Dietary Director reported that Resident #50 had voiced concerns about not receiving what she ordered. The meal tickets are always coming back throughout the day. There's a delay with getting the tickets back on time and that was the reason residents were not getting what they were ordering for meals. At this time, they are still getting meal tickets for breakfast today and breakfast was over. The Dietary Director reported for the cottage cheese and fruit tray, there should be at least two different fruits and it should be on a plate. Surveyor presented the picture of Resident #50's lunch tray with the cottage cheese and grapes and the Dietary Director stated, That's not a full meal. A review of the Cottage Cheese & Fruit Plate recipe provided by the Dietary Director revealed the following ingredients were in the recipe: fresh lettuce bunches, low fat cottage cheese, white seedless grapes, diced strawberries, and cantaloupe. The directions for the recipe indicated to line salad plate with lettuce, place a scoop of cottage cheese on the plate, cut fruit into bite size pieces, and arrange each fruit around the cottage cheese on the lettuce head. On 11/16/20 at 1:30 p.m., the Administrator reported that they were low on milk and staff went to the store to buy more and provided receipts. A receipt dated 11/09/20 at 7:59 a.m., revealed that 2 gallons (32 cups) of milk were purchased. According to the Calculating Staffing for Long Term Care Facilities document provided by the facility, the census was 94 on 11/09/20. A receipt dated 11/13/20 at 16:32 revealed that 3 gallons (48 cups) were purchased. According to the Calculating Staffing for Long Term Care Facilities document provided by the facility, the census was 93 on 11/13/20. 105320 Page 6 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0585 8. The policy Resident and Family Grievance revised 2017 revealed the following: Level of Harm - Minimal harm or potential for actual harm 10. Procedure: Residents Affected - Some b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. c. Forward the grievance form to the Grievance Official as soon as practicable. d. The Grievance Official will take steps to resolve the grievance, and record information about the grievances, and those actions, on the grievance form. g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. 12. The facility will make prompt efforts to resolve grievances. Based on resident and staff interviews and record reviews, the facility did not act upon grievances and recommendations made by resident council. The facility did not consistently provide responses, actions and rationale regarding resident concerns. Four (#46, 151, 50, and 74) of eight residents, participating in interviews expressed concerns with meals and food service. Findings included: 1. A resident council meeting was facilitated by the Council President on 11/18/20 at 11 a.m., attended by 8 regular members. During the meeting, members reported that the facility does not respond to their grievances and that they request the same thing over and over. It was reported that food issues are always the same, including meals passed without silverware, meals are always late, food is served cold and eggs are horrible. The council president reported that the facility ran out of milk the previous week and a request to clean gutters that cause of flooding in the patio has been reported during the last three meetings without response. A review of the facility's Resident council meetings minutes for the months of June 2020 to November 2020 conducted on 11/18/20 showed no evidence that residents' complaints were addressed, or that old business and previous grievances were reviewed or resolved. A further review of minutes reflected that Residents were not offered the opportunity to discuss concerns during quarantine. There was no evidence that specific complaints were discussed. Generalized documented responses were noted such as: complaints were discussed with dietary manager, complaints handled in the meeting, resolution was discussed and approved during meeting. The section on reviewing previous meetings and resolved grievances was noted blank. On 11/18/20 at 1:40 p.m., an interview was conducted with Certified Dietary Manager (CDM) and the Dietary Manage (DM). When asked how dietary concerns are addressed following resident council, CDM acknowledged that residents had brought up some concerns such as meals being late, inconsistent menus, and food temperatures. CDM further stated, I know the meals are still late. We have many new staff and with the changeover, things are a bit hectic. When asked who ensures that the residents receive feedback after council meetings and how that process is facilitated, the DM reported that she is new and that she addressed the residents at her first meeting this month. When asked if there was any 105320 Page 7 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documentation to show concerns were being addressed following resident council meetings, CDM stated she had written the concerns on a piece of paper and proceeded to go through a pile of papers on her desk. Evidence for documentation of follow through could not be obtained. A follow-up interview was conducted with the Activities Director (AD) on 11/19/20 at 11:26 a.m. When asked how she ensures that the resident's grievances are addressed by the respective areas, she stated that she lets the respective areas know what the concerns are, and that there was no formal process. AD acknowledged that she dropped the ball and that that they needed to stay on top of that. AD also said, I agree, we have not been completing the circle of communication. 