Health inspection·October 2, 2020

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interviews, the facility failed to ensure that the Quarterly Minimum Data Set Assessment (MDS) accurately reflected the resident's status for suctioning for one resident (#28) of one resident with a tracheotomy in the facility. Residents Affected - Few Findings included: On 9/30/2020 a medical record review was conducted for Resident #28 for respiratory treatments and procedures. The admission Record revealed that Resident #28 was admitted to the facility on [DATE] with a re-admission date of 7/4/2019 and had multiple diagnoses but not limited to COPD (chronic obstructive pulmonary disease), solitary pulmonary nodule, malignancy neoplasm of the larynx, and acute chronic respiratory failure with hypoxia. The medical record was reviewed for physician orders and administration of the orders. A review of the July 2020, Medication Administration Record (MAR) revealed an order effective 5/3/2020 for oral suctioning using flexible suction tubing, and indicated as needed for increased secretions with a start date of 5/3/2020 and, Trach suction - may suction using flexible suction tubing, via trach every 8 hours and as indicated as needed for congestion/increased secretions, with a start date of 5/3/2020. A review on 10/1/2020 at 12:22 p.m. of the MDS Quarterly Assessment, dated 7/29/2020, Section (O) Special Treatments, Procedures and Programs was conducted for Resident #28. In this section, Question (D) for Suctioning was checked as No it was not performed while a resident of this facility and within the last 14 days. A review of the MAR for the month of July 2020 indicated oral suctioning did occur on 7/28/2020 and Trach suctioning was done on 7/19/2020 and 7/21/2020. These dates fall within the look back period for coding for the MDS dated [DATE]. On 10/01/2020 at 1:33 p.m. an interview with the MDS Coordinator along with the Director of Nursing was conducted regarding the coding for the MDS Quarterly assessment dated [DATE] for suctioning. The MDS Coordinator reported that she looked back five days and the lookback period is 14 days. She confirmed that the coding was not accurate for suctioning and that it should be coded as a Yes. The facility policy titled, Certifying Accuracy of the Resident Assessment, with a revision date of December 2014, indicated: All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Page 1 of 9 105393 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement the care plan related to checking the placement of a wander/elopement alarm for one resident (Resident #27) out of the sampled thirty-five residents. Findings included: On 10/02/20 at 10:13 a.m., Resident #27 was observed in bed sleeping. A wander/elopement alarm was observed on the resident's left ankle. On 10/02/20 at 11:30 a.m., Resident #27 was observed sitting in the wheelchair next to his bed. The wander/elopement alarm was observed on his left ankle. A review of the admission Record revealed that Resident #27 was initially admitted into the facility on [DATE] with diagnoses of anxiety disorder, major depressive disorder, unspecified dementia without behavioral disturbance, and unspecified psychosis not due to a substance or known physiological condition. Section C for Cognitive Patterns of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #27 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating severe impairment. Section P for Restraints and Alarms revealed that the resident used a wander/elopement alarm daily. The care plan initiated on 01/05/20, revised on 06/17/20, and with a target date of 12/24/20 revealed that Resident #27 was at risk for elopement and wandering related to history of attempts to leave the facility unattended. The interventions included but were not limited to: WANDER ALERT: Device number of device. Restorative to check weekly, initiated on 1/5/2020 and revised on 6/17/2020. A review of the Order Summary Report with active physician orders for 08/01/20 and 09/01/20 did not reflect an order for the wander/elopement alarm. A review of the Order Summary Report with active physician orders as of 10/01/20 reflected an order for the wander/elopement alarm with a start date of 10/02/20. The order indicated to apply and check code alert/wander/elopement alarm placement every shift for wandering/exit seeking. The Medication Administration Record (MAR) for August, September, and October 2020 did not reflect documentation related to staff checking the functioning of the wander/elopement alarm. The Treatment Administrator Record (TAR) for August, September, and October 2020 did not reflect documentation related to staff checking the functioning of the wander/elopement alarm. A review of the POC Response History report for the code alert bracelet restorative check was reviewed for the last 30 days. The only day that the wander/elopement alarm was checked for Resident #27 by restorative was on 09/20/20 at 12:49. On 10/02/20 at 11:14 a.m., Staff M, Certified Nursing Assistant (CNA), verified that the resident 105393 Page 2 of 9 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had a wander/elopement alarm on his left ankle. Staff M, CNA, confirmed that she was the assigned CNA for Resident #27. She reported that she doesn't check the wander/elopement alarm. On 