Health inspection·September 23, 2021

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 observations, staff interview, and medical record review, the facility failed to assess four lower extremity areas/wounds, either during bathing/showers and or weekly skin checks for one (Resident #11) of thirty sampled residents. Residents Affected - Few Findings included: During wound care observation of Resident #11 on 9/21/21 at 4:10 p.m. with Staff D, LPN, the resident's right ankle was observed with two purple areas on the outer ankle. Resident #11 was wearing tight brown non-skid socks which indented the skin around both ankles. Staff member D, LPN removed both socks and confirmed both feet were swollen and stated the areas should be documented by the nurse or the aide during care and asked the aide to get larger socks for the resident. The nurse confirmed the resident's feet were flaky and removed the flaky skin with a 4x4 gauze. After observation of both feet, Staff D, LPN confirmed the right foot had 3 wounds and the left heel was pink and blanchable. The nurse measured the areas of discoloration to include: Right outer ankle area A: 1 cm x 1.5 cm Right outer ankle area B. 1.8 cm x 1.5 cm located on the inner ankle. Staff member D, LPN confirmed both areas purple in color and are due to the tight socks. Right fifth toe area measured 1.0 cm x 1.5 cm, red/purple intact Right mid foot area discolored 0.5cm x 0.5 cm, thick brown scab Left heel pink and blanchable measured 1.5 cm x 2.5 cm. On 9/23/2021 at 10:45 a.m., an interview with Resident #11 revealed that staff assisted him with dressing to include putting on his socks. He said he wore special boots sometimes but they were not comfortable, so he did not wear them all the time. He revealed he did not know what size socks he wore but sometimes they were tight, but he did not say anything to staff about it. On 9/21/2201 a review of Resident #11's electronic medical record revealed he was admitted to the facility on [DATE] and readmitted from the hospital on 7/5/2021. Review of the advance directives revealed he was his own responsible party. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Schizoaffective disorder, Pressure ulcer of sacral region stage IV, Edema Page 1 of 9 105438 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current Minimum Data Set (MDS) 5 day assessment, dated 8/4/2021, revealed a Brief Interview for Mental Status (BIMS) score of 14 of 15, which indicated intact cognition. Skin Conditions - Has pressure ulcer/injury. Risk for pressure ulcer, unhealed pressure ulcer; 1 stage IV pressure ulcer with pressure ulcer care. The assessment did not address the following wounds/areas: 1. Right lateral ankle purple center and red surrounding two areas; 2. Right lateral foot purple; 3. Right lateral 5th digit redness; and 4. Left heel blanchable redness. On 9/21/2021, a review of the current Physician's Order Sheet dated for the month 9/2021 revealed the following orders: - Sacrum wound - Cleanse with wound cleanser, pat dry, apply silver alginate to wound bed and cover with foam dressing, use silver alginate rope to fill all wound space every evening shift. - Check skin integrity beneath bilateral heel protectors every shift - Bilateral heel proctors as tolerated - Low air loss mattress There were no physician orders or nurse's progress notes dated from 6/22/2020 through to 9/21/2021 reflective of wounds or areas to the right lateral ankle, right lateral foot, right lateral 5th digit, or the left heel. Review of the current care plans with the next review date 9/29/2021 revealed that the resident, Has actual skin breakdown related to: Pressure wound, pressure wound to sacrum and with interventions in place. There were no care plan problem areas with goals and interventions reflective of areas to the right lateral ankle, right lateral foot, right lateral 5th digit, or the left heel. Review of the weekly skin assessments dated 8/1/2021, 8/8/2021, 8/15/2021, 8/22/2021, 8/29/2021, and 9/5/2021 were completed with no documentation of areas/wounds to the right lateral ankle, right lateral foot, right lateral 5th digit, or the left heel. On 9/23/2021 at 9:00 a.m., an interview with the wound care nurse was conducted related to Resident #11's wounds and wound care observation dated 9/21/2021. She said that nurses, therapy staff, and direct care staff would be responsible for the identification of any areas to include wounds, bruises, and discoloration of the skin. The areas of concern would be reported to her so she could assess those areas appropriately. The wound care nurse revealed it was expected that nursing completed weekly skin checks for all residents, which were to be conducted every seven days. She said that if a wound or area was identified, she along with the Interdisciplinary Team (IDT), would develop a care plan with interventions for care and treatment. The wound care nurse confirmed there was a missed weekly skin assessment during the week of 9/12/2021 - 9/18/2021. She revealed that the facility's electronic medical record system had a glitch that week and as a result, the normal scheduled weekly skin assessment was not completed for Resident #11. On 9/23/2021 at 10:44 a.m., an interview was conducted with CNA Employee A, who had Resident #11 on her assignment during the current 7:00 a.m. - 3:00 p.m. shift. Employee A revealed she knew Resident #11 and what his ADL care expectations were. She revealed that she had not had him on her 105438 Page 2 of 9 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assignment the previous two weeks but had him today, 9/23/2021. Employee