105320 Page 8 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a care plan was developed for one (#38) out of 40 sampled residents regarding the application of a neck brace and failed to implement the plan of care for one (#9) out of 40 sampled residents in regards to the 1-on-1 activities. Findings included: 1. Resident #38 was originally admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and abnormal posture. On 11/16/20 at 12:12 p.m., an observation was made of Resident #38 sitting in a Broda wheelchair. The resident was wearing a type of neck brace and her head was resting past shoulder level in the opposite side of the brace. At 9:45 a.m. on 11/19/20, the resident was observed lying in bed, bilateral mid-torso side rails were raised, and the resident's head was positioned on the right shoulder. The resident was not wearing the neck brace, as it was observed lying in the resident's wheelchair. On 11/17/20 at 9:32 a.m., Staff Member B, Licensed Practical Nurse (LPN), stated the neck brace (seen on 11/16/20) was a neck brace that therapy got for the resident as the resident leans her head to the left. The staff member stated therapy put the brace on the resident. At 9:46 a.m. on 11/19/20, Staff Member C, Certified Nursing Assistant (CNA), stated therapy applied the neck brace on Resident #38. She stated therapy was working on getting her another brace which would be more effective and Speech Therapy was working with her. She picked up the gray neck brace from the wheelchair and placed it back on the seat of her wheelchair. On 11/19/20 at 10:25 a.m., the staff member stated Resident #38 had the neck brace for about 3-4 weeks and that PT applied the brace. She stated she she had been instructed by PT on how to apply the neck brace, but other than the first time, she had not put it on the resident. On 11/19/20 at 9:53 a.m., Staff Member D, Occupational Therapist (OT), stated that Resident #38's neck brace was for her neck contracture and that she was no longer on the therapy rotation. At 9:55 a.m. on 11/19/20, Staff Member E, Physical Therapist (PT), reported that the aides had been trained to put Resident #38's neck brace on and that he does not apply it. When asked if restorative applied the brace, he stated both (restorative and CNA's) were trained to put the brace on the resident. At 10:32 a.m. the PT stated that the resident had been picked up for therapy, a trial for the neck brace. When asked if the resident had the brace 3-4 weeks ago, the OT stated, oh she's had it longer than that, probably a month prior to that. A review of the OT progress and updated plan of care, dated 9/23/20, indicated the justification for the update was to reduce left upper extremity (LUE) pain due to d/t right (R) lateral neck flexion. The PT progress and updated plan of care, dated 8/31/20, indicated the goals were adjusted and the neck master Cervical extension support was ordered per the facility material's management. The note indicated the plan for transition to restorative program upon safe tolerance of the brace with skilled PT. The PT note, dated 9/28/20, identified the head master collar and extension support had not yet arrived to the facility. 105320 Page 9 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 10:21 a.m. on 11/19/20 an interview was conducted with three restorative aides, Staff Members F, G, and H. Staff Member G stated she had the resident a week ago when the resident had a decline in Activities of Daily Living to assist with grooming. She stated she was not instructed in the use of Resident #38's neck brace and did not apply it. The care plan for Resident #38 indicated that the resident had been started on the Restorative Program for dressing/grooming as of 10/16/20. The interventions identified restorative was to assist with grooming training and compensatory techniques, dressing training and compensatory techniques, and transfers: sit to stand lift trials with progression of supported standing tolerance as tolerated. The care plan did not include a focus or interventions related to the residents' neck brace. The Director of Nursing confirmed, on 11/19/20 at 11:42 a.m., that there was no care plan developed regarding Resident #38's neck brace. 2. Resident #9 was admitted to the facility with a diagnosis of hemiplegia and hemiparesis following other cerebrovascular disease, major depressive disorder, dementia without behavioral disturbance and anxiety per the admission record. A review of Resident #9's quarterly minimum data set (MDS) dated [DATE] found a brief interview for mental status (BIMS) score of 3. Section G, functional status, found that Resident #9 was totally dependent on staff for all mobility and activities of daily living (ADL) assistance. On 11/16/20 (Monday) at 11:40 a.m., Resident #9 was observed laying in bed. An interview was attempted but, Resident #9 did not respond. An observation was made of a note posted by the bed reading, please get Resident #9 up for the day on Monday, Wednesday and Friday. Following subsequent visits on 11/16/20 at 11:43 a.m., 12:30 p.m. and 1.45 p.m., Resident #9 was observed in bed without interaction, engagement or change in position. Further observations were made on 11/18/20 at 8.42 a.m., 9.12 a.m. and 12:45 p.m. Resident #9 was observed laying in bed with eyes closed. A review of Resident #9's Care Plan, dated 10/13/20, revealed that Resident #9 was at risk for activities of daily living (ADL) related declines with a goal to reduce a risk of new or increased decline in range of motion (ROM). The intervention stated that the resident was dependent on care, staff to provide care and to watch for decline in ADL abilities. Resident #9 was further noted as a long-term resident whose needs will be met daily and on an on-going basis. The care plan intervention for this goal stated that staffing would occur, per facility's protocol, to address resident's needs. A review of the treatment administration record (TAR) schedule for November 2020, showed an order to get resident up on Monday, Wednesday and Friday and keep up until 5:00 p.m. or after shower. The tracking log revealed no check marks to indicate task was completed. On 11/18/20 at 8:42 a.m., an interview was conducted with staff K, Certified Nurse's Aide (CNA) who stated that she worked closely with Resident #9 and that she should get him out of bed as much as possible. She further confirmed the documented scheduled goal of Monday, Wednesday and Friday to assist resident out of bed. On 11/19/20 10:03 a.m., an interview was conducted with Staff A, Restorative Nurse (RN) who confirmed that the CNA's are supposed to get Resident #9 up. Staff A, RN was notified of the observations made on 11/16/20 and 11/18/20. Staff A