10/02/20 at 11:17 a.m., the Director of Nursing (DON) reported that wander/elopement alarms are checked every shift by the nurse and weekly by the restorative aide and Risk Manager. The DON confirmed the wander/elopement alarm was not being checked weekly by restorative and the Risk Manager, and it was not being checked every shift by the nurse for Resident #27. On 10/02/20 at 11:30 a.m., Staff N, Registered Nurse (RN), confirmed that the physician order for the wander/elopement alarm was just added. Staff N, RN, reported that restorative was designated to check wander/elopement alarms She reported that she only makes sure the wander/elopement alarm was on the resident's ankle. Staff N, RN, reported that restorative takes care of checking the function of the wander/elopement alarm. On 10/02/20 at 11:36 a.m., the DON confirmed that there was no order for the wander/elopement alarm for Resident #27 prior to today. The facility policy titled, [Wander/elopement alarm], revised on 01/19/19 revealed the following: Policy Statement Wander/elopement alarm system use on patients to assist in prevention of Elopement. Policy Interpretation and Implementation 4. The patients care plan will indicate the patient is a high risk for elopement or other safety issues. Interventions to try to maintain safety, such as wander/elopement alarm placement, redirection, frequent checks will be instituted. 5. When initiating a wander/elopement alarm, the MD (medical doctor) and family must be notified (if applicable) and an order obtained from the MD must be obtained. 7. Wander/elopement alarms are checked daily for placement by the Nurse assigned to the patient for placement every shift and the function checked weekly by Restorative/Risk Manager. 105393 Page 3 of 9 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

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 interviews and review of the medical record, the facility failed to ensure that one dependent resident (#20) out of 35 residents sampled, received the necessary services for meal set up and assistance as needed. Resident #20 was unable to carry out meal activities by herself. Residents Affected - Few Findings included: A policy was requested pertaining to assistance with meals or activities of daily living. The Director of Nursing said, We do not have a specific policy on that. An observation was conducted on 10/01/2020 at 1:10 p.m., Resident #20 was in her room in her bed that was positioned in a low position. The resident's mattress was positioned with the head lower than her feet and she was lying on her back with her eyes closed. On the bedside table next to her bed was a meal tray with 4 containers that were covered with three with plastic wrap and one container was covered with a plastic lid (pureed diet). There was not a sandwich or any other items on the lunch tray. There was 1 small container of butter that was not opened, and a carton of milk not opened. There was not a sandwich or side foods/ snack items on the tray. The silverware was still wrapped up in the napkin` sitting on the meal tray. There was no adaptive equipment on the meal tray. (photographic evidence was obtained). An interview was attempted with Resident #20 on 10/01/2020 at 1:10 p.m., when asked if she was okay Resident #20 said, Can you help me? An interview was conducted on 10/01/2020 at 1:17 p.m., Staff F, Certified Nursing Assistant (CNA) said, We have about 4 residents on the hall that need help with their meals. Their trays should stay in the delivery cart until we are ready to help them. Resident #20 is one of the residents on this hall that need help with her meals. An observation was conducted on 10/01/2020 at 1:18 p.m., Resident #20's food tray was still sitting at the bedside. A second observation was conducted 10/01/20 at 1:20 p.m., Resident #20 was still in her bed, eyes closed, bed in the low position. The tray of food was still sitting on the bedside table still covered. An observation was conducted on 10/01/20 at 1:22 p.m., Staff C, CNA,walked into Resident #20's room and said, [Resident #20] do you want your meal? Resident #20 opened her eyes and Staff C, CNA elevated the head of her bed. Then without washing or sanitizing his hands picked up a cup of fluid off the meal tray and handed it to the resident an she drank it all of the fluid in the one attempt. Then Staff C put the empty cup back down on the tray. Then without saying another word to Resident #20, Staff C picked up her tray and walked out of the resident's room and down the hall. Staff C placed the tray in the silver dining cart. An interview was conducted on 10/01/20 at 1:25 p.m., Staff C, CNA said, [Resident #20] does not eat much. When Staff C was asked why he did not offer her the food on her tray or for alternative choices Staff C said, She likes tomato soup. Then Staff C walked off. Resident #20 did not refuse her meal nor to eat during this observation. 