Health inspection·August 6, 2021

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dignity and respect were maintained for three (# 53, # 54, and #89) out of six residents related to call light response, concerns raised in resident interviews, in the resident grievance process, and during the Resident Council Meeting. Findings included: In an interview on 08/04/21 at 4:30 p.m. with Resident #54, he stated, Someone comes in and turns off the call light, but they don't come back to provide the care. The resident revealed that he had an episode of bowel incontinence and was waiting for the aide to return with help to transfer him back to bed to provide peri care. A review of the medical record for Resident # 54 showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, based on the admission Minimum Data Set (MDS) dated [DATE], indicating the resident had minimal cognitive impairment. Further review of the MDS data dated 06/14/21, revealed the resident was totally dependent on staff and required the assistance of two staff for transfers. Review of the resident's care plan revealed the resident was to have the call light within reach, required assistance of two with transfer and one with toileting, and was encouraged to use the call light when requiring assistance. In an interview during the Resident Council Meeting on 08/04/21 beginning at 2:00 p.m., when asked how things were going, Resident #89 stated, I can only speak for myself where care is concerned, but I have had to wait what I consider too long for staff to come assist me. All call light wait time is a 1/2 hour to 45 minutes. In between shift change, it is a long wait. Resident # 53 stated she had recently filed a grievance regarding call lights. Resident #53 recalled being in the bathroom waiting with the call light on and staff was taking too long to answer the light. Resident # 53 tried to get up to return to bed unassisted & fell in bathroom. The Certified Nursing Assistant (CNA) did not come until Resident # 53 had already fallen. During an interview with resident # 53 on 08/04/21 beginning at 2:50 p.m., she confirmed that she fell when trying to return from the bathroom to bed unassisted. She said the staff took too long to answer the call light. She reported that on a different occasion she had been told to urinate in her brief by a CNA who told her she could not get her out of bed to the toilet. Resident # 53 stated she reported this to the Physical Therapist (PT), Staff D who came to work with her that day. During a subsequent interview on 08/06/21 at 1:45 p.m., Staff D confirmed that he had filed a grievance on behalf of Resident # 53 on 05/11/21 because the resident had been told to urinate in her brief by an aide. Staff D stated that there was no reason why Resident # 53 could not get out of bed with Page 1 of 5 105426 105426 08/06/2021 Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615

F 0557 assistance to use the toilet. Level of Harm - Minimal harm or potential for actual harm A review of the quarterly Minimum Data Set assessment for resident # 53, dated 06/10/21, revealed the resident had a BIMS score of 15 out of 15, indicating no cognitive impairment. The resident had been identified as needing extensive assistance by two staff members for transferring and one staff person for toileting, and that she was frequently but not always incontinent of bladder and bowel. Resident #53's care plan indicated the intervention of keeping the call light within reach due to an increased risk for moisture related damage to her skin and the risk for falls. Residents Affected - Few A review of Resident Grievances revealed: 1. 05/11/21 - Staff D reported a care concern r/t (related to) care for Resident #53. The concern did not have a Date resolved entry. During an interview on 08/05/21 at 6:08 p.m., Staff C, Social Service (SS) confirmed having received grievances by Residents #53 and #54 related to care. Staff C stated that the CNA staff was given education related to providing care and answering call lights in a reasonable amount of time. The Nursing Home Administrator who was present during this meeting stated that turning off a call light without providing care was not the behavior she expected from the staff. An interview with the Director of Nursing (DON) was completed on 08/05/21 at 3:50 p.m. The DON stated that it was not reasonable for a CNA to turn off a resident's call light and not return with another aide to provide care, she stated, that CNA would be educated, that is not acceptable. A review of facility provided policy titled Dignity with a revised date of February 2021, revealed: Policy Statement: Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self worth and self esteem. Policy interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents for example: a. promptly responding to a resident's request for toileting assistance. 105426 Page 2 of 5 105426 08/06/2021 Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to 1. maintain the privacy for six (Residents #9, #53, #70, #89, #98 and #208) of six residents in a confidential and private manner related to video camera recording of the residents during a resident council meeting without their knowledge. 2. The facility had 13 cameras through out the common areas without the resident's consent. Residents Affected - Some Findings included: On 08/04/21 at 2:00 p.m. in the main dining room (MDR), a confidential and private resident council meeting with six residents in attendance was conducted. During the meeting, an observation was made of two video cameras in the MDR where the meeting was held. Both cameras had a green light on indicating that both were recording. An observation was made of a camera in the MDR which was located above the sink facing the back door. A second camera was observed on the back wall facing the entire dining room and the residents. The cameras had the capability of recording video and audio. At the end of the meeting, the Nursing Home Administrator (NHA) was approached at the door of the main dining room and asked if she had notified residents that they were being recorded during the confidential resident council meeting. She responded that she was unaware of the cameras, then stated that the cameras had been there since she started four years ago. She was asked to provide any form of documentation that was provided to the residents informing them of the cameras and that they were being recorded. When asked if she thought that the resident's privacy was being maintained during the resident council meeting, she responded I know what you mean. On 08/04/21 at 3:08 p.m., in the hallway, the NHA and the Director of Maintenance approached the surveyor and stated that there were no cameras in resident rooms only the hallways and common areas. The Director of Maintenance said that the cameras had audio capabilities but that function was turned off. When the surveyor asked to demonstrate that the audio was turned off, the NHA told the Director of Environmental Services, Don't go there. The surveyor asked the NHA to provide documentation showing that the residents were aware and had consented to being recording in all the common areas. The NHA stated I totally understand. The admission packet was reviewed and was silent regarding informing the residents of video recording throughout the common areas including the main dinning area or during their group meetings or during their participation in a group activity. The facility did not have a written consent related to video cameras. Policy Review: dated 10/2017 reads: Our facility will protect and safeguard resident confidentiality and personal privacy. #2. the facility will strive to protect the resident's privacy regarding his or her: F.- family and resident group meetings. 105426 Page 3 of 5 105426 08/06/2021 Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615

