Health inspection·November 25, 2020

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to demonstrate responsiveness to resident council concerns regarding nursing care when voiced grievances were not addressed and acted upon for three out of three months reviewed. The facility did not provide the resident council with responses, actions, and rationale taken regarding their concerns. Residents Affected - Some Findings: An interview was conducted with the facility Life Enrichment Director on 11/23/20 at 1:45 p.m. She confirmed that she was the appointed facility staff facilitator for the resident council. She reported that there was no council president in accordance with the residents' wishes. She reported that the council met monthly but that during the coronavirus disease (COVID-19) pandemic the group format had been stopped and replaced with a monthly survey format. She explained that the survey was conducted individually by life enrichment staff with each resident as an opportunity for residents to voice any concerns. She reported that concerns voiced in the survey were taken to appropriate department heads, and minutes were compiled from the survey and distributed back to the residents. Resident council minutes were reviewed for September 2020, October 2020, and November 2020. At the top of each document was the following: The meeting of the Resident Association was unable to be held due to restrictions related to COVID, however Residents were visited by [staff name] to allow them to voice their opinions by filling out a questionnaire where resident answers were kept anonymous. The minutes for each month revealed No concerns under the heading Old Business. The minutes for September, dated 09/17/20, revealed the following under the heading New Business .Nursing: Some residents shared they get the help and care they need without waiting, and some shared that sometimes there is a wait, and it depends on the staff member. Life Enrichment met with [name], the Director of Nursing (DON). [DON] is going to write up a grievance and do retraining with the staff. The minutes for October, dated 10/15/20, revealed the following under the heading New Business .Nursing: Some residents shared they get the help and care they need without waiting, and some shared that sometimes there is a wait, and it depends on the staff member. One resident expressed needing to use the restroom every 30 minutes due to a diuretic, which is more than what her scheduled bathroom times are, so she sometimes has to wait to get help. The minutes for November, dated 11/18/20, revealed the following under the heading New Business .Nursing: Most residents think that Staff give the help that the Residents need without waiting a long time, and others shared that they wait a long time at night and think that more Staff are needed Page 1 of 5 105378 105378 11/25/2020 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some during that time. [Life Enrichment Director] asked Residents what makes them think more Staff are needed. It was shared that they hear the Aide's (sic) conversations outside their rooms, and 'why else would they be waiting so long.' [Life Enrichment Director] shared that we have the State required staff needed at night and the long wait would be looked into. Facility grievance logs were reviewed for September, October, and November 2020. There were no entries on behalf of the resident council. During a review of facility grievances with the facility Social Services Director on 11/24/20 at 1:30 p.m., it was confirmed that there were no grievances filed on behalf of the resident council. On 11/24/20 at 3:30 p.m. a small group meeting with three regular resident council members was conducted. Attendees were Residents # 4, # 6, and # 32. A review of the Minimum Data Set (MDS) for each resident was conducted and revealed the following Brief Inventory of Mental Status (BIMS) for each: Resident # 4 had a BIMS of 14 which meant that she cognitively intact; Resident #6 had a BIMS of 14 which meant that she was cognitively intact; Resident #32 had a BIMS of 12 which meant that the resident had moderate cognitive impairment (score range 8-12). The residents confirmed that they were regular council members, confirmed that there had been no group council meetings due to precautions related to COVID, confirmed they participated in the replacement survey format, and reported that they did receive the minutes but that it doesn't say the outcome of the concern. Regarding concerns about nursing care, long wait times, and staffing revealed in the September, October, and November council minutes, all three residents confirmed the concerns and that they were ongoing. Resident # 6 stated that there had been occurrences twice in the last two weeks where the facility was short nurses on the night shift and the facility Director of Nursing (DON) had to come in and cover. Resident # 4 stated that there was often just one nurse and one aide on each hallway at night and said, takes a long time for them to come to my room and answer my light .sometimes as long as calling four times. The residents could not identify specifics about the facility grievance process and council concerns. The residents stated they did not know what happened with the concerns they expressed in council meetings. On 11/24/20 at 4:30 p.m. a follow-up interview to the council meeting was conducted with the Life Enrichment Director. Regarding the nursing care concerns revealed in the minutes for [DATE] - November 2020 she stated that her role was to report the concern to