Health inspection·March 9, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of resident records, and interviews with staff, the facility failed to ensure a resident's call light was within reach at all times in the event the resident needed assistance for one (Resident #24) of one sampled resident observed with a call light out of reach, from a total of 28 residents in the sample. Residents Affected - Few The findings include: A record review for Resident #24 found she was admitted to the facility on [DATE]. She had diagnoses including, but not limited to, repeated falls, hypertension, malnutrition and hip fracture. Resident #24 required extensive assistance with bed mobility and toilet use, and total assistance with transfers. She used a wheelchair as a mobility aid. An observation of Resident #24 was conducted on 3/7/23 at 9:32 AM. She was in her bed. Her call light was observed hanging from it's wall receptacle behind the resident's bedside table. The cord was looped and the call button was clipped to the cord, approximately four to five feet away from the resident. (Photographic evidence obtained) When asked if she knew how to use her call light, Resident #24 replied, Yes. An observation of Resident #24 on 3/7/23 at 11:10 AM, found she was still in bed and the call light was still clipped to itself in the same location, out of reach. (Photographic evidence obtained) On 3/7/23 at 1:56 PM, Resident #24 was observed again, still in bed. Her call light remained clipped to itself in the same location on the wall. (Photographic evidence obtained) An interview was conducted with the Unit Manager (UM) on 3/7/23 at 2:00 PM. She was asked if Resident #24 knew how to use her call light. She stated the resident should be able to. The UM was alerted to the location of the resident's call light. The UM accompanied the surveyor to Resident #24's room and confirmed the device was out of reach. She relocated the call light, clipping it to Resident #24's blanket, reminding her to use it when she needed assistance. . Page 1 of 6 105349 105349 03/09/2023 Alliance Health and Rehabilitation Center 130 W Armstrong Avenue Deland, FL 32720

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure privacy and confidentiality of medical records for one (Resident #43) in a total of sample of 28 residents. Residents Affected - Few The findings include: On 3/7/23 at 4:45 PM, the medication administration computer was left open on the second floor 300 hall exposing Resident #43's medication administration record. The information could be seen by residents and guests who were observed passing along the hallway. The following information could be seen from the screen: The resident's name, date of birth , room number, diagnoses, allergies and medications. (Photographic evidence obtained) In an interview on 3/7/23 at 4:50 PM, Registered Nurse (RN) D confirmed that she had gone to administer medication to the resident and forgot to hide the screen. A reviewed of the facility's admission Packet (Page 8, Section 5 - Resident Privacy) read, The facility will maintain the confidentiality of the residents' protected health information, which includes but is not limited to information contained on the resident's medical and financial records, in accordance with the applicable state and federal law. (Photographic copy obtained) . 105349 Page 2 of 6 105349 03/09/2023 Alliance Health and Rehabilitation Center 130 W Armstrong Avenue Deland, FL 32720

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure 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, by failing to date mark numerous open food packages in the dry storage room, the refrigerator, and the freezer. 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: A tour of the kitchen was conducted on 3/6/2023 at 10:29 a.m. During the tour, no date markings were observed on an open box of white potatoes, an open box of celery and cherry tomatoes, an open box of large tomatoes, an open box of green and red peppers, an open box of cabbage, an open bag of lettuce, an open box of sweet potatoes, and two bunches of asparagus sitting in a box on the shelf in the walk-in refrigerator. In the dry storage room, there was one open package wrapped with no date marking. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 3/7/2023 at 8:38 a.m., and the same observations were made of the abovementioned food items. At the same time, new observations of one open box with carrots, one open box of cucumbers, one box of mushrooms, and an open bag of onions were on the shelf in the walk-in refrigerator with no date marking. (Photographic evidence obtained) An interview was conducted on 3/9/23 at 1:45 p.m. with [NAME] F, who confirmed that the facility policy for food storage was to ensure the food was labeled and dated. Open food was to be wrapped, date marked, and discarded after three days. An interview was conducted on 3/9/23 at 1:50 p.m. with Dietary Aide G, who confirmed he was responsible for food storage, but Any Dietary Aide can put away food. He confirmed the First In, First Out system was used when storing food, and all open food was to be dated when opened and discarded after the third day. An interview was conducted on 3/9/23 at 1:55 p.m. with Certified Dietary Manager H, who stated everyone was responsible for maintaining food storage standards, but currently one staff member was assigned to concentrate on that duty. He stated food was kept in boxes to keep the manufacturer codes. He confirmed that the food policy for food storage date marking was that open food should be labeled and dated, then discarded after 72 hours. A review of the facility's policy and procedure entitled Food Storage Overview (Dated 2015), revealed: Purpose: Food is stored by methods designed to prevent contamination. Procedures: 4. Plastic containers with tight-fitting covers are to be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. Containers are to be labeled . 8. All stock is to be rotated. a. Old stock is always used first (first in - first out method). b. Food should be dated with date received as it is placed on the shelves . f. Foods are to be covered, labeled and dated including month, day, and year. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention 105349 Page 3 of 6 105349 03/09/2023 Alliance Health and Rehabilitation Center 130 W Armstrong Avenue Deland, FL 32720