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 resident record review, interviews, observation, and review of policy and procedures, the facility did not ensure it implemented a person centered care plan with individualized approaches for activities for one (Resident #57) of 46 sampled residents. Findings include: On 08/03/21 at 11:09 a.m., Resident #57 was observed in his room, laying in a low bed, and starring at the wall. The resident was alert with confusion. He only spoke Spanish. The resident was interviewed in Spanish regarding leaving his room for activities or being offered to be taken to an activity of choice. The resident stated that he had not been invited to any activities and would enjoy some especially if they had them in Spanish. He also would like to go out and get some fresh air. A review of Resident #57's plan of care for activities revealed that he was interested in activities and was at risk to decreased social interaction. The care plan indicated that he would receive visits from the activities department with a courtesy cart and provided reading material, movies and music with a portable CD & DVR, art supplies and audio books. However, none of these items were observed in the resident's room during the four days of the survey. The resident had not been invited to any daily group activities or encouraged social interaction. A review of Resident #57's Minimum Data Set (MDS) dated [DATE] for a significant change, indicated under section F- How important is it to you to listen to music you like, keep up with the news, participate in favorite activities, go out to get fresh air.: response was: somewhat important. On 08/05/21 at 10:04 a.m., an interview was conducted with the Director of Activities in regard to Resident#57's interests for activities. She reported that they provided a courtesy cart for him. Meaning, that a staff member from activities would go around to all rooms with a cart and ask the residents if they would like to listen to some music or read a magazine, movies etc. She was asked if she had any documentation for Resident#57 indicating the type of activities that had been offered to him in the past 3 months. A review of the activities narrative notes that were reviewed in his medical record were copied and pasted for the following dates: 4/28/2021, 6/13/2021,7/22/2021 and 8/3/2021- readmission. There was no documentation to indicate if the resident had participated in an activity. An interview was conducted with the Nursing home administrator in regards her expectation of ongoing activity notes and was shown the progress notes for Resident#57 for 4/28/2021, 6/13/2021,7/22/2021 and 8/3/2021, she nodded No, indicating that progress notes should not be copied and pasted. 105426 Page 4 of 5 105426 08/06/2021 Woodbridge Care Center and Rehab 8720 Jackson Springs Rd Tampa, FL 33615

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to provide activities, according to the resident's reported preferences to one (Resident #57) of 46 sampled residents. Residents Affected - Few Findings included: A medical record review for Resident #57 revealed that the resident was admitted to the facility on [DATE] and a re-admission of 8/2/2021. The resident was admitted with multiple diagnoses but not limited to dysphagia, mood disorder, and muscle weakness. The resident had a BIMS (Brief Interview for Mental Status) of 14 indicating cognitively intact. On 08/03/21 at 11:09 a.m., the resident was observed in his room, laying in a low bed, and starring at the wall. The resident was alert with confusion and spoke only Spanish. The resident was interviewed in Spanish. Resident #57 stated that he had not been invited to any activities and would enjoy some especially if they had them in Spanish. He also would like to go out and get some fresh air. On 08/05/21 at 10:04 a.m., during an interview with the Director of Activities, she reported that the activities department provided a courtesy cart for Resident #57. The staff member from activities would go around to all rooms with a cart and ask the residents if they would like to listen to some music or read a magazine, watch movies etc. A review of the activities narrative notes that were in his medical record were copied and pasted for the following dates: 4/28/2021, 6/13/2021,7/22/2021 and 8/3/2021- readmission. There was no documentation to indicate if the resident had participated in an activity. An interview was conducted with the Nursing Home Administrator in regards her expectation of ongoing activity notes and was shown the progress notes for Resident#57 for 4/28/2021, 6/13/2021,7/22/2021 and 8/3/2021, she nodded, No, indicating that progress notes should not be copied and pasted. A review of Resident #57's plan of care for activities revealed that he was interested in activities and was at risk for decreased social interaction. The care plan indicated that he would receive visits from the activities department with a courtesy cart that provided reading material, movies and music with a portable CD & DVR, art supplies, and audio books. However, none of these items were observed in the resident's room during the four days of the survey. The resident had not been invited to any daily group activities or encouraged social interaction. A review of Resident #57 Minimum Data Set, dated [DATE] for a significant change, indicated under section F- How important is it to you to listen to music you like, keep up with the news, participate in favorite activities, go out to get fresh air.: response was: somewhat important. A review of the facility policy titled: Activity Programs reads as follows: activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. #9- All activities are documented in the resident's medical record. #12: Individualized and group activities are provided that: C. reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents. 105426 Page 5 of 5