Health inspection·January 14, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure assistance with Activities of Daily Living (ADL) for dependent residents was provided for six (Resident #17, #26, #27, #21, and #78) of 33 sampled residents. Residents Affected - Some Findings included: A review of Resident #17's Medical Record revealed that she was admitted to the facility on [DATE] with diagnoses of dementia and Major Depressive Disorder. A review of Resident #17's Care Plan revealed a problem, revised on 01/14/2022, that she had poor intake by mouth and was at risk for weight loss/dehydration. Interventions included to provide super foods as indicated, provide diet per order, and provide a home made chocolate milkshake two times daily. Resident #17's Care Plan also revealed a problem, initiated 10/06/2020, that she required maximal direction with daily decision making. Interventions included to observe for changes in the resident's cognitive and communications status and have Speech Language Pathology (SLP) evaluation and treatment as needed. A review of Resident #17's Minimum Data Set (MDS) Assessment, dated 10/07/2021, revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. An observation was conducted on 01/12/2022 at 11:52 AM of Resident #17 during the lunch meal. She was observed in bed with the head of the bed elevated and a meal tray in front of her on the bedside table. Resident #17 was observed talking to herself, had frequent and sporadic arm movements, and did not appear to be able to feed herself. She was observed knocking her meal tray into her bed and onto the floor. At 12:06 PM, facility staff was observed cleaning up the meal tray that Resident #17 spilled and exiting the room. Resident #17 was not provided another meal tray and was not observed being assisted with the lunch meal. An observation was conducted on 01/12/2022 at 5:43 PM of Resident #17 during the dinner meal. Staff A, Certified Nursing Assistant (CNA) was observed bringing in a dinner tray for Resident #17, turning the light on, and exiting the room. An observation inside of the resident's room at 5:56 PM revealed her meal tray was set up, uncovered, on her bedside table and out of her reach. She was observed laying flat in the bed and was not provided assistance with the dinner meal. An observation was conducted at 6:48 PM of Staff A, CNA collecting the tray of Resident #17's roommate and putting it on the meal cart. Staff A, CNA did not collect Resident #17's tray and did not provide assistance with Resident #17's dinner meal. Staff A, CNA was observed collecting other resident trays in the unit Page 1 of 17 105385 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0677 hallway. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 01/12/2022 at 6:51 PM with Staff A, CNA. She stated she was not sure if she collected Resident #17's tray when she entered her room and stated that she was going to check to see if the tray was collected. Staff A was observed taking Resident #17's dinner tray out of the room and putting it back onto the meal cart. An interview was conducted with Staff A following the observation. Staff A stated Resident #17 was no longer able to feed herself due to an increase in her hand and arm movements and was able to feed herself up until a couple of weeks ago. Staff A addressed she did not assist Resident #17 with her dinner meal and did not attempt to assist the resident because she had a history of refusing meals and resisting attempts to assist with dining. Residents Affected - Some An interview was conducted on 01/14/2022 at 07:55 AM with the facility's Certified Dietary Manager (CDM). The CDM stated that he was not informed by facility staff that Resident #17 needed assistance with her meals. He said the CNA staff should be communicating any changes in the resident's ability to feed themselves to the nurse so it could be addressed. An interview was conducted on 01/14/2022 at 2:36 PM with Staff B, Licensed Practical Nurse (LPN). Staff B stated Resident #17 had some decline in her functioning over the last week and was more agitated and anxious then usual. Staff B also stated that the nurse should be notified by the CNA staff of any decline in resident functioning so they could be assessed and the proper referrals and notifications could be made. A review of Resident #17's Meal Intake Record from 12/30/2021 to 01/14/2022 revealed that Resident #17 had an intake of 0% to 25% of meals for 31 of 40 recorded meals and refused 9 of 40 recorded meals. A telephone interview was conducted on 01/14/2022 at 3:18 PM with the facility's Registered Dietician (RD). The RD stated that any drastic change in a resident's intake should be communicated to the CDM and herself to assess the cause for the decreased intake. Decreased intake could be related to dysphagia, decreased appetite, infection, depression, an overall decline, or a decreased ability to feed themselves. The RD also stated that she was at the facility on 01/10/2022 and staff did not inform her that Resident #17 had a change in her ability to feed herself. A review of Resident #17's annual Nutritional Assessment, dated 10/07/2021, revealed that the resident's meal intake varied from 25% to 76% at meal times and she required encouragement for meal and supplement intake. The Nutritional Assessment also revealed under the section titled Nutrition Goals that Resident #17 