Health inspection·May 6, 2021

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interview, and record review, the facility failed to have documentation of an evaluation for self-administration of medications and a physician's order to keep medications at bedside for 1 (Resident #68) of 6 residents reviewed for medication administration. Residents Affected - Few The findings included: Review of facility policy and procedure for Medication Administration Self-Administration by Resident, dated 11/17 stated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration (3) The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. (4) If the resident demonstrates the ability to safely self-administer medications, a further assessment of bedside medication storage is conducted. (Refer to Section 4.3-Bedside Medication Storage). The Policy and Procedure for Medication Storage Bedside Medication Storage dated 10/07 states Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgement of the nursing care center's interdisciplinary resident assessment team. (2) A written order for the bedside storage of medication is present in the resident's medical record. (3) Bedside storage of medications is indicated on the resident medication administration record (MAR) for the appropriate medications. On 5/5/21 at 9:40 a.m., during observation of medication administration for Resident #68, Licensed Practical Nurse (LPN) Staff B, stated Resident #68 administered his own inhalers, which he kept at bedside in his locked drawer. On 5/5/21 at 1:40 p.m., in an interview, Resident #68 stated he knew when to take his inhalers and he kept them at bedside. Resident #68 stated the nurses asked him if he had taken them and reminded him to rinse his mouth. On 5/6/21 at 9:00 a.m., in an interview, the Director of Nursing (DON) said he could not find the self-administration assessment in Resident #68's records. DON stated, We can't get into our old system to retract his assessment for self-administration. On 5/6/21, record review of Resident #68's electronic Medical Records (eMAR) showed the orders for Combivent and Symbicort inhalers, but it did not specify they could be kept at bedside. Page 1 of 9 105363 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