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. . 105349 Page 4 of 6 105349 03/09/2023 Alliance Health and Rehabilitation Center 130 W Armstrong Avenue Deland, FL 32720

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #25) of four residents on transmission-based precautions, and for two (Residents #25 and #234) residents from a total sample of 28. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. Residents Affected - Few The findings include: During a tour on 3/6/23 at 11:50 AM, an occupational therapy assistant (OTA) was observed wheeling Resident #25 to her room. On the resident's door was a kit with personal protective equipment (PPE) and a stop sign instructing those entering the room to see the nurse beforehand. On 3/6/23 at 12: 30 PM, Resident #25 was observed wheeling herself to the bathroom inside her room. On 3/6/23 at 1:00 PM, Resident #234 was observed self-propelling herself in her wheelchair. She stated she had lunch in the dining room and was going back to her room. Resident #234 confirmed that she was Resident #25's roommate. As soon as she got to the room, she wheeled herself into the bathroom. (Shared bathroom for both Resident #234 and Resident #25) On 3/7/23 at 9:45 AM, Residents #25 and #234 were observed in their room. Both residents confirmed that they shared the bathroom. When asked if their bathroom was cleaned after each use, Resident #234 stated no. Both residents confirmed they were continent, required minimal assistance with transfers, and therefore, did not bother to call the staff if they could use the bathroom independently. A review of Resident #25's clinical record indicated that she was admitted to the facility on [DATE] and had a primary diagnosis of urinary tract infection (UTI). Her secondary diagnoses included, but were not limited to, dementia, major depressive disorder, acute angle-closure glaucoma and needs assistance for personal care. The resident's physician's order, dated 3/3/23, revealed she was to be on contact isolation for Vancomycin-Resistant Enterococci (VRE), with Hiprex (Antibiotic) one gram (gm) two times a day (BID) as a UTI preventative, and Microdantin (Nitrofurantoin - Antibiotic) 50 milligrams (mg) every evening for VRE. A review of Resident #25's care plan, initiated on 2/21/23, revealed that Resident #25 had a UTI related to Extended-Spectrum Beta-Lactamase (ESBL). The care plan was then revised on 3/3/23 indicating that urine culture results showed VRE. Interventions included contact isolation precautions due to VRE UTI. Dedicate equipment to this resident - no sharing, wear gown/gloves during care only if risk of exposure to this resident's bodily fluid (Photographic copy obtained). A review of Resident #25's annual Minimum Data Set (MDS) assessment, dated 12/20/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating that she was cognitively intact. She was independent with bed mobility, eating and toilet use, and required supervision with transfers. In an interview on 3/9/23 at 10:39 AM, Certified Nursing Assistant (CNA) C confirmed that both 105349 Page 5 of 6 105349 03/09/2023 Alliance Health and Rehabilitation Center 130 W Armstrong Avenue Deland, FL 32720

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #25 and Resident #234 were continent of bowel and bladder. She added that these residents were expected to call for help to the restroom, but most of the time they did not call. When asked about about the isolation precautions, CNA C stated she was notified to wear PPE while providing care to Resident #25. During an interview on 3/9/23 at 12:42 PM, Licensed Practical Nurse (LPN) E confirmed that Resident #25 was diagnosed with ESBL. A few weeks later, after finishing her antibiotics, the urine culture came back positive for VRE. She also confirmed that Resident #25 had a roommate throughout the course of her antibiotic treatment. When asked to describe the isolation precautions required, LPN E stated Resident #25 was on contact isolation and staff were required to wear PPE only while providing care. When asked if the resident could share equipment, LPN E stated she was not sure and would consult the infection control specialist. In an interview on 3/9/23 at 2:51 PM, the Infection Control Specialist (ICS) stated Resident #25 had VRE as of 3/3/23. She added that the resident was also on contact precautions and staff should wear a gown and gloves whenever they were providing care. She stated it was okay for the resident to go out of her room as long as she did not share the bathroom since she was continent. When asked whether Resident #25 had a roommate, the ICS said no, then looked up the census and stated the resident had a roommate who was a new admission. She added that if they were both continent, one should use a bedside commode and the other should use the bathroom. Staff should empty the commode. A review of Resident #234's clinical record revealed that she was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 2/25/23, revealed that Resident #234 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. She required minimal assistance with bed mobility, toilet use and transfers. A review of the facility's policy and procedure entitled Infection Control-Infection Surveillance (Last reviewed in 2013), indicated that the facility used prevention strategies to reduce the risk of transmission of infection including, but not limited to, barrier precautions, cleaning, disinfection, and education. . 105349 Page 6 of 6