had goals to consume all/most supplements, tolerate diet, and improve meal intake 75% for 2 of 3 daily meals. An interview was conducted on 01/14/2022 at 6:28 PM with the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON stated that the CNA or nursing staff share observations of residents during meal times and refer them to therapy if any changes were identified. CNA staff were expected to notify the nurse if a resident was not able to feed themselves or had had a change in their functional ability. CNA staff would also be expected to provide assistance with meals as needed. The DON stated he was notified that Resident #17 had recently needed more assistance with meals and even though she refused meals he would still expect the CNA staff to attempt to provide assistance to the resident at meal times. A review of the facility policy titled Assistance with Meals, revised in July 2017 revealed under 105385 Page 2 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0677 Level of Harm - Minimal harm or potential for actual harm the section titled Policy Statement that residents shall receive assistance with meals in a manner that meets individual needs of each resident. The policy also revealed under the section titled Resident requiring full assistance that resident who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Residents Affected - Some Photographic evidence obtained. 2. An observation of dependent roommates (Resident's #26 and #27) on 1/13/22 at 8:30 a.m. revealed: Resident #27 laying on her bed sideways (head closest to the door and feet toward the window) with her legs crossed and feet hanging over the right side of the bed just above her soiled brief that was lying on the floor mat. Resident #27 was observed without clothes, a brief, or covers. Her brief was on the floor mat and covers were toward the foot of the bed. Her water cup was observed on the bedside table with the paper still covering the top of the straw. Resident #26 was observed lying on her back on an air mattress with her mouth wide open . The head of the bed was elevated and her tube feeding was infusing at 75 ml per hour. The residents' room was observed from the conference room. Staff E, LPN was observed going in twice to provide medication to Resident #26 and #27 around 9:30 a.m. on 1/13/22. An interview with Staff E, on 1/13/22 at 10:10 a.m., confirmed she did not cover Resident #27 or alert the CNA that the resident was without clothes and had a soiled brief on the floor. Resident #26 and #27 were observed on 1/13/22 at 10:45 a.m., in the same position with Resident #27 still uncovered without clothes and the soiled brief under her feet on the floor mat. Resident #27's water cup remained the same with paper covering the straw. An observation of Resident #26 and #27 on 1/13/22 at 11:40 a.m., revealed Resident #26 still lying on her back with her mouth wide open and head of bed elevated. Resident #27 was observed in a fetal position without clothes or covers and her feet were hanging over the soiled brief on the floor. Her blankets were observed toward the foot of the bed. Her tray table was observed with the water cup untouched and the straw covered with paper at the top. Meal trays were observed coming down the 300 hallway at 11:41 a.m. on 1/13/22. Staff I, CNA was getting the trays ready to deliver. He stated he last checked on Resident #27 about 45 minutes ago and was unable to say if she was clothed or wearing a brief. He said he did not offer her water at that time and said she had a history of removing her clothes. Staff I went to check on the resident and said he would get her cleaned up and dressed immediately. An interview was conducted with Staff H, CNA on 1/13/22 at 12:16 p.m. She stated she was taking care of Resident #26 and last checked on her a while ago. Staff H could not say if she observed the roommate (Resident #27) and what state she was in when she went into the room. Staff H, stated she needed to complete peri care on Resident #26 and would do that soon with [Staff I] and then walked away. On 1/13/22 at 1:24 p.m., Staff H and Staff I were observed walking into Resident #26's room with supplies. Resident #26 was lying on her back with her mouth wide open. A white incontinence pad was observed saturated with dark yellow urine and a white brief was observed saturated from front to back with dark yellow urine. Staff H, said, oh wow as she removed the saturated brief and incontinence 105385 Page 3 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pad. Resident #26 was observed with stool stuck to her bottom. Staff H cleaned the stool with a soapy wash cloth at least 4 times leaving some stool on the residents bottom. Staff H, CNA confirmed she did not apply the brief and was unaware the resident was wearing a brief as this was the first time she changed the resident today. Staff H finished cleaning the resident and applied a blue incontinence pad without a brief under the resident. Staff H and Staff I applied lotion to the resident without removing the soft boots on both feet. Both staff members stated they never remove the boots to apply lotion or clean the resident that the nurse did that. Resident #26 was then positioned on her right side facing the window and covered up. Resident #26 was admitted [DATE] for diagnoses to include dysphasia following nontraumatic intracerebral hemorrhage and vascular dementia. A