confirmed that Resident #9 was not assisted out of bed on 105320 Page 10 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Monday, 11/16/20 and Wednesday, 11/18/20 per care plan. Staff A, RN stated that she did not know what happened. A follow up was conducted on 11/19/20 10:56 a.m. with the Director of Nursing (DON) to confirm her expectation on care plan implementation. She stated that the CNA's and nurses were to follow the expectations per care plan orders. She confirmed that failure to assist a resident out of bed was not acceptable. A review of the facility's undated policy titled Comprehensive Care Plans, reflected that qualified staff were responsible for carrying out interventions specified in the Care Plan. 105320 Page 11 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to revise a resident's care plan to include interventions following falls for one (Resident #33) of two residents sampled for accidents and hazards Findings included: A review of Resident #33's medical record revealed that Resident #33 was admitted to the facility on [DATE] with diagnoses of muscle weakness, lack of coordination, low back pain, abnormalities of gait and mobility, difficulty walking, pain in right leg, presence of right artificial hip joint, syncope and collapse, and chronic pain, per the admission record. A review of Resident #33's Care Plan, initiated on 8/14/2020, found that Resident #33 was at risk for falls related to weakness, lack of coordination, low back pain, neck pain, right leg pain, neuropathy, insomnia, artificial right hip joint, syncope, restless legs, and chronic pain, and documented falls on the following dates: - 10/23/2020: Observed hanging from railing sitting on floor, no injury. - 09/27/2020: Fall on floor, complained of back pain, leg pain, and pain in chest. Skin tear to left elbow. - 08/23/2020: Fall on floor, no injury. - 08/13/2020: Rolled out of bed, no injury. Resident #33's Care Plan interventions included the following interventions on the following dates: - 10/26/2020: Alternative bed placement - 08/23/2020: Scoop mattress - 08/14/2020: Bed in lowest position - 08/14/2020: Bilateral floor mats - 08/14/2020: While in bed, position in center A review of Resident #33's Minimum Data Set (MDS) Assessment, dated 11/11/2020, found under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. A review of the facility's Monthly Resident Incident Trend Worksheet for August 2020 found that Resident #33 rolled out of bed with no injury on 08/13/2020 at 07:50 p.m., with interventions of neuro checks, low bed, and mats. The facility's Monthly Resident Incident Trend Worksheet for September 2020 revealed that Resident #33 was found on the floor and complained of back and chest pain and had a 105320 Page 12 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin tear to the left elbow on 09/17/2020 at 08:10 AM. The worksheet documented that Resident #33 was sent to the emergency room following the fall but did not reveal any fall interventions. The worksheet also revealed that Resident #33 was found on the floor and complained of left leg pain on 09/27/2020 at 08:35 p.m. The worksheet documented that Resident #33 was sent to the emergency room following the fall but did not reveal any fall interventions. A review of the facility's Monthly Resident Incident Trend Worksheet for October 2020 did not reveal any fall incidents for Resident #33. A review of Resident #33's Physician's Orders revealed an order, dated on 09/27/2020 to send Resident #33 to the hospital for evaluation and treatment after a fall with complaint of back pain. An interview was conducted on 11/19/2020 at 01:51 a.m., with the facility's Risk Manager. The Risk Manager was not able to find any information regarding Resident #33's falls on 09/17/2020 or 09/27/2020 and stated that there was no indication that an intervention was put into place following either fall. The Risk Manager stated that the only information that she could find was that Resident #33 was sent to the hospital after both falls. An interview was conducted on 11/19/2020 at 02:55 p.m., with the facility's Director of Nursing (DON). The DON stated that no fall interventions were put into place following Resident #33's falls on 09/17/2020 or 09/27/2020. The DON also stated that in the event of a fall, the fall was discussed the next morning during the morning meeting to discuss an appropriate intervention to prevent further occurrences. The DON stated that her expectation was for nursing staff to put in an immediate intervention following a resident's fall to prevent further occurrences. The DON also stated that interventions should have been put into place and added to Resident #33's care plan following her falls on 09/17/2020 and 09/27/2020. A review of the facility policy titled Fall Prevention Program revealed, under the section titled Policy Explanation and Compliance Guidelines, that when any resident experienced a fall, the facility would review the resident's care plan and update it as indicated and document all assessments and actions. The policy also revealed that interventions would be monitored for effectiveness and the plan of care would be revised as needed. 105320 Page 13 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

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 record reviews, the facility did not ensure that 1:1 activity therapy was provided per the care plan for one Resident (#9) of forty sampled residents. Residents Affected - Few Findings included: Resident #9 was admitted to the facility with a diagnosis of hemiplegia and hemiparesis following other cerebrovascular disease, major depressive disorder, dementia without behavioral disturbance and anxiety. A review of Resident #9's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 3. Section G, functional status revealed that Resident #9 is totally dependent on staff for all mobility and activities of daily living (ADL) assistance. On 11/17/20 a review of the care plan dated 10/13/20 revealed that Resident #9 is bed bound most of the time. The focus on activity preferences included listening to music, watching westerns, sports and family shows. The interventions included 1:1 room visits to