105393 Page 4 of 9 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 10/01/20 at 1:26 p.m., Staff D, Licensed Practical Nurse (LPN) was out in the hallway outside of Resident #20's room and observed the conversation with Staff C. Staff D said, It would be my expectation that they offer her something to eat and maybe an alternative before they just take her tray away like that. An interview was conducted on 10/01/2020 at approximately 2:00 p.m., and explained the meal observation with Resident #20 and Staff C, CNA to the Director of Nursing (DON) and she said, That concerns me too. A review of the facility patient information sheet revealed a recent admission date of 2/20/2019 with pertinent diagnosis of dementia. A review of the minimum data set (MDS), dated [DATE] revealed under Section C a Brief Interview for Mental Status a score of 1 out of 15 indicating the resident is severely cognitively impaired. A review of Section G Functional Status/Activities of Daily Living: Bed mobility-The resident requires extensive assistance of two+ physical assist; Dressing-Extensive assistance of one-person physical assist; Eating-Supervision with one-person physical assist; Toilet use-Extensive assistance of one-person physical assist' Bathing-Total dependence. A review of Resident #20's weights revealed: 11/12/2019 107 pounds 12/10/2020 103 pounds 1/14/2020 98 pounds 1/21/2020 98 pounds Then the next weight documented was 8/01/2020 of 91 pounds. A review of the care plan for Resident #20 with a Focus area identified as: Resident #20 has an ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance, Alzheimer's, cognition and impaired through process, musculoskeletal impairment initiated on 11/16/2018 and revised on 11/16/2018 with pertinent interventions in place for: Eating: Resident #20 requires staff to setup meal and sometimes cue/prompt with meals initiated on 11/16/2018 and revised on 4/05/2019. Focus area: Resident #20 is at nutritional risk related to decreased po (by mouth) intake. Receives pureed diet due to chewing difficulty. History of weight fluctuations with overall weight decline. Often refuses to allow staff to weigh her. Palliative care measures are in place. wishes are no feeding tubes or IV fluids. Interventions listed: Adaptive equipment as ordered, Serve food in separate bowls. Resident #20 likes oatmeal, applesauce, peaches and [NAME] toast with syrup initiated on 11/06/2018. Diet as ordered: Pureed diet, may have mechanical soft items as desired. super foods with 105393 Page 5 of 9 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meals. offer soft sandwich with lunch and dinner meals imitated on 11/02/2018 and revised on 6/25/2020. Encourage resident to use adaptive equipment as provided to facilitate self-feeding initiate on 12/26/2018 and revised on 10/09/2019 and to honor food preferences with date initiated of 11/02/2018. A family interview was conducted on 10/01/2020 at 10:51 a.m., the family member said, She has a poor appetite, but they do bring her a sandwich which she will eat. I told them if she wants to eat that is fine and if she doesn't that is fine. I don't want anyone trying to force her to eat. An interview was conducted on 10/01/20 at 1:42 p.m., the Director of Nursing (DON) said, To me meal set up means setting up the resident to eat , taking the lids or plastic off of the food and assisting the resident as needed. I will initiate education on this. 105393 Page 6 of 9 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interviews the facility failed to provide wound care in accordance with professional standards of practice for one resident (#280) out of two residents sampled for pressure injuries as evidence by a skin tear dressing applied on September 7, 2020 and not addressed until 10/2/2020. Residents Affected - Few Findings included: After pressure ulcer treatment, which began at 10:31 a.m. on 10/2/20 with Staff Member I, Wound Care Registered Nurse, an observation was made of a clear adhesive dressing on Resident #280's left shin. The clear dressing was dated /7/20. The month was obscured but Staff I stated it looked like a 9 or a 7. The staff member removed the dressing that had a small amount of dried deep red/black substance attached to it. Staff I stated the area looked like a little skin tear that had healed. A record review of Resident #280's progress notes indicated a nursing note written on 9/7/20 at 22:07 (10:07 p.m.) that identified the resident had sustained a small skin tear measuring 3 centimeters (cm) long on the left anterior shin from a piece of tape used to cover the left heel pressure ulcer dressing during a shower. The Weekly Skin Observation, dated 9/10/20, indicated Resident #280 had skin/wound treatments to the heels and bilateral buttocks and that there was no new skin/wound issues. The Weekly Nursing Summary which included a skin assessment, dated 9/17/20, identified treatments to Resident #280's bilateral heels and buttocks with no new skin areas. The Weekly Nursing Summary with Skin, dated 9/24/20, indicated treatments to the buttocks, and bilateral heels. The summary identified redness to the right great toe but did not identify a skin tear to the left shin. The Weekly Nursing Summary with a skin assessment, dated 10/1/20, indicated skin treatments to the buttocks and left heel. The summary did not identify any other skin issues. A review of Resident #280's September 2020 Order Summary Report did not include a physician order for a dressing change to the residents skin tear that had occurred on 9/7/20. During an interview on 10/2/20, the Director of Nursing stated her expectation would have been for staff to have a physician order to dress the skin tear and that the dressing should have been changed between the time of 9/7 and 10/2/20. 