review of the MDS dated [DATE], under Section C a BIMS revealed a score of 99 which indicated the resident was unable to be assessed. Section G for functional status revealed the resident needed extensive assistance of two plus persons for mobility and personal hygiene . A review of the care plan focus area for activities of daily (ADL) living status revealed the resident had a history of cerebral vascular accident with dysphagia and was nonverbal, initiated on 7/24/19. Interventions included assisting resident with repositioning in bed, initiated on 7/24/19. Resident required assist of two for all incontinence care, initiated on 1/18/20. Resident needed staff to provide pericare, initiated on 7/24/19. Resident needed two staff to move her up in bed using a draw sheet as indicated, initiated on 7/24/19. A review of the task sheet for toilet use dated 1/13/22, revealed the resident was totally dependent using full staff performance at 5:56 a.m. and 9:21 a.m. The task sheet for bowel continence dated 1/13/22 revealed at 5:56 a.m. and at 2:59 p.m., Resident #26 was incontinent of large loose stool and incontinent of urine. Resident #27 was admitted on [DATE] for diagnoses to include Alzheimer's disease and unspecified dementia with behavioral disturbance. A review of the MDS dated [DATE], under Section C a BIMS revealed a score of 5 which indicated severe cognitive impairment. Section G for functional status revealed for bed mobility and toileting the resident needed extensive assistance of two plus persons for physical assist. Dressing, personal hygiene and eating required extensive assistance of one person physical assist. A review of the care plan focus area for activities of daily living revealed the resident had decreased ability to participate with her ADL care related to generalized weakness and impaired cognition and mobility. She required assist of two for bathing and incontinence care due to her repetitive behaviors initiated 2/20/18. Interventions included resident needed staff to assist her with dressing, initiated on 4/26/18. Resident liked to disrobe and preferred a fetal position in bed, initiated on 10/17/19. Provide resident with incontinence checks and pericare, initiated on 4/26/18. Provide level of assistance as needed for each meal. Offer to assist resident with her meals. Resident would ask for snacks at a later time if she did not feel like eating her meal, initiated on 4/26/18. Resident was incontinent of bowel and bladder, resident used briefs when she was out of bed, initiated on 4/26/18. A review of the task list for nutrition and number of times fluids were offered for 1/13/22, included only 5:55 a.m. with fluid offered 3 times. The task list was printed on 1/13/22 at 4:55 p.m. The 105385 Page 4 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some task list for bowel continence and urinary continence dated 1/13/22, revealed the resident was incontinent at 5:56 a.m. and 10:36 p.m. A review of the Kardex revealed Resident #27 had a tendency to turn sideways in bed. Reposition when necessary and as tolerated. Required floor mats to both sides of bed when resident was in bed. Provide privacy and then redirection when resident began to disrobe to maintain her dignity. Provide resident with incontinence checks and pericare. Resident was incontinent of bowel and bladder, resident used briefs when she was out of bed. Encourage resident to drink fluids throughout each shift. During an interview on 1/13/22 at 4:29 p.m. with the Director of Nursing (DON), he stated his expectation would be to check and change the resident every 2 hours and stated he believed in his staff and they would not leave a resident for a long period of time but stated he would verify by surveillance. The DON confirmed soft boots should be removed by aides to wash and apply lotion and the nurse would apply any treatments. During an interview with the DON on 1/13/22 at approximately 7:00 p.m., he brought in a piece of paper with handwritten times and stated management reviewed the facility surveillance and the longest time between staff entering Resident #26's and #27's room was one hour and fifty-eight minutes. The DON stated he was unable to say if the staff provided care for Residents #26 or #27 and fluids for Resident #27 as he only looked at people entering the resident's room. The DON confirmed that any aides entering the room should have offered resident #27 water and provided care for a resident that was without clothes and removed the soiled brief that was on the floor. 3. On 01/11/22 at 1:10 p.m., an observation was made of Resident #21. He was lying in bed, watching the television. His facial hair, mustache & beard was not groomed. On 01/12/22 at 11:15 a.m. an observation was made of Resident #21. He was lying in bed, watching television. Facial hair remained ungroomed. On 01/13/22 at 11:16 a.m. an observation was made of Resident #21. He was lying in bed, watching television. Facial hair remained ungroomed. On 01/14/22 at 12:35 p.m. an observation was made of Resident #21. He was lying in bed, facial hair remained ungroomed. Staff G, Certified Nursing Assistant (CNA) was called into the room and asked when the resident would be shaved. Staff G walked to the side of the bed and slightly kneeled down to be at eye level with Resident #21. She asked if he wanted to be shaved. He nodded his head up & down, to indicate