A revealed that she had in the past dressed Resident #11 and had also put socks on both of his feet. She revealed when she dressed Resident #11, she would use the red non-skid socks as they were the extra-large sized socks. Employee A said, if she or any other staff member observed wounds or areas of concern on a resident, they were to report it immediately. She confirmed that nurses did a weekly skin assessment, and the aides would see the resident's entire body usually when providing showers/baths. The Director of Nursing was not available for an interview during the last two days of survey, 9/22/2021 and 9/23/2021. On 9/23/2021 the Nursing Home Administrator provided the Skin Audits by Nursing Assessments policy and procedure for review. The policy was not dated. The policy read; It is our policy to communicate changes in skin condition to appropriate personnel as part of our systematic approach for pressure injury prevention and management. The policy establishes responsibilities of nursing assistants in communicating changes in skin condition. The policy explanation and compliance guideline revealed: 1. Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. 2. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. 3. Skin conditions that shall be reported include, but are not limited to: a. Redness, b. Bruising, c. Swelling, d. Rashes/Hives, e. Blisters, f. Skin tears, g. Open areas/ulcers/lesions. 4. Notification shall be made to the nurse verbally or in writing. 5. A body audit form is available in a binder at each nursing station for the nursing assistant to use to communicate changes in skin condition. 6. The communication form is considered an in-house communication and shall not be placed in the resident's medical record. 105438 Page 3 of 9 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 review, the facility failed to provide restorative services to ensure that the resident's abilities in activities of daily living did not decline for one ( Resident #47) of two sampled residents. Residents Affected - Few Findings included During a facility tour on 09/20/21 at 11:33 a.m., Resident #47 was observed in her room laying in bed. Resident #47 stated that she was not receiving any therapy. She stated that she suffered a stroke a year ago, had speech limitations and could no longer walk. She said, she was supposed to be in a program to help her gain strength but did not know what happened. She said, My toes never used to wiggle, now they do. I can move my legs a little a bit. I need therapy. Resident #47 stated that she rarely gets out of bed and, maybe once a week if at all. Review of Resident #47's admission record revealed an initial admission date of 9/25/20 and a re-entry date of 07/30/21, with diagnoses that included Chronic Obstructive Pulmonary Disease, morbid obesity, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia, and acute respiratory failure with hypoxia. A significant change MDS (minimum data set) dated 08/06/21, section C revealed a BIMS (brief interview for mental status) of 15, indicating intact cognition. Section G, functional status indicated that Resident #47 required extensive assistance with two persons assist for ADL's (activities of daily living) including transferring out of bed. Section G, Functional range of motion indicated impairment on one side. Section O showed no special treatments or procedures, no therapies to include Speech therapy (ST), Occupational therapy (OT) and Physical Therapy (PT). A review of physician orders dated 09/23/21 showed active orders for OT /ST /PT to treat and evaluate dated 8/3/21. A restorative log titled Restorative nursing record dated February 2021 revealed orders for Resident #47, Recommend getting OOB (out of bed) via Hoyer daily at patient's tolerance starting with 1 hour and increase AAROM (active assistive range of motion) BLE (both lower extremities) An interview was conducted on 09/22/21 at 3:49 p.m. with Director of Rehabilitation (DOR). She stated that when a resident had new orders, the therapist would conduct a screening and evaluation to determine if the resident was appropriate for rehab services. The DOR stated that she had screened Resident #47 at the beginning of August 2021 after the resident's hospitalization. The DOR stated that there was no functional change and the resident would not make therapeutic gains in therapy. We recommended she remain in restorative to maintain functions. The Rehab director presented a restorative order form, dated [DATE], that was given to the nursing staff to start restorative nursing. The DOR stated the goal was to encourage Resident #47 to get up and into the chair daily, to improve her trunk stability. She said, Instructions were to maybe start an hour and then increase progressively, but I have heard she refuses. The DOR stated, It should be in her restorative care plan. There should be documentation if she is refusing. An interview was conducted with Nursing Home Administrator (NHA) on 09/23/21 at 8:46 a.m. The NHA 105438 Page 4 of 9 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported that she reviewed the restorative program and did not have any documentation for Resident #47's participation. She stated that Certified Nurse's Aides (CNA's) were getting her up whenever she complied, which was part of her restorative program. She stated, The problem is that the restorative aide is not documenting the refusals or any participation. On 09/23/21 at 9:59 a.m., and interview was conducted with Staff A, CNA / Restorative Aide. Staff A stated, She [Resident #47] is not in my book. I don't remember having received