Health inspection·December 29, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interviews, and record review the facility failed maintain a clean and sanitary environment for one (Resident #208) out of twenty-one residents in the sample group regarding not deep cleaning and sanitizing a room. Findings included: During the initial tour of the facility, on 12/27/21 at 09:45 a.m. an empty room was entered. No resident names were noted on the door. Resident items were still present in the room. On a shelf in the closet, designated for bed A, there was a bottle of water, a bed pan, and a bedside commode bucket observed. In the closet, designated for bed A, there were clothes labeled with Resident #208's name on them. The dresser, designated for bed A, had wound care supplies in the top drawer. The dresser for bed A had a wrist band with Resident #208's name on it, a telfa gauze, 4x4 sponges, two rolls of cloth tape, one roll of gauze bandage, a roll of edema wrap, two no stick barrier wipes, and a clear plastic bag labeled wound care supplies which contained a roll of clear tape, and a container of no stick barrier spray. A second plastic bag contained a roll of cloth edema wrap and four Mepitel gauzes. In the closet, designated for bed B, were clothes labeled with Resident #209's name on them. Photographic evidence was obtained. A review of the current facility census, dated 12/27/21, indicated Resident #208 and Resident #209 were no longer in the facility. A review of the medical records revealed Resident #208 was discharged on 12/20/21 to the hospital. A review of the medical records revealed Resident #209 was discharged on 12/16/21. Review of a nursing admit/readmit form for Resident #208 dated 12/27/21 at 11:16 p.m. revealed the resident was admitted back to the previous room, in bed B, where the items were discovered on 12/27/21 at 9:45 a.m. in the empty room. Resident #208 had previously been in bed A before discharge. On 12/28/21 at 06:40 AM, in an interview was conducted with the Director of Nursing (DON). The DON stated, The room should have been terminally cleaned by housekeeping before yesterday, and definitely after the resident in the room was discharged a week prior. The DON confirmed the items in the closet were still there, and the photographic evidence taken the day before was the same and the Resident #208 had been admitted back into the room to the other bed prior to the terminal cleaning being completed. On 12/29/21 at 1:23 pm an interview was conducted with the Plant Operations Director (POD), Plant Operations Manager (POM), and Nursing Home Administrator (NHA). The POD stated there is no time frame Page 1 of 5 105378 105378 12/29/2021 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on when the rooms get terminally cleaned before the next resident moves in, but it is usually within two days of a resident leaving the room. He stated it is the Certified Nursing Assistants (CNA) job to make sure that all the personal items are removed from a room. He stated the clothing, wound care supplies, bedpan, and bed side commode bucket should have been taken care of by the CNAs. The NHA stated the CNAs should have taken the items out of the room. He stated the rooms are to be emptied and cleaned before the resident comes into the room. He makes sure empty rooms are clean before the next resident comes into the room. Review of the policy titled Routine Cleaning and Disinfection, with a copyright date of 2021, revealed the following: Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Policy Explanation and Compliance Guidelines: 6. Frequency of cleanings will vary a. Patient rooms inspections will be done by the housekeeping staff daily. Cleaning will be done as needed. b. All patient rooms will be deep cleaned after each vacancy and also reinspected prior to a new resident moving in. 105378 Page 2 of 5 105378 12/29/2021 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

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 observations, interviews, facility policy and record reviews the facility failed to ensure the interventions on the resident centered care plan were revised, related to wound care for one (Resident #3) of twenty-one residents in the sample group. Findings included: On 12/28/2021 at 1:37 p.m. a wound care observation was conducted for Resident #3. The wound was located on the left lower lateral calf and was diagnosed as a venous stasis wound related to Peripheral Vascular Disease (PVD). A review of the medical record for Resident #3 indicated he was admitted on [DATE] with diagnoses that included peripheral vascular disease (PVD). A review of the Order Summary Report for Resident #3 revealed an active order for wound care started on 2/28/2021 to Cleanse area to left lateral lower extremity with normal saline and apply oil emulsion and cover with Collagen and dry dressing and change every day and as needed (PRN), for PVD. A review of the Comprehensive Care Plan for Resident #3 was conducted on 12/28/21, a focus area for Resident #3 was listed as follows: Focus: He is at risk for further skin alterations related to unavoidable risk due to decreased mobility, fragile skin, PVD, bowel and bladder incontinence, scratches self. He was admitted with multiple skin alterations (date initiated: 9/2/20) Goals: He will not sustain further skin alterations of unknown origin thru next review date (revision on: 10/13/21). Skin alteration to RLE (right lower extremity) will heal without complications by next review date (revision on: 2/17/21) Skin tear to RLE will resolve by next review date (revision on: 12/17/21) Skin tear to right upper arm will heal without complications by next review date (revision on 12/17/21) Skin alterations to left heel will heal without complications by next review date (revision on 12/17/21) Skin tear to left forearm will heal without complications by next review date (revision on: 12/17/21) 105378 Page 3 of 5 105378 12/29/2021 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

F 0657 Skin tear to left upper arm will heal without complication by next review date (revision on 12/17/21) Level of Harm - Minimal harm or potential for actual harm Review of the Care Plan showed no goal related to the left lateral lower extremity associated with the wound care observations conducted on 12/28/21. Residents Affected - Few Interventions related to specific wound area included:: Treatment to right upper arm per orders see TAR (treatment administration record) (date initiated 9/7/21) Treatment to left forearm per orders see TAR (date initiated 11/28/21) Treatment to left heel per orders see TAR (date initiated 9/28/21) Treatment to left upper arm per orders see TAR (date initiated 12/27/21) Treatment to right lower extremity per order see TAR (date initiated 11/23/21) An interview was conducted on 12/29/2021 at 9:00 a.m., with the Clinical Manager for MDS, who is responsible for updating care plans. During the interview she confirmed a goal and intervention for Resident #3's left lower leg Venous Stasis wound was not listed on the current care plan. She stated I pulled his care plan yesterday (12/28/2021) and noticed I had resolved it accidentally, by completing the intervention on 10/13/2021, and it is my fault that it's not there right now on the care plan. The wound should have been on his care plan the whole time. Immediately after the interview, the Clinical Manager revised Resident #3's care plan and showed the survey team she added the intervention. The intervention read Treatment to left lateral lower extremity per orders see TAR. (date initiated 12/27/21). A review of the facility policy titled Comprehensive Care Plans, with revision made in September 2021, Pages 01-02 read as follows: POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and compliance guidelines: 2. The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 105378 Page 4 of 5 105378 12/29/2021 St Mark Village 2655 Nebraska Ave Palm Harbor, FL 34684

F 0657 Level of Harm - Minimal harm or potential for actual harm b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR (Preadmission Screening and Resident Review) recommendations. Residents Affected - Few d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 105378 Page 5 of 5