Yes. Staff G asked him if he wanted his mustache shaved, he shook his head from side to side, to indicate No. Staff G asked the resident if he only wanted his beard shaved, he nodded his head up & down, to indicate Yes. Staff G stated that she would shave him right away. On 01/14/22 at 4:28 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) regarding ADL care related to shaving. She stated the residents should be shaved as needed or as requested according to their preference. Her expectation was that CNA's would offer the residents a shave daily, while they were providing care. She would not expect the CNA's to wait until a resident's shower day to offer a shave since they may require one in between those times. A review of Resident #21's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of but not limited to, unspecified dementia without behavioral disturbance, contracture of left hand and contracture of right hand. 105385 Page 5 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0677 Level of Harm - Minimal harm or potential for actual harm A review of the current MDS assessment dated [DATE] revealed a BIMS score of 07, which indicated Resident #21 had severe cognitive impairment. Further review of the MDS assessment Section G, Functional Status, indicated the resident required extensive assistance of at least one person to use the toilet, bathe, eat, dress & perform personal hygiene activities. He also had functional limitation in range of motion with impairment on both sides of the upper & lower extremities. Residents Affected - Some Review of Resident #21's most recent care plan dated 07/19/21, revealed a focus area for ADL's related to a functional deficit due to generalized weakness, impaired mobility, and impaired cognition. Goals were to have daily needs met to maintain safety, comfort, and dignity through next review date (10/28/22). Interventions included but not limited to resident needed staff to wash him up, dress him in the morning, and offer to shave him daily. On 01/11/22 at 1:07 p.m., an interview was conducted with Resident # 78. He was asked if he preferred to have the facial hair that was observed on his face. Resident #78 stated that he would have liked to have it cut but understood that the staff did not have time to shave him. He had not said anything about it because he did not like to complain. On 01/12/22 at 11:15 a.m. Resident #78 was observed in bed. He had not received a shave; his facial hair was observed in the same manner as the day prior. On 01/13/22 at 11:25 a.m. Resident #78 was observed in bed. He had not received a shave; his facial hair was observed in the same manner as the day prior. A review of Resident #78's admission Record revealed he was admitted to the facility on [DATE] with a diagnoses of but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and contracture of left elbow. A review of the current MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #78 was cognitively intact. Further review of the MDS assessment Section G, Functional Status, indicated Resident #78 required extensive assistance of at least one person to use the toilet, bathe, dress & perform personal hygiene activities. Resident #78 also had functional limitation in range of motion with impairment on one side of the upper extremities. Review of Resident #78's most recent Care Plan dated 12/16/21, revealed a focus area for ADLs related to assistance needed with oral hygiene, toileting hygiene, personal hygiene, etc. Goals were for Resident #78 to have daily needs met to maintain safety, comfort, and dignity through next review date (03/16/22). Interventions included but not limited to assist resident with oral care and encourage him to participate by washing face, hands, and areas that can be reached. On 01/14/22 at 4:28 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) regarding ADL care related to shaving. She stated that the residents should be shaved as needed or as requested according to their preference. She expected the CNA's to offer the residents a shave daily, when they were providing care. Review of facility policy for activities of daily living, supporting dated March 2018, 2001 Med-pass, inc, page 5 and 6 revealed: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Resident who are unable to care out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. 2. Appropriate care and services will 105385 Page 6 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene, b. mobility, c. elimination, d. dining and e. communication. Review of facility policy for activities of daily living, dressing and undressing the resident, revised 2010, Med-pass 2001, page 53 and page 54, revealed: The purpose of this procedure are to assist the resident as necessary with dressing and undressing and to promote cleanliness. 7. Residents who may need some assistance with dressing and undressing include: d. A confused resident who may need assistance in putting on clothing properly. 