any orders on [Resident #47]. I would remember. Staff A said they did not have enough staff, so she ended up on the floor assigned CNA duties and not restorative. Staff A stated that typically when residents were finished with therapy, they were transferred to her for restorative. Staff A stated that during restorative programming there would be on-going assessment of goals to evaluate whether a resident was meeting goals and if interventions needed to change. Staff A stated that it had been a little hectic since Covid hit. An follow up interview was conducted with the NHA on 09/23/21 at 11:08 a.m. She stated that she would have expected to see follow through on the restorative orders. She said, The expectation is that her care plan would have been updated to indicate the resident is receiving restorative therapy. She said that the restorative aide was also working as a CNA due to staffing challenges. She stated that they were working on implementing a complete program. Review of an undated facility policy titled, Restorative Nursing Programs, states It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning #6. States that residents as identified during the comprehensive assessment process, will receive services from restorative aides to include: (a.) Passive or active range of motion (c.) Bed mobility training and skill practice. (h.) communication training and skill practice. Review of an undated policy titled, Restorative nursing documentation shows, the facility maintains complete, accurate and organized documentation of restorative treatments and the response to those treatments. A job description position title, Restorative nursing assistant dated April 20202, reveals under summary a requirement to provide routine restorative nursing care to selected residents under the direction of a restorative nurse and to function as a certified assistant. 105438 Page 5 of 9 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dialysis services were provided consistent professional standards of practice for one (Resident #75) of one resident receiving Dialysis. Residents Affected - Some Findings Included: During an interview with the Staff C, LPN on 9/22/21, she confirmed the dialysis book was at the nurse's station and she had one [Resident #75] that received dialysis three days a week on Tuesday, Thursday, and Saturday. She opened the dialysis book which was empty and stated that she completed the dialysis form yesterday morning prior to Resident #75 going to dialysis. She said the unit manager took the book last night before she left and Staff C was unaware of where the forms were located. During an interview with Staff I, Unit manager on 9/22/21 at 12:15 p.m., she brought in the dialysis book and stated it was at the nurses desk with all of the documents completed. She stated, that she had the book in her office and since she was in the building on the days the Resident #75 went to dialysis, she pre-completed the dialysis communication forms for pre and post dialysis herself. Staff I then said, Maybe I should not fill them out ahead of time. Staff member I confirmed, the forms dated 9/21/21, without the time in the pre and post section, were in her hand writing. Staff I confirmed that she took the vitals for the resident and checked the shunt location for bruit and thrill upon return from dialysis. Staff I confirmed the same information on the dialysis communication forms dated 9/16/21, 9/14/21, 9/9/21, 9/7/21, 9/3/21, 9/2/21 and 8/31/21. Staff I confirmed she did not remove the dressing covering the shunt due to the potential to bleed. Staff member I said she would return with the dialysis policy and left the room. A review of the dialysis communication forms dated 9/21/21, revealed pre-dialysis information with the blood pressure as 116/63, pulse 66, respirations 18, temperature as 97.6 and denied pain. A review of the medical record revealed the vitals were taken at 9:45 a.m. on 9/21/21. Completed by Staff member I, UM . A review of the dialysis communication forms dated 9/21/21, revealed post-dialysis information with the blood pressure as 122/68, pulse 70, respirations 16, temperature as 97.9 and denied pain. Review of the medical record did not reflect the vital signs documented. Completed by Staff I. The dialysis communication form for 9/18/21 was not completed or available. A review of the dialysis communication forms dated 9/16/21, revealed pre-dialysis information with the blood pressure as 114/64, pulse 68, respirations 18, temperature as 97.6 and denied pain. Review of the medical records did not reflect the vital signs documented. Completed by Staff I. A review of the dialysis communication forms dated 9/16/21, revealed post-dialysis information with the blood pressure as 112/75, pulse 76, respirations 18, temperature as 97.8 and denied pain. Review of the medical record reflected the vital signs were taken at 4:17 p.m. on 9/16/21. Completed by Staff I. A review of the dialysis communication forms dated 9/14/21, revealed pre-dialysis information with the blood pressure as 111/65, pulse 78, respirations 16, temperature as 97.7 and denied pain. Review of the medical records reflected the vital signs were taken at 8:25 a.m. on 9/14/21. Completed by 105438 Page 6 of 9 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0698 Staff I. Level of Harm - Minimal harm or potential for actual harm A review of the dialysis communication forms dated 9/14/21, revealed post-dialysis information with the blood pressure as 110/63, pulse 76, respirations 18, temperature as 97.7 and denied pain. Review of the medical record reflected the vital