105393 Page 7 of 9 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record reviews the facility failed to maintain professional standards for food service safety as evidenced by: 1. The facility failed to ensure food and snack items were dated and labeled properly in one nutrition room (Light House Way) out of 2 nutrition rooms sampled, 2. The facility failed to ensure hydration carts were maintained in a clean and sanitary manner for one hydration cart (Light House Way) out of three sampled. Findings included: The U.S. Food and Drug Administration (FDA) defines labeling as all labels and other written, printed, or graphic matters (1) upon any article or any of its containers or wrappers, or (2) accompanying such an article. This may include packaging, instructions, product inserts, websites, and other promotional materials. https://www.registrarcorp.com/fda-labeling 1. An observation was conducted during the initial tour of the facility on 9/29/2020 at 9:42 a.m., of the nutrition room located on Light House Way. A loaf of bread was observed sitting on the counter beside the microwave and had a small white blank sticker on the outside of the plastic bag. The bread bag was not labeled or dated. There was also a large plastic bag filled with smaller individual plastic bags of cookies. The smaller individual bags of cookies were not labeled or dated, nor was there a label with a date or information on the outside of the large bag. (Photographic evidence was obtained). A second observation was conducted on 9/30/2020 at 9:30 a.m., in the nutrition room located on Light House Way there was the same loaf of bread (9/29/2020) without a label or date on it. (Photographic evidence was obtained). A third observation was conducted on 10/01/2020 at 9:28 a.m., in the nutrition room located on Light House Way and the same loaf of bread was on the counter next to the microwave without a label and not dated. (Photographic evidence was obtained) A fourth observation was conducted on 10/02/2020 at approximately 9:40 a.m., in the nutrition room located on Light House Way, the same loaf of bread that had been observed from 9/29/2020-10/01/2020 now had a date written on the white sticker on the outer wrapping of the bread. The date written in black marker showed 9/30/2020. There was also a large plastic bag filled with smaller individual plastic bags of cookies and none of the bags for the cookies were dated. (Photographic evidence was obtained). An interview was conducted on 10/02/20 at 9:42 a.m., Staff I, Registered Nurse (RN), confirmed the cookies did not have a date or label of any kind. Staff I said, Why don't I just throw them out. An interview was conducted on 10/02/20 at 12:17 p.m., and the Dietary Supervisor said, Well I know the bread came in on 9/27/2020. No, the bread does not have a label on it. I am not sure who wrote in the date. Yes, the date on there is 9/30/2020. The Dietary Supervisor confirmed the bags of cookies did not have a date or label on them. The Dietary Supervisor said, Yes, all food should be dated. 2. An observation was conducted on 9/29/20 at 9:42 a.m., in the nutrition room located on Light House Way. A hydration cart in the nutrition room had a tray on one of the shelves with plastic white 105393 Page 8 of 9 105393 10/02/2020 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few spoons out and not covered. The ice scoop was observed on the hydration cart in a round plastic container (silverware holder), with holes in it that was attached to the side of the cart. The container with the ice scoop in it was not covered. (Photographic evidence was obtained) An observation was conducted on 9/29/20 at approximately 10:10 a.m., Certified Nursing Aides were observed pushing the hydration cart on Light House Way hall. The ice scoop was being used to scoop ice out of the ice chest into individual resident bedside hydration cups. The CNAs then placed the scoop in a plastic container with holes in it that was attached to the side of the hydration cart. The container with the ice scoop in it was not covered. (Photographic evidence was obtained) An interview was conducted on 9/29/20 at 10:40 a.m., Staff J, CNA said, Yes, we were passing water with ice out to the residents. We use this ice chest and this scoop. I am not sure when it gets cleaned. A second observation was conducted on 9/30/20 at 9:30 a.m., in the nutrition room located on Light House Way. The ice scoop on the hydration cart was stored in a silverware holder and uncovered. (Photographic evidence was obtained) A third observation was conducted on 10/01/20 at 9:28 a.m., in the nutrition room located on Light House Way. The ice scoop on the hydration cart was stored in a silverware holder and uncovered. (Photographic evidence was obtained) A fourth observation was conducted on 10/02/20 at approximately 9:40 a.m., in the nutrition room located on Light House Way. The ice scoop on the hydration cart was stored in a silverware holder and uncovered. (Photographic evidence was obtained) An interview was conducted on 10/02/20 at 9:42 a.m., Staff I, Registered Nurse (RN), confirmed that the ice scoop was not covered. A facility policy was requested but not provided by the end of the survey on 10/2/20. 105393 Page 9 of 9