105385 Page 7 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure wanderguard functioning and placement was properly and consistently documented for one (Resident #239) of two residents sampled for wanderguards. Findings included: A review of Resident #239's Medical Record revealed that Resident #239 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #239's Care Plan revealed a problem, dated 12/31/2021, that Resident #17 exhibited behaviors of wandering, had independent locomotion in her wheelchair, wandered toward exits, was forgetful, confused, and exhibited poor safety awareness, was at risk for elopement, and required a wanderguard. Interventions included to apply a wanderguard, check the wanderguard for functioning every Monday and Thursday on night shift, and check wanderguard placement on Resident #239's right ankle every shift. A review of Resident #239's Minimum Data Set (MDS) assessment, dated 12/28/2021 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Resident #239's MDS assessment also revealed under Section P - Restraints and Alarms, that Resident #239 used a wander/elopement alarm on a daily basis. A review of Resident #239's Physician's Orders revealed an order, dated 12/22/2021 to check wanderguard and placement every shift. A review of Resident #239's Physician's Orders did not reveal an order to check Resident #239's wanderguard for functioning. A review of Resident #239's Treatment Administration Record (TAR) for January 2022 revealed the following documentation for the order to check wanderguard and placement every shift: - No documentation recorded on the 7 AM to 3 PM shift on 01/07/2022. - No documentation recorded on the 3 PM to 11 PM shift on 01/01/2022. - No documentation recorded on the 11 PM to 7 AM shift on 01/03, 01/04, 01/10, or 01/11/2022. An observation was conducted on 01/14/2022 at 1:12 PM of Resident #239 propelling herself in her wheelchair. Resident #239 was observed propelling herself toward the front entrance of the facility with another resident. Resident #239 was redirected by facility staff without difficulty. Resident #239 was observed to have a wanderguard bracelet to her right ankle. An interview was conducted on 01/14/2022 at 1:21 PM with Staff C, Certified Nurses Aide (CNA). Staff C, CNA stated that Resident #239 would normally propel herself in her wheelchair around the building and would sometimes head toward the entrance of the facility after family visits. Staff C, CNA also stated that Resident #239 was easily redirected by staff and that she had a wanderguard bracelet that the nurse would check. An interview was conducted on 01/14/2022 at 1:26 PM with the facility's Director of Nursing (DON). 105385 Page 8 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated that wanderguards were normally checked for functioning twice weekly and that placement of wanderguards should be verified every shift. The DON addressed that Resident #239 did not have an order in place to check the functioning of her wanderguard and stated that the order should have been put into place. The DON also addressed that documentation related to the functioning of Resident #239's wanderguard was missing from the TAR and stated that he would expect the nursing staff to complete required documentation in the TAR and verify the placement as ordered. 105385 Page 9 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and review of the employee orientation and training handbook, the facility failed to ensure one of four nurses working on 1/13/22 from the 3:00 p.m. to 11:00 p.m. shift was trained and competent using the electronic medical record to ensure resident safety regarding medication and treatment administration. Findings Included: During an interview with Staff J, RN agency nurse on 1/13/22 at 4:55 p.m., she confirmed today was her first day working in the building. Staff J confirmed she was not trained on the facility computer system and never had an in-service to find, document, and ensure medications and treatments were completed as ordered. Staff J confirmed Resident #26 was in need of wound care that was not completed during the day. She said she was unable to access the computer system to find where and what type of wound care to provide. Staff J stated she was just figuring out how to find the medications for the resident and document they were given. Staff J attempted to find the resident and the treatments needed but was unsuccessful and stated she would have to find someone to help her navigate the system and find the treatments. Staff J stated she was given infection control information and notified if the facility had Covid but that was the only training she received prior to the start of her shift. During an interview with the Assistant Director of Nursing (ADON) on 1/13/22 at 5:56 p.m., she stated that agency nurses were trained on infection control when they enter the building. The training did not include what type of computer system was used to document and provide medications and treatments, as it was a system that was widely used. The ADON stated she never thought to ask the agency staff if they were familiar with the electronic medical record prior to their shift and went to Staff J to begin the training process. During an interview with the ADON on 1/13/22 at 6:18 p.m., she stated she was training the nurse on quick tips to use the computer but did not have three hours to provide the education needed. During an interview with the Director of Nursing (DON) on 1/13/22 at 6:36 p.m., he confirmed Staff J was not familiar with the electronic medical record as she only worked at a hospital and it would take a minute to teach the system as it was not easy to learn for those that had never used it. During an interview with the ADON on 1/13/22 at 6:55 p.m., she confirmed the staffing coordinator was now providing the staffing agencies with the type of electronic medical record and required the staff to know how to use the system prior to being assigned at the facility. Review of the Clinical Employee Orientation & Training handbook completed on December 21, 2021 for Staff J revealed the training and orientation packet did not include computer training or orientation. Review of the employee new hire (agency) education packet did not reveal any computer training. 