the appropriate department which she identified as nursing but that beyond that she couldn't comment. On 11/25/20 at 9:10 a.m. an interview was conducted with the facility Administrator, the DON, and the Life Enrichment Director. The Life Enrichment Director re-confirmed that her role was to take concerns expressed by the resident council to the relevant department head. She confirmed that she had brought the concerns expressed about nursing care, long wait times, and staffing to the DON for the months of September and October. The Administrator, DON, and Life Enrichment Director all confirmed that there was not a facility process/practice for grievances/concerns voiced by the resident council. The DON stated the nursing care/wait times/staffing concerns voiced by the resident council had been brought to her attention. Regarding the concerns expressed in September 2020 she stated that the concerns were addressed in the Certified Nursing Assistant (CNA) meeting stating she, would have to double check on a nurses meeting if I addressed with nurses .but did address with the CNAs .addressed about answering call lights promptly, making sure residents got their needs met appropriately. She stated that the CNAs had not provided any feedback as to why long wait times were happening and that no further root cause analyses had been conducted. Regarding the concerns expressed in October 2020 she said, I haven't addressed it yet .was going to at the next CNA meeting again . The 105378 Page 2 of 5 105378 11/25/2020 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

F 0565 Administrator said, it sounds like we need to do a root cause analysis for the facility related to this area. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Resident and Family Grievances with a revision date of October 2019 revealed: Policy Explanation and Compliance Guidelines: .8. Grievances may be voiced in the following forums: .d. Verbal complaint during resident or family council meetings .; 10. Procedure: .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 .The Grievance Official will take steps to resolve the grievance, and record information about the grievance .The Grievance Official, or designee, will keep the resident or family member appraised of progress towards resolution of grievances Residents Affected - Some 105378 Page 3 of 5 105378 11/25/2020 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to immediately monitor and document the status of the resident upon returning from the dialysis treatment for one (Resident #153) of one Dialysis resident reviewed. Residents Affected - Few This failure had the potential to result in delayed management of changes in condition and complications arising from dialysis. Findings: Resident #153 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified Chronic Kidney Disease and Type 2 Diabetes Mellitus without complications. A review of the Order Summary Report indicated Resident #153 had Dialysis at 10:15 a.m. on Tuesdays, Thursdays, and Saturdays with an offsite vendor. The care plan for Resident #153 identified that the resident needed hemodialysis related to renal failure and staff were to monitor/document/report as needed (prn) any signs/symptoms (s/sx) of infection to access site: redness, swelling, warmth or drainage and monitor/document/report prn new/worsening peripheral edema. An observation and interview was conducted with Resident #153 on 11/23/20 at 4:21 p.m., as she sat in her wheelchair in her room after returning from Dialysis. At 2:03 p.m. on 11/23/20, Staff Member C, Licensed Practical Nurse (LPN) stated she sent a communication form with the resident, which was completed by the Dialysis Center and returned to the facility. On 11/25/20 at 12:24 p.m., Staff Member C stated Resident #153 did not return to the facility until after her shift ended. A review of the Dialysis Communication Reports and progress notes related to Resident #153 was conducted with Staff Member C. The reports indicated Facility Nursing staff to document the following in the Resident's Medical Record when the resident returns to the facility: - a. Vital signs; - b. Skin integrity; - c. any bleeding or concern with dialysis access site (Notify the dialysis center also); - d. Any other issue with the Resident regarding dialysis. Review of the communication reports and progress notes in the resident's medical record indicated that on 11/7/2020 and 11/13/2020 two out of seven opportunities (from 11/7/2020 through 11/23/2020), there was no documentation of the resident's status including vital signs and skin integrity immediately after return. There was also no documentation if there had been any bleeding or concerns with the dialysis site and any other issue regarding dialysis. There had been no documentation as instructed in the resident's medical record. The staff member confirmed these findings and stated they (nursing) were suppose to document her return with the items listed on the communication report. 105378 Page 4 of 5 105378 11/25/2020 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Service Agreement between the facility and the Dialysis Center indicated that both parties were to ensure there was documented evidence of collaboration of care and communication between the Nursing Facility and ESRD Dialysis Unit. On 11/25/20 at 4:51 p.m., the Director of Nursing stated the facility audited the Dialysis forms and would be implementing a new one. She added that there should have been at least a progress note on the resident's status when returning from Dialysis. 105378 Page 5 of 5