provide with leisure activities, socialization and emotional support. The care plan further revealed that Resident #9 exhibits a severe level of cognitive loss. A goal to have optimal quality of life through socialization was noted with interventions to include, invite and assist resident to attend activities of interest. Resident #9 has a diagnosis of depressive disorder. A care plan intervention states to offer non-pharmacologic interventions which may include but not limited to activities and music therapy. An observation of Resident #9 on 11/16/20 at 11:43 a.m. revealed resident laying in bed without interaction or engagement. An interview attempt was not successful. Resident #9 was noted on subsequent observations made on 11/16/20 at 11:43 a.m., 12:30 p.m. and 1:45 p.m. not engaged in any activities. A TV in his room was noted off. A radio was not observed. A review of the facility's 1:1 activity binder revealed that Resident #9 was not receiving 1:1 room activity as care planned. A review of the facility's activity participation calendar for the month of November revealed that Resident #9 was not documented as having participated in or offered any activities. Further observations of Resident #9 were made on 11/18/20 at 8.42 a.m., 9.12 a.m. and 12:45 p.m. Resident #9 was observed laying in bed with eyes closed. On 11/18/20 at 12:13 p.m. an interview was conducted with Staff A, Activities Assistant, who stated that her job duties included providing 1:1 activity to the residents who are bed bound. When asked about Resident #9, she stated that he used to be a race car driver. When asked how often he is offered activities related to his interests, Staff A could not identify. Staff A stated that Resident #9 likes music especially Elvis. When asked how Resident #9 listens to the music, she stated that he does not have a radio, and does not listen to the music. Staff A also confirmed that she was not aware that resident #1 had a care plan for 1:1 activity. When asked if Resident #9 participated in any activities, Staff A explained that he used play Bingo before COVID-19 hit. An interview was conducted with the Activities Director (AD) on 11/19/20 at 10:46 a.m. who reported that bed bound residents were provided 1:1 activity therapy as stated in their individual care plans. The AD confirmed that Resident #9's care plan indicated that he should have been receiving 1:1 room activity therapy. The AD also stated, it was oversight on my part. 105320 Page 14 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that respiratory equipment was stored and maintained in accordance with professional standards for 2 (Resident #35 and #64) of 2 residents sampled for respiratory care. Residents Affected - Few Findings included: 1. A review of Resident #35's medical record revealed that Resident #35 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis and pneumonia, per the admission record. An observation was made on 11/16/2020 at 11:34 a.m., of Resident #35's room. Resident #35 was resting in bed at the time of the observation. A nebulizer and an EzPAP machine were observed at Resident #35's bedside table. The nebulizer tubing attached to the EzPAP machine was dated 11/09/2020. Resident #35's nebulizer mask was stored inside of a plastic bag, which was also dated 11/09/2020. A follow up observation was made on 11/17/2020 at 09:32 a.m., of Resident #35's room. Resident #35 was sleeping in bed at the time of the observation. A nebulizer mask was observed sitting on top of Resident #35's EzPAP machine and was not properly stored inside of the storage bag. The nebulizer tubing attached to the EzPAP machine was dated 11/09/2020. A review of Resident #35's Physician's Orders revealed an order, dated on 11/01/2019, to change and label all oxygen/nebulizer/nasal cannula/masks and tubing every Friday on night shift. Resident #35's Physician's Orders also revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 milligrams per milliliter, 1 inhalation orally three times daily and every 4 hours as needed with EzPAP machine. An interview was conducted on 11/17/2020 at 03:40 p.m., with Staff P, Licensed Practical Nurse (LPN). Staff P, LPN stated that respiratory equipment in the facility was changed out by an outside company and that they no longer change the equipment out. All respiratory equipment should be stored inside of a plastic bag when not in use. Staff P, LPN, stated that he did not observe Resident #35's nebulizer tubing dated for 11/09/2020 but addressed that it should have been changed out. A review of Respiratory Therapy Forms, provided from the outside company that provided maintenance and changing out of respiratory equipment, found that the company visited the facility on 11/09/2020. The company did not return to the facility to change out respiratory equipment until 11/17/2020. The form also revealed that Resident #35's EzPAP set up was changed during both visits. An observation was made on 11/19/2020 at 07:17 a.m., of Resident #35's room. Resident #35 was observed watching television at the time of the observation. Resident #35's nebulizer mask was observed sitting on top of the EzPAP machine at Resident #35's bedside and not stored inside of the storage bag. An interview was conducted on 11/19/2020 at 08:15 a.m., with Staff O, LPN. Staff O, LPN stated that Resident #35 had orders for nebulizer treatments using the EzPAP machine and addressed that the nebulizer mask was sitting on top of the machine. Staff O, LPN addressed that the nebulizer mask should not be stored on top of the machine and stated that the nebulizer mask should have been stored inside of the storage bag. Staff O, LPN stated that he had explained to the other nurses before that the nebulizer masks needed to be stored properly, but it did not always get completed. 