105385 Page 10 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane 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** Based on interviews and record reviews, the facility failed to ensure proper monitoring of psychotropic medication was implemented for one (Resident #239) of six residents sampled for Unnecessary Medications. Findings included: A review of Resident #239's Medical Record revealed that Resident #239 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #239's Physician's Orders revealed the following orders: - An order, dated 01/08/2022, for Buspar 5 milligrams (mg) by mouth in the morning for anxiety. - An order, dated 12/22/2021, for Quetiapine Hydrochloride (HCl) 25 mg by mouth at bedtime for sundowning behavior. Resident #239's Physician's Orders did not reveal orders for monitoring of side effects or behaviors related to use of Buspar or Quetiapine HCl. An interview was conducted on 01/14/2022 at 1:26 PM with the facility's Director of Nursing (DON). The DON stated that Resident #239 was put on Buspar and Quetiapine HCl due to restlessness and sundowning behaviors and was followed up by psychiatric services. Residents that received psychotropic medications would have monitoring orders in place for behaviors and side effects. The DON addressed that Resident #239 did not have orders in place for monitoring of behaviors or side effects related to use of Buspar or Quetiapine HCl. The DON stated that he would expect either the nurse entering the medication order or the Unit Managers to enter the orders for behavioral monitoring and side effect monitoring for psychotropic medication use. An interview was conducted on 01/18/2022 at 5:00 PM with the facility's Consultant Pharmacist (CP). The CP stated that he would recommend monitoring for certain medications and that he would expect to see side effect monitoring and behavioral monitoring for any antipsychotic medication use. The CP also stated that the electronic charting system that the facility used had a way to monitor side effects and behaviors related to certain medication usage. 105385 Page 11 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure a medication administration error rate of less than 5%. A total of 34 administration opportunities were observed with 16 medication errors for three (Resident #70, Resident #72, and Resident #240) of six residents observed for medication administration, resulting in a medication administration error rate of 47.06%. Residents Affected - Some Findings included: A review of Resident #70's Medical Record revealed that Resident #70 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. A review of Resident #70's Physician's Orders revealed the following: - An order, dated 11/11/2021, for Insulin Aspart Solution subcutaneously before meals and at bedtime as per sliding scale: 151 - 200 = 2 units. A review of Resident #70's Care Plan revealed a problem, dated 11/24/2021, that Resident #70 had a diagnosis of Diabetes. Interventions included to administer insulin as ordered and rotate injection sites for comfort. An observation of medication administration was conducted on 01/13/2022 at 10:55 AM for Resident #70 with Staff E, Licensed Practical Nurse (LPN). After performing a blood glucose check for Resident #70 and obtaining a result of 186, Staff E prepared Resident #70's insulin for administration. Staff E gathered Resident #70's Insulin Aspart pen and attached a needle to the tip of the insulin pen. Staff E dialed 2 units on the insulin pen's dosage selector, gathered an alcohol wipe, and entered Resident #70's room for insulin administration. Staff E did not prime the insulin pen needle with insulin prior to dialing 2 units on the dosage selector. Staff E donned clean gloves, cleansed Resident #70's upper left arm with an alcohol wipe and administered insulin before doffing the gloves and exiting the room. A review of Resident #72's Medical Record revealed that Resident #72 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A review of Resident #72's Physician's Orders revealed the following: - An order, dated 12/01/2021, for Humalog KwikPen Solution subcutaneously before meals and at bedtime as per sliding scale: 201 - 250 = 4 units. A review of Resident #72's Care Plan revealed a problem, dated 12/13/2021, that Resident #72 had a diagnosis of Diabetes. Interventions included to administer insulin as ordered and rotate injection sites for comfort. An observation of medication administration was conducted on 01/13/2022 at 11:02 AM for Resident #72 with Staff E, LPN. After performing a blood glucose check for Resident #72 and obtaining a result of 209, Staff E prepared Resident #72's insulin for administration. Staff E gathered Resident #72's Humalog KwikPen and attached a needle to the tip of the insulin pen. Staff E dialed 4 units on the insulin pen's dosage selector. Staff E did not prime the insulin pen needle with insulin prior to 105385 