F 0554 Level of Harm - Minimal harm or potential for actual harm On 5/6/21 at 11:10 a.m., DON reviewed the electronic Medication Administration Record and verified the orders for Resident #68 did not indicate the resident could they could keep medications at bedside. The DON also verified the lack of documentation of an evaluation to ensure Resident #68 was safe to self-administer his medications. Residents Affected - Few 105363 Page 2 of 9 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, the facility failed to provide the resident and the representative, if applicable, with a written summary of the baseline care plan which included initial goals, a summary of current medications and dietary instructions for 2 (Resident #310 and #313) of 6 residents reviewed for baseline care plans. This has the potential to cause confusion as to the care expected to be provided by the facility. The findings included: Review of facility's Baseline Care Plan Process revised 7/19/18 stated, (3) Create Baseline Care Plan, High risk areas must be cared plan within 24 hours. (4) Baseline line care plan will be a working tool for the first 48 hours (6) The Baseline Care Plan Summary will be reviewed and presented to the resident and/or representative prior to completion of the Comprehensive Care Plan. 7. (a) Provide copy of completed and signed care plan summary form to resident/or POA/Family/Representative. (b) Place Original completed and signed care plan summary form (CP1005) in the resident's chart under the Care Plan Tab. 1. On 5/5/21, record review revealed Resident #310 had an admission date of 4/21/21. The clinical record lacked evidence of a written summary of the baseline care plan, which included initial goals, and a summary of current medications and dietary instructions. There was no documentation Resident #310 or representative was provided a copy of the baseline care plan as required. On 5/6/21 at 11:09 a.m., the Assistant Director of Nursing (ADON) verified they did not have a baseline care plan summary for Resident #310. 2. On 5/5/21 at 3:10 p.m., in an interview, Resident #313 said he did not receive a copy of a list of his medication, or any other document related to his care when he was admitted . On 5/5/21 at 3:20 p.m., record review revealed Resident #313 was admitted to the facility on [DATE]. The clinical record lacked evidence a written summary of the baseline care plan was provided to the resident or resident representative as required including initial goals, summary of current medications, and dietary instructions. On 5/6/21 at 11:09 a.m., the Assistant Director of Nursing (ADON) verified they did not have a baseline care plan summary for Resident #313. On 5/5/21 at 2:32 p.m., in an interview, Minimum Data Set (MDS) Coordinator Staff M stated they did not do the baseline care plans in the MDS department and did not know who was doing them. 105363 Page 3 of 9 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review and staff interview, the facility failed to have documentation of a fall investigation to ensure adequate preventive interventions for 1 (Resident #310) of 2 residents reviewed for falls. Residents Affected - Few The findings included: Review of facility policy and procedure on Falls, revised 11/6/19 stated, (3) If a fall occurs the following actions will be taken: (a) Evaluate resident including neuro checks, pain, Range of Motion (ROM), skin, joints, extremities, vital signs. (b) Evaluate resident each shift for 72 hours. (c) Neuro Checks will be completed on residents that experience an unwitnessed fall or a fall that results in head trauma. (e) Notify physician and family and document notification in the Electronic Medical Record (EMR). (f) Document the evaluation, pertinent facts and incident in the EMR. On 5/5/21, record review revealed Resident #310 had an admission date of 4/21/21 with diagnoses including dementia with a Brief Interview for Mental Status (BIMS) score of 5, indicative of severe cognitive impairment. On 4/21/21 at 11:15 p.m., a nurse's note stated, Writer was told by CNA [Certified Nursing Assistant] and nurse on unit that patient was on floor, unsure if patient had fallen, by time. this nurse entered room, said patient got himself off the floor and back to bed. Patient assessed and no obvious injury noted, vital signs stable, and patient denied pain. Patient baseline mental status confused, but easy to redirect. Vital signs checked and stable. Will monitor for changes. On 5/5/21 review of incidents and accidents report did not show any falls for Resident #310. Review of the medical record revealed no neuro checks were completed, no evaluation each shift for 72 hours and no notification of the physician and/or family. On 5/5/21 at 11:41 a.m., in an interview, Director of Nursing (DON), verified the lack of documentation of an incident report, neuro checks, notification to Physician/family for Resident #310. 105363 Page 4 of 9 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, record review, and staff and resident interview, the facility failed to maintain urinary catheters in a safe and sanitary manner for 2 (Resident #25 and Resident #104) of 2 residents sampled with indwelling urinary catheter. The findings included: 1. Review of Resident #25's clinical record showed a urine culture (a test used to detect the type of bacteria), dated 12/21/20 indicated the resident had a urinary tract infection. A physician progress note dated 4/14/21, documented Resident #25 had a diagnosis of urinary retention. On 5/3/21 at 10:00 a.m., Resident #25 was observed sitting in her wheelchair with the drainage bag of the indwelling catheter in a privacy bag attached to the base of the wheelchair. The catheter tubing was not secured and was in contact with the floor. On 5/3/21 at 3:00 p.m., Resident #25 was observed in her bed and the catheter drainage bag and tubing were resting on the floor next to the bed. **Photographic Evidence Obtained** 2. Review of the clinical record for Resident #104 showed a diagnosis of dementia and urinary tract infections. The clinical record showed urine cultures dated 1/23/21 and 2/11/21 indicated Resident #104 had a urinary tract infection. On 5/3/21 during random observations at 10:24 a.m., and 11:44 a.m., Resident #104 was in her wheelchair. The urinary catheter drainage bag was in a privacy bag attached to the base of the chair. The catheter tubing was not secured and was in contact with the floor. On 5/3/21 at 3:06 p.m., Resident #104 was observed in her bed. The drainage bag and tubing were on the floor. On 5/4/20 at 8:30 a.m., Resident #104 was observed in bed. The catheter drainage bag was attached to the bed frame, the tubing was not secured and was on the floor. **Photographic Evidence Obtained** On 5/6/21 at 8:35 a.m., in an interview, Licensed Practical Nurse (LPN) Staff N said the Certified Nursing Assistants and nurses were responsible to ensure a patient with a urinary catheter had the drainage bag in a privacy bag and the bag and tubing were not on the floor. LPN Staff N said she checked to ensure residents with catheters had the tubing and drainage bags properly placed. LPN Staff N said the facility provided in-service education on catheter care and said the catheter tubing and drainage bag should not have been on the floor. On 5/6/21 at 8:40 a.m., in an interview, LPN Staff O said it was the nurse's responsibility to make sure the positioning of the catheter tubing and drainage bags were off the floor. 105363 Page 5 of 9 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