105320 Page 15 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 11/19/2020 at 09:50 a.m., with the facility's Director of Nursing (DON). The DON stated that an outside company was hired to provide changing of respiratory equipment on a weekly basis and that they did not come out on the day that they were supposed to. The DON also stated that the nursing staff should be checking to ensure that the respiratory equipment is being changed out on a weekly basis and that it was stored properly in a plastic bag when not in use. The DON stated that she would not expect to see a nebulizer mask stored on top of the machine and would expect it to be stored inside of a plastic bag when not in use. 2. An observation was made on 11/19/2020 at 11:42 a.m., of Resident #64's room. A nebulizer machine and nebulizer mask were observed on Resident #64's bedside table. Resident #64's nebulizer mask was observed to be stored in a holder in the nebulizer machine and not inside of a plastic bag. An interview was conducted following the observation with Staff Q, LPN. Staff Q, LPN stated that Resident #64's nebulizer mask was accidentally left out and that it should be stored in the plastic bag instead of in the machine itself. A review of Resident #64's medical record found that Resident #64 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), per the admission record. 3. A review of the facility policy titled Respiratory Therapy Equipment, dated 11/2017, revealed under the section titled Medication Nebulizers/Continuous Aerosol that the administration sets should be stored in a plastic bag, marked with the date and resident's name, between uses. The policy also revealed to discard administration set-up every 7 days and to date new tubing. Photographic evidence was obtained. 105320 Page 16 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure consent for use of bed rails was obtained for one (Resident #33) of one residents sampled for bed rails. Findings included: A review of Resident #33's admission record revealed that Resident #33 was admitted to the facility on [DATE] with diagnoses of muscle weakness, lack of coordination, low back pain, abnormalities of gait and mobility, difficulty walking, pain in right leg, presence of right artificial hip joint, syncope and collapse, and chronic pain, per the admission record. A review of Resident #33's Minimum Data Set (MDS) Assessment, dated 11/11/2020, found under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. An observation was made on 11/16/20 at 12:03 p.m., of Resident #33 resting in bed. Resident #33 was observed to have bilateral 1/2 length bed rails installed and in place. A review of Resident #33's Physician's Orders did not reveal an order for use of bed rails. A review of Resident #33's medical record did not reveal consent for use of 1/2 length bed rails. A review of Resident #33's Side Rail Rationale Screen, dated 09/07/2020 at 06:30, revealed that Resident #33 used bed rails for assisting with turning from side to side in the bed and that entrapment precautions were reviewed. An interview was conducted on 11/18/2020 at 04:10 p.m., with the facility's Director of Nursing (DON). The DON stated that residents that have bed rails should have a physician's order for bed rails and that a consent from either the resident or the resident representative for use of the bed rails should be in the resident's medical record. The DON addressed that Resident #33 did not have a physician's order for bed rails or a consent in place for use of bed rails in her medical record. The DON stated that Resident #33 should have a physician's order for bed rails and should have a consent from her representative for use of bed rails. A follow up interview was conducted on 11/18/2020 at 04:34 p.m., with the DON. The DON stated that Resident #33 had an order for bed rail use, but it was discontinued when she was sent to the hospital and the order was not renewed when she returned to the facility. The DON was not able to locate a consent for use of bed rails in Resident #33's medical record. The DON stated that consent would normally be obtained by the resident if they were alert and oriented or by the resident representative either in person or over the phone with 2 nurse's signatures on the consent form. An interview was conducted on 11/19/2020 at 08:17 a.m., with Staff O, Licensed Practical Nurse (LPN). Staff O, LPN stated that residents are assessed by the therapy department prior to installing side rails to ensure that the rails are used to assist the resident with bed mobility and to assess for the possibility of them restraining the resident. Consent would also be obtained prior to 105320 Page 17 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0700 installation of the bed rails by either an alert and oriented resident or the resident representative. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled, Proper Use of Side Rails revealed, under the section titled Policy Explanation and Compliance Guidelines, that the facility should obtain informed consent from the resident, or the resident representative for the use of bed rails, prior to installation/use. The policy also revealed that a physician's order should be obtained for the use of side/bed rails. Residents Affected - Few 105320 Page 18 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #48 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified psychosis not due to a substance or known physiological condition, unspecified dementia with behavioral disturbance (2/18/20), and unspecified dementia without behavioral disturbance (2/25/20). The Quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status score of 11 out of 15, moderate impairment. The MDS indicated the resident had reported feeling down, depressed, or hopeless, feeling tired or having little energy, and a poor appetite or overeating on 2-6 days of the assessment, with a score of 3 out of 27. According to the MDS, Resident #48 had not exhibited any physical or verbal behaviors directed toward others or other behavioral symptoms not directed toward others. The comprehensive assessment indicated the resident received 7 days of antipsychotic and 6 days of antidepressant medications during the assessment period. On 11/18/20 at 3:43 p.m., Resident #48 was observed sitting in a wheelchair in the main Dining Room watching a movie. A review of the September 2020 Medication Administration Record (MAR) indicated Resident #48 was being administered daily the psychotropic medications of Olanzapine for unspecified psychosis not due to a substance or known physiological