Page 12 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dialing 4 units on the dosage selector. Staff E donned clean gloves, cleansed Resident #72's right lower abdomen with an alcohol wipe, and administered insulin before doffing the gloves and disposing the needle into a sharps container. An interview was conducted following the observation with Staff E. Staff E stated that she had training related to insulin pens at other facilities but was never told that the insulin pen needles required priming before dialing the dose and administering it to the resident. Staff E also stated that she did not know the procedure for priming an insulin pen needle. A review of Resident #240's Medical Record revealed that Resident #240 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypertension, Gastro-Esophageal Reflux Disease, and Fibromyalgia. A review of Resident #240's Physician's Orders revealed the following orders: - An order, dated 01/07/2022, for Acidophilus 1 capsule by mouth one time a day at 08:00 AM. - An order, dated 01/07/2022, for Vitamin C 2000 milligrams (mg) by mouth one time a day at 09:00 AM. - An order, dated 01/07/2022, for Benadryl 25 mg by mouth one time a day at 09:00 AM. - An order, dated 01/07/2022, for Calcium-Vitamin D 600 mg-400 mg by mouth one time a day at 09:00 AM. - An order, dated 01/09/2022, for Coenzyme Q-10 200 mg by mouth one time a day at 08:00 AM. - An order, dated 01/09/2022, for Cyanocobalamin 1000 micrograms (mcg) by mouth one time a day at 08:00 AM. - An order, dated 01/09/2022, for Duloxetine Hydrochloride (HCl) 60 mg by mouth two times a day at 08:00 AM and 05:00 PM. - An order, dated 01/07/2022, for Furosemide 40 mg by mouth two times a day at 09:00 AM and 05:00 PM. - An order, dated 01/07/2022, for Glimepiride 4 mg by mouth two times a day at 09:00 AM and 05:00 PM. - An order, dated 01/09/2022, for Multivitamin Tablet 1 tablet by mouth one time a day at 09:00 AM. - An order, dated 01/07/2022, for Omeprazole 20 mg by mouth two times a day at 08:00 AM and 04:00 PM. - An order, dated 01/07/2022, for Potassium Citrate 99 mg by mouth one time a day at 08:00 AM. - An order, dated 01/07/2022, for Lyrica 150 mg by mouth three times a day at 09:00 AM, 02:00 PM, and 09:00 PM. - An order, dated 01/07/2022, for Red Yeast [NAME] Extract 600 mg by mouth one time a day at 09:00 105385 Page 13 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0759 AM. Level of Harm - Minimal harm or potential for actual harm An observation of medication administration was conducted on 01/13/2022 at 11:37 AM for Resident #240 with Staff D, Registered Nurse (RN). Staff D gathered the following medications to administer to Resident #240: Residents Affected - Some - Acidophilus 1 capsule by mouth. - Vitamin C 2000 mg by mouth. - Benadryl 25 mg by mouth. - Calcium-Vitamin D 600 mg-400 mg by mouth one time a day at 09:00 AM. - Coenzyme Q-10 200 mg by mouth. - Cyanocobalamin 1000 mcg by mouth. - Duloxetine HCl 60 mg by mouth. - Furosemide 40 mg by mouth. - Glimepiride 4 mg by mouth. - Multivitamin Tablet 1 tablet by mouth. - Omeprazole 20 mg by mouth. - Potassium Citrate 99 mg by mouth. - Lyrica 150 mg by mouth. - Red Yeast [NAME] Extract 600 mg by mouth. Staff D performed hand hygiene, donned Personal Protective Equipment (PPE) and entered Resident #270's room. Staff D administered medications to Resident #270 at 11:50 AM and exited the room. An interview was conducted following the observation with Staff D. Staff D stated that medications would normally be given within an hour before to an hour after the scheduled time of the medication and if medications were to be administered late, the resident's physician would be notified after the medication pass was completed. An interview was conducted on 01/14/2022 at 6:09 PM with the facility's Director of Nursing (DON). The DON stated that he would expect that anyone with a nursing license should know that an insulin pen needle needed to be primed with 2 units of insulin and a drop should be seen at the tip of the needle before administration. If the needle to the insulin pen is not primed then the pen will deliver less insulin than ordered. The DON also stated that medications should be administered within one hour before to one hour after the scheduled administration time unless the physician's order specified otherwise. If the nurse was not able to meet the required timeframe, the resident's physician should be notified prior to the administration in cases any changes are needed to the order. 105385 Page 14 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A telephone interview was conducted on 01/18/22 at 5:00 PM with the facility's Consultant Pharmacist (CP). The CP stated that they conducted monthly visits to the facility and a consultant nurse also conducted medication administration audits once every quarter. The CP also stated that he reminds nursing staff that the insulin pens needed to be primed prior to administration in order to deliver an accurate dose. If the insulin pen was not primed, the resident may not be administered an accurate dose. The CP stated that medications being administered late was a universal problem and that it is mostly related to nursing staff shortage throughout the industry. A review of the facility policy titled Insulin Administration, revised September 2014 revealed under the section titled Preparation that nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. A review of the facility policy titled Adverse Consequences and Medication Errors, revised in April 2014 revealed under the section titled Policy Interpretation and Implementation, that a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. The policy also revealed examples of medication errors, including wrong time and failure to follow manufacturer instructions and/or accepted professional standards. A review of the facility policy titled Administering Medications, revised in December 2012 revealed under the section titled Policy Statement that medications shall be administered in a safe and timely manner, and as prescribed. The policy also revealed under the section titled Policy Interpretation and Implementation that medications must be administered in accordance with the orders, including any required time frame and that medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. A review of the manufacturers instructions for the Novolog (insulin aspart) FlexPen indicated the following steps under the section titled Priming your Novolog FlexTouch Pen: - Turn the dose selector to select 2 units. - Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. - Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. - A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat the steps no more than 6 times. If you still do not see a drop, change the needle. 105385 Page 15 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident #84) of 25 resident beds was inspected to ensure the frame and mattress were compatible with the resident's height to ensure safety from his feet hanging over the end of the bed. Findings Included: Observation on 1/11/22 at 10:00 a.m., revealed Resident #84 sitting up in bed with his feet to his heels hanging off the end of the bed. The resident stated he was 6 foot 2 inches and his heels always hung off the end of the bed. The bed was observed without a foot board, bed extender, or side rails. Observation on 1/13/22 at 8:54 a.m. revealed Resident #84 sitting up in bed with his feet hanging over the end of the bed. The resident stated he never had a footboard that he could remember or extender on his mattress. During an interview with the Maintenance Director on 1/13/22 at 8:55 a.m., he stated the nurses were responsible to ensure the residents height and weight fit the bed. He walked into the residents room and stated, Wow he does not have a foot board or extender on his bed. We will have to fix that. He confirmed the resident should have an extender and foot board on his bed and stated he would go and get one. During an interview with the ADON on 1/13/22 at 9:00 a.m., she confirmed the residents are checked by the nurses to see if they fit the mattress and are safe in the bed. The ADON walked into the residents room and stated, He is too tall for his bed and does not look comfortable. She said she needed to check into why he did not have a footboard or mattress extender. During an interview with Staff I, CNA on 1/13/22 at 9:09 a.m., he confirmed the resident needed assistance to sit up in bed and stated his feet hung over the bed because he was too tall and his feet would rub the footboard. During an observation of Resident #84 on 1/13/22 at 10:38 a.m., the resident was lying in bed with the foot board and extender attached to the bed and his feet did not come close to the footboard. During an interview on 1/13/22 at 11:35 a.m., the Maintenance Director stated they did monthly bed checks for rails and safety but the nurses were responsible for making sure the resident beds fit the resident. Resident #84 was admitted on [DATE] and readmitted on [DATE]. He had diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. A review of the MDS Section G dated 12/17/21 revealed the resident needed extensive assistance with two plus persons for bed mobility and was totally dependent on staff for transfers. A review of the Brief Interview for Mental Status (BIMS) revealed a score of 12 which indicated moderate cognitive impairment. 105385 Page 16 of 17 105385 01/14/2022 Royal Oak Nursing Center 37300 Royal Oak Lane Dade City, FL 33525

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan revealed a focus area for activities of daily living. The resident had a deficit in his ability to perform ADL's at his usual level, initiated on 7/26/19. Interventions included assistance of two staff to move him up in bed using a draw sheet, initiated on 7/26/19. During an interview with the DON on 1/13/22 at 4:00 p.m., he stated that the resident had moved from the door bed to the window bed then back to the door bed. The bed extender did not move with him because it made the bed too long. The resident would push his feet against the foot board and that would give him the possibility of a wound. The DON went on to say that without the extender he was able to float his heels by letting his feet hang off the end of the bed. Review of facility policy revealed Bed safety revised December 2007, 2001 Med-Pass, pages 3 and 4, revealed: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, and freedom of movement. 2. To try to prevent injuries from the beds and related equipment (including the frame and mattress) the facility shall promote the following approaches: b. the review shall consider situations that could be caused by the resident's weight, movement or bed position. 105385 Page 17 of 17