signs were taken at 4:45 p.m. on 9/14/21. Completed by Staff I. Residents Affected - Some Dialysis communication form for 9/11/21 was not completed or available. A review of the dialysis communication forms dated 9/9/21, revealed pre-dialysis information with the blood pressure as 120/62, pulse 68, respirations 18, temperature as 97.4 and denied pain. Review of the medical records did not reflect the vital signs documented. Completed by Staff I. A review of the dialysis communication forms dated 9/9/21, revealed post-dialysis information with the blood pressure as 131/69, pulse 67, respirations 18, temperature as 97.7 and denied pain. Review of the medical record reflected the vital signs were taken at 4:22 p.m. on 9/9/21. Completed by Staff I. A review of the dialysis communication forms dated 9/7/21, revealed pre-dialysis information with the blood pressure as 128/78, pulse 72, respirations 16, temperature as 97.7 and denied pain. Review of the medical records did not reflect the vital signs documented. Completed by Staff I. A review of the dialysis communication forms dated 9/7/21, revealed post-dialysis information with the blood pressure as 118/70, pulse 66, respirations 17, temperature as 97.4 and denied pain. Review of the medical record reflected the vital signs were taken at 6:34 p.m. on 9/7/21. Completed by Staff I. A dialysis communication form for 9/4/21 was not completed or available. A review of the dialysis communication forms dated 9/3/21, revealed pre-dialysis information with the blood pressure as 130/82, pulse 70, respirations 16, temperature as 98.0 and denied pain. Review of the medical records did not reflect the vital signs documented. Completed by Staff I. A review of the dialysis communication forms dated 9/3/21, revealed post-dialysis information with the blood pressure as 122/68, pulse 66, respirations 18, temperature as 97.8 and denied pain. Review of the medical records did not reflect the vital signs documented. Completed by Staff I. During an interview and time card detail report review with Staff J, Staffing Coordinator on 9/22/21 at 12:59 p.m., he confirmed that Staff member I took paid time off on 9/3/21 and was not working in the building. A review of the dialysis communication forms dated 9/2/21, revealed pre-dialysis information with the blood pressure as 136/74, pulse 68, respirations 17, temperature as 97.8 and denied pain. Review of the medical records did not reflect the vital signs documented. Completed by Staff I. A review of the dialysis communication forms dated 9/2/21, revealed post-dialysis information with the blood pressure as 133/69, pulse 66, respirations 20, temperature as 97.3 and denied pain. Review of the medical record reflected the vital signs were taken at 4:41 p.m. on 9/2/21. Completed by Staff I. 105438 Page 7 of 9 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of health status note dated 9/2/21 at 3:37 p.m., revealed the resident refused to go to dialysis due to thinking she had another appointment later that day. The nurse was notified after transportation left. Dialysis center rescheduled the appointment for 9/3/21 at 11:45 a.m. Director of Nursing made aware. Resident #75 was admitted on [DATE] with readmission on [DATE] for chronic kidney disease stage 5, type 2 diabetes, legal blindness and congestive heart failure. Review of physician orders revealed: Assure the dressings are removed from resident's arm after dinner time. Every evening shift every Tuesday, Thursday and Saturday for removal of dressing after 24 hours of return from dialysis dated 6/18/21. Dialysis Tuesday, Thursday and Saturday for chair time of 11:45 a.m. and pickup at 10:45 a.m. dated 8/13/21. Monitor dialysis access sit right upper arm for signs of bleeding and or infection every shift. Document unusual findings in progress notes and notify doctor dated 6/18/21. Review of the care plan revealed a focus area of potential complications related to dialysis for diagnosis of end stage renal disease reviewed on 9/1/21. Interventions include Checking the shunt for signs and symptoms of infection, pain, or bleeding daily and as needed and notify the doctor of abnormalities dated 11/27/20. During an interview with the Administrator on 9/22/21 at 3:45 p.m., she stated Staff I, UM told her all of the dialysis communication forms were shredded by accident and she made new ones based on the information in the computer and permanent record as she panicked and wanted to provide something. During the interview with the Administrator, she was made aware that the dialysis documents provided detailed vital signs that were not in the resident's permanent record; and, the dialysis form for 9/2/21 was completed but the resident did not go to dialysis that day. The Administrator confirmed she was unaware and would follow up as to where the information was obtained. Review of facility policy for hemodialysis, copyright 2020, two pages, revealed: The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan. Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis and or peritoneal dialysis consistent with professional standards of practice. 1. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. 2. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications. implementation of appropriate interventions, and using appropriate infection control practices. 7. The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications. Review of facility policy for hemodialysis, copyright 2020, one page, revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all 105438 Page 8 of 9 105438 09/23/2021 Aspire at Ridge Haven 4927 Voorhees Rd New Port