condition and Mirtazapine for depression. The Behavior Monitoring Flowsheet (BMF) indicated that the behaviors to be monitored were anxious and uncooperative. The BMF instructed staff to document the number of times behavior occurred each shift, every shift for behaviors. The BMF indicated no behaviors were documented on 9/1, 9/10, or 9/15/20 during the night shift for both medications. The review of Resident #48's progress notes and BMF identified the following: - 9/2/20 night shift, documentation indicated the resident asleep, refused medication by mouth. The BMF did not indicate any behaviors were documented. - 9/3/20 at 3:46 a.m., an orders - administration note indicated the patient refused. No behaviors were documented. - 9/10/20 at 11:56 a.m., an orders-administration note indicated Resident #48 refused. No behaviors were documented during the day shift. - 9/12/20 during the day shift, two orders-administration notes indicated the resident refused medications. The BMF indicated the resident had no behaviors. - 9/12/20 at 1:14 p.m., the administration notes identified that the resident refused medications. - 9/15/20 at 6:46 and 6:47 a.m., the notes revealed resident refused. The notes did not indicate what the resident refused. The BMF did not indicate the resident had any behaviors. - 9/17/20 at 11:33 and 11:35 a.m., the three notes indicated the resident refused medications. The BMF documentation indicated the resident did not exhibit any behaviors during the day shift. 105320 Page 19 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0758 Level of Harm - Minimal harm or potential for actual harm - 9/23/20 at 6:10 and 6:11 a.m., identified the resident refused medications. The BMF did not reflect that the resident was uncooperative. - 9/26/20 at 6:22 a.m., a progress note indicated the resident refused all medications and Blood Sugar (BS) check. The BMF did not identify the resident had any behaviors. Residents Affected - Few - 9/27/20 at 11:23, 11:24, and 11:35 a.m., revealed the resident spat out medications. The BMF did not indicate any behaviors were exhibited. - 10/4/20 at 3:30 p.m., indicated the resident became aggressive and violent during patient care. The BMF did not identify Resident #48 had exhibited any behaviors during the day or afternoon shift. The night shift did not document whether behaviors had or had not happened. At 10:48 p.m., the resident refused constipation medication and the BMF did not indicate any behaviors. - 10/6/20 at 1:08 p.m., the resident refused nutritional liquid supplement. The BMF did not indicate the resident had any behaviors. - 10/7/20 at 11:09 a.m., and 9:41 p.m., the resident refused an oral medication (11:09 a.m.) and refused three times to have blood glucose level obtained or insulin administered. The BMF did not indicate the resident had been anxious or uncooperative. - 10/20/20 at 2:25 p.m., the resident refused to have blood glucose checked. The BMF did not indicate the resident had any behaviors. 10/30/20 at 12:51 p.m., the progress notes indicated the resident refused a shower twice. The BMF did not identify that the resident had exhibited any anxiety or uncooperativeness. The Psychiatric Evaluation, dated 10/22/20, documented that the resident demonstrates occasional moments of agitation and aggression which are worse in the morning, however, are mostly redirectable. A review of the BMF indicated that side effects for the antipsychotic medication, Olanzapine, and the antidepressant, Mirtazapine, were being monitored as one and not individualized to the medications. The care plan for Resident #48 identified that the resident used antipsychotic and antidepressant medications, initiated on 9/15/20. The interventions instructed staff to monitor/record occurrence of for target behavior symptoms and document per facility protocol. The resident was identified as having an increase in aggressive behaviors, both physical and verbal, refusing care and began removing her clothing, tendency to make accusations against male staff members, and at risk for adverse effects of meds as well as variations in her mood and behavioral status. The interventions related to the residents increased aggressive behaviors instructed staff to utilize Behavior Monitoring Flowsheet (BMF) to manage/document any observed behaviors. On 11/18/20 at 3:53 p.m., Staff Member I, Licensed Practical Nurse (LPN), was asked what medication was being monitored for side effects order #1 and order #2. She stated they went with the behaviors. She asked Staff Member J, Restorative Nurse, to review Resident #48's BMF. Staff Member J stated the BMF did not identify what medications were being monitored and neither Olanzapine and Mirtazapine were prescribed for Anxiety. 105320 Page 20 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 4:10 p.m. on 11/18/20 the Director of Nursing (DON) stated the previous corporation did not monitor for different medications but the new corporation does. When asked if the medications Olanazapine and Mirtazapine had the same side effects, she stated she did not know. Based on record reviews and interviews, the facility failed to ensure that a PRN (as needed) psychotropic medication was limited to 14 days without a rationale to extend the medication for one resident (Resident #50) and failed to ensure behavior monitoring was documented for two residents (Resident #1 and #48) out of the sampled five residents for unnecessary medications. Findings included: 1. The policy Use of Psychotropic Drugs with a revised dated of November 2017 revealed the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 8. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believing that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 2. A review of the admission Record for Resident #50 revealed that the resident was initially admitted into the facility on [DATE] with diagnoses of anxiety disorder, depressive disorder, and unspecified Dementia with behavioral disturbance, per the admission record. A review of the Medication Administration Record (MAR) dated 11/01/20-11/30/20 revealed that the order Alprazolam Tablet 0.5 MG (Give 0.5 mg by mouth every 8 hours as needed for anxiety) was administered on the 1st, 4th-12th, 14th, and the 16th. According to the MAR, the Alprazolam had an order date of 08/25/20. A review of the MAR dated 10/01/20-10/31/20 revealed that the order Alprazolam Tablet 0.5 MG (Give 0.5 mg by mouth every 8 hours as needed for anxiety) was administered on the 1st-4th, 6th-10th,12th-14th, 16th-18th, 20th, 21st, 23rd-26th, 29th, and 31st. According to the MAR, the Alprazolam had an order date of 08/25/20. A review of the MAR dated 09/01/20-09/30/20 revealed that the order Alprazolam Tablet 0.5 MG (Give 105320 Page 21 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 0.5 mg by mouth every 8 hours as needed for anxiety) was administered on the 1st, 2nd, 4th, 6th-18th, 20th-28th, and 30th. According to the MAR the Alprazolam had an order date of 08/25/20. A review of the physician notes, dated 09/08/20 and 10/06/20, revealed the following: Alprazolam 0.5 mg tablet- 1 tablet by mouth every 8 hours as needed for chronic intermittent anxiety for 180 days. A review of the Medication Regimen Review dated 11/12/20, revealed that the patient had a PRN order that had been in place for greater than 14 days without a stop date: Xanax 0.5 mg every 8 hours PRN for anxiety since 08/25/20. The recommendation had not been signed. On 11/19/20 at 9:45 a.m., the Director of Nursing (DON) verified that the order had been in place since August. The DON stated medication should not have been ordered for longer than 14 days. She stated she believed psych wanted Resident #50 on the medication because she was agitated. 3. A review of the admission Record for Resident #1 revealed that he was initially admitted into the facility on [DATE] with diagnoses of unspecified Dementia with behavioral disturbances, and depressive disorders, per the admission record. The Order Recap Report dated 10/01/20 to 10/31/20 revealed that Resident #1 had the following active orders: Donepezil HCL Tablet Give 5 mg by mouth at bedtime for dementia. Escitalopram Oxalate Tablet Give 10 mg by mouth one time a day for depression. Memantine HCL Tablet Give 10 mg by mouth every 12 hours for dementia. The Order Recap Report, dated 10/01/20 to 10/31/20, revealed that the order for behavior monitoring had an end date of 10/06/20 and the order for side effect monitoring had an end date of 10/06/20. The MAR dated, 11/01/20 to 11/30/20, revealed that donepezil was administered daily from the 1st-16th, escitalopram was administered daily on the 1st-17th, and memantine was administered daily on the 1st-17th. There was no behavior monitoring chart for the month of November. The MAR dated 10/01/20 to 10/31/20 revealed that donepezil was administered on the 1st, 2nd, and 8th-31st, escitalopram was administered daily on the 1st, 2nd, and 9th- 31st, memantine was administered daily on the 1st, 2nd, 8th-31st , and risperidone was administered on the 8th-12th. The Behavior Monitoring chart dated 10/01/20 to 10/31/20 revealed that behaviors were monitored on the 1st-5th and side effects were monitored on the 1st-5th. The behavior monitoring and side effect monitoring had a discontinued date of 10/06/20. On 11/19/20 at 10:30 a.m., the DON confirmed that the behavior monitoring and side effect monitoring order was discontinued. 105320 Page 22 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 10:25 a.m., on 11/24/20, an interview was conducted with the Consulting Pharmacist. She stated she was new to the facility and had completed one month of review, November 2020. When asked what her feelings were regarding Alprazolam being as needed (prn) since August, she stated that it should have a 14-day stop date, then be re-evaluated after that we need justification for continued use and have a stop date for continued evaluations. The Consultant confirmed that the facility should be monitoring behaviors for a prescribed antidepressant. She stated that any behaviors, refusing medications and aggression, noted in the progress notes should also be reflected on the BMF. 105320 Page 23 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews the facility failed to serve a meal that conserved the flavor and appearance of the food for one of one test trays (11-16-20). Residents Affected - Few Findings included: On 11/16/20 at 11:26 a.m., Resident #46 stated, when asked how the food was at the facility, it _____ lately and reported that the facility changed to a new food vendor. She reported that the poached eggs served for breakfast tasted rubbery. On 11/19/20 at 7:32 a.m., the Kitchen Manager (KM) stated breakfast was scrambled eggs and plain muffins. She reviewed the menu and stated the menu indicated it was cheesy scramble eggs, a choice of eggs and choice of bread. The [NAME] was observed removing a pan of eggs from the steamer and pouring approximately half a bag of grated cheese on top of the eggs. At approximately 7:40 a.m., the breakfast meal began to be plated. A test tray, which contained scrambled eggs, bacon, and oatmeal was delivered to the last hall served breakfast then taken to the Main Dining Room. The eggs were a yellowish color with a gray tint and left an unwanted texture in the mouth. The eggs, that were suppose to be cheesy was very plain tasting, no cheese, and rubbery. The CDM admitted , at 9:20 a.m., that the eggs were plain eggs, taste like plain eggs, and did not contain any cheese. 