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 observation, staff interview and clinical record review, the facility failed to ensure a physician's order was in place prior to delivery of oxygen therapy to 1 (Resident #38) of 1 resident reviewed for oxygen therapy. Residents Affected - Few The findings included: Reviewed facility policy, Oxygen Administration - Nasal Cannula Clinical Practice Guideline, facility reviewed 10/23/20 which said, Oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Guideline step 1 said, Check the resident's medical record to confirm the presence of a complete and appropriate physician's order. Step 6 said, Place an Oxygen in Use sign on the outside of the room entrance door. Step 18 said, Document in the medical record per documentation guidelines. Reviewed facility policy, Review of Physician Orders facility reviewed 4/14/21 said step 1, Physician orders be reviewed daily by nursing administration during the Clinical Meeting. On 5/3/21 at 11:20 a.m., Resident #38 was observed in bed with nasal cannula (medical device used to give oxygen into the nose) in place attached to oxygen machine at 3.5-liter flow rate. Resident #38's door had no signage for oxygen therapy. On 5/4/21 at 11:28 a.m., Resident #38 was observed in bed with eyes closed and nasal cannula in place delivering 3.5-liter flow of oxygen. Resident #38's door did not have signage indicating oxygen in use. On 5/5/21 at 10:43 a.m., in an interview, Licensed Practical Nurse (LPN) Staff C said, I have taken care of Resident #38 many times since he moved to room [ROOM NUMBER]. He was moved to room [ROOM NUMBER] on 3/18/21 when the private room opened up. LPN Staff C said, Resident is on oxygen nasal cannula and has been since he was moved to room [ROOM NUMBER], if not longer. LPN Staff C was asked to review the order for oxygen therapy in the resident clinical record. LPN Staff C was unable to find an order for oxygen in the clinical record. LPN Staff C said, I can't find an order for his oxygen. I will contact the Nurse Practitioner to get an order. He should have one. On 5/5/21 at 10:55 a.m., observed Resident #38 in bed, resting with nasal cannula in place, delivering 3.5-liter flow of oxygen. Resident #38's door did not have signage indicating oxygen in use. On 5/6/21 at 9:58 a.m., in an interview, the DON confirmed Resident #38 had been receiving oxygen via nasal cannula for months without a physician's order. The DON said, It was our mistake. There should have been orders. I had the respiratory team assess all residents with oxygen today. 105363 Page 6 of 9 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to maintain a safe, sanitary and clean environment for residents. The findings included: On 5/3/21 at 9:31 a.m., during an initial tour of the A wing nursing unit, the following was observed: The A wing resident shower room had dusty air vents. The bottom of the shower chair had a brown substance on the bottom of the chair. On 5/4/21 at 9:00 a.m., in the B wing shower room there was a brown substance on the toilet seat. On 5/05/21 at 10:08 a.m., during a tour of the facility with the Maintenance Director and the Director of Housekeeping, the following observations were made: On the A wing the dietary storage had stained ceiling tiles and live insects were observed crawling on top of the boxes of dry goods. The door handle to the 100-110 double door was missing the end cap exposing sharp metal. A Wing corridor Light cover have dust and dead insects in them. A Wing Records storage room emergency exit was blocked by a pallet of boxes. A Wing Soiled utility room stain and water damage ceiling tiles. A Wing Soiled utility room vent dusty. The bottom of the A Wing Shower chair remained with the brown substance observed on 5/3/21. The shower room vent remained dusty. A Wing Shower has unlocked cabinet with unlabeled personal grooming supplies. A Wing Shower room floor built up dirt on floor along with debris missing corner cove base. Resident room [ROOM NUMBER] restroom visible bubbling of paint and drywall / wet to touch. Resident room [ROOM NUMBER] room visible bubbling of paint and drywall. Main corridor light cover has dust and insects inside them. Main corridor 4 ceiling tiles had water stains. Main Corridor employee break room has visible green and black mold on wet deteriorating wall under 105363 Page 7 of 9 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

F 0921 wall mounted air-conditioner. Level of Harm - Minimal harm or potential for actual harm B Wing Ice room floor had debris behind vending machine. room [ROOM NUMBER] floor had food stains and debris. Residents Affected - Some B wing Vent inside alcove dusty. B Wing outside of activities room wet ceiling tile with mold and dust. Activities room light cover have dust and insects inside them. B Wing Soiled Utility Room sink cabinet is deteriorating from water and noticeable odor of mold. B Wing storage room had water stains on ceiling tiles. Therapy Gym floors had visible debris. C Wing Med room had stained ceiling tiles. C Wing Soiled Utility room with debris on floor. C Wing light covers had dust and insects inside them. C Wing ice machine had hard water stains on side. C Wing beauty salon vent dusty. C Wing Linen room has a large hole in ceiling tile. On 5/5/21 at 11:15 a.m., the Maintenance Director and Housekeeping Director both acknowledged all the findings. On 5/3/21 at 10:37 a.m., during the initial tour of the facility, an uncovered bedpan was observed resting on the toilet of the shared bathroom for rooms [ROOM NUMBERS]. ** photographic evidence obtained** On 5/3/21 at 11:37 a.m., during the initial of the facility, an uncovered bedpan was observed resting on the sink of the shared bathroom for rooms [ROOM NUMBERS]. ** photographic evidence obtained** On 5/4/21 at 9:42 a.m., during a tour of the facility, an uncovered bedpan was observed resting on the grab bar of the shared bathroom of rooms [ROOM NUMBERS]. ** photographic evidence ** On 5/4/21 at 9:59 a.m., during a tour of the facility, an uncovered bedpan, uncovered urine 105363 Page 8 of 9 105363 05/06/2021 Charlotte Bay Rehab and Care Center 4033 Beaver Lane Port Charlotte, FL 33952

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some measuring container, and an uncovered syringe were observed in the shared bathroom of rooms [ROOM NUMBERS]. ** photographic evidence obtained** On 05/06/21 at 12:27 p.m., the ADON (Assistant Director of Nursing) viewed the photographic evidence and said the resident care items were not stored correctly but did not have a specific policy addressing the storage of personal care items. 105363 Page 9 of 9