105320 Page 24 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. On 11/17/20 at 12:06 p.m., the Dietary Director was observed sitting in an office chair in the kitchen area using a blue towel to hand dry wet trays used to serve meals and stacking them on a cart. Two staff members were observed washing the trays by hand in the three-compartment sink. The Dietary Director left the kitchen area and went to her office. Staff T, Dietary Aide, started drying the trays with the blue towel. The same towel was used to try the trays. Staff T was asked what was the policy for drying dishes and she was stated that she would go ask the Dietary Director. She came back and stated the Dietary Director told her to dry the trays with paper towels instead to avoid cross contamination. Staff T proceeded to dry the trays with brown paper towels and stack the trays on top of each other on a cart. Staff T stated that the Dietary Director told her to dry with paper towels because it was an emergency. The Regional Registered Dietitian was asked what was the expectation for drying dishes and she stated that they should be air dried and they should never use a towel or paper towel to dry dishes. The policy Three Compartment Sink Handwashing of Pots and Pans dated November 2017 revealed the following: Policy All pots, pans and items cleaned in the scullery by means of handwashing will be cleaned and sanitized in an effective method to prevent food-borne illness. Policy Interpretation and Implementation 8. Items must be allowed to air dry before storage. Do not towel dry or stack items that are not fully dried. Based on interviews, observations and documentation and policy review, the facility did not ensure proper food storage and food service safety for 88 out of 93 residents. The facility failed to ensure the dishwashing machine was operating at the required temperatures, refrigerators were cleaned, and the kitchen and cooking equipment were maintained in a sanitary manner. Findings included: During an initial tour of the kitchen conducted on 11/16/20 at 11:03 a.m. with the Certified Dietary Manager (CDM) and Dietary Manager (DM), the following was confirmed: (photographic evidence was obtained) 1. During the tour at 11:05 a.m., the walk-in refrigerator was noted with dirt, grime on the floor of the cooler and spilled dried matter, caked on the bottom shelf. CDM stated that they should clean the refrigerators more often. The refrigerator door was noted with black- like matter on the rubber sealing of the door. CDM confirmed that the black matter was not sanitary and stated that they would get it cleaned. 2. 105320 Page 25 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some At 11:10 a.m., the deep fryer was observed with dark brown oil and crumbs all over the surface. CDM stated that it did not look that bad when she last fried chicken. 3. The CDM conducted the water temperature check at the dish sanitization sink area on 11/16/20 at 11:14 a.m. The water temperature went up to 104.1 (F). CDM stated it should go up to at least 121 (F). A low temperature Warewash instruction poster on the wall revealed that the correct water temperature gauge was 120 (F) to 140 (F). CDM confirmed that the water temperature was too low and that she would call maintenance to fix it. 4. At 11:17 a.m., the vegetable refrigerator was noted soiled, with dirt and a dried brownish substance spilled on the bottom of the refrigerator. DM confirmed the observation and stated that all the refrigerators should be cleaned daily. 5. During a tour of the main refrigerator and freezer combo on 11/16/20 at 11:23 a.m., an observation was made of the floor with food particles, dirt, grimy and sticky surface. A puddle of water was noted on the floor of the refrigerator. Drops of water noted coming down from the ventilation fan dripping on a carton with vegetables. CDM stated that it was not like that before she went on leave. CDM asked Staff L, Dietary Aide to mop the water. A shelf on the inside of the refrigerator was noted with black-like matter. CDM said, we will clean it all. 6. On 11/16/20 at approximately 11.29 a.m., CDM explained that the dishwasher was a low temperature dish machine. A machine operational requirement from the manufacturer noted on the machine, revealed a required wash temperature of 120 (F) and a rinse temperature of 120 (F). CDM proceeded to test the dishwashing machine. She stated that the machine had to run at least 2 -3 cycles. After 3 cycles, the temperature gauge was noted going up to 98 (F). CDM confirmed that this was not the required temperature. CDM stated, I will call maintenance. An interview was conducted on 11/16/20 with Staff L, Dietary Aide at 11:20 am and Staff M, Dietary Aide at 12.24 a.m. They confirmed that they are expected to clean the kitchen and all equipment every day. A follow -up with the DM on 11/16/20 at 11:30 a.m. confirmed that there was a cleaning checklist that the Dietary Aides should have been using. During an interview with the CDM on 11/16/20 at 11:35 a.m., she acknowledged that, the kitchen looks really bad and it should be cleaned right away. On 11/17/20 at 9:16 a.m., a tour of the kitchen was conducted. Staff N, Dietary Aide was observed running the dishwasher. Staff N stated that she had run the dishwasher 6 times, the temperature is barely making it to 100 (F). A review of the temperature log revealed that the temperatures were not checked on 11/16/20 during lunch and dinner. The CDM came to assist and started a wash cycle. The 105320 Page 26 of 27 105320 11/19/2020 Dade City Health and Rehabilitation Center 37135 Coleman Ave Dade City, FL 33525

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature gauge showed a reading of 105 (F). CDM stated that maintenance had replaced a couple fuses and she thought the hot water element was now working and proceeded to call a vendor. A follow-up was conducted with the Corporate Registered Dietician (RD) on 11/17/20 at 9:30 a.m. When asked if she was aware of the water temperature concern related to the dishwasher, she reported that she had just been notified. When asked what the company policy of ensuring residents were served in sanitary dishes was, she stated that they would use disposables until repairs are made. A follow - up was conducted with the Nursing Home Administrator (NHA) on 11/16/10 at 12 p.m. He reported not being aware of water temperature problems, but that it would be addressed. He confirmed the observation of dirt, grime and black-like matter on the refrigerators, the doors and shelving and stated that they would clean things up. A review of the facility policy provided by the DM titled, Dish machine Temperature, with a date of November 2017 states, if wash temperatures are noted to be outside the safe zone of 120 (F) for low temperature machine, the dietary supervisor must be immediately notified. A review of the facility's weekly kitchen cleaning logs dated 10/11/20 to 11/19/20 showed that the facility did not maintain cleanliness as indicated in their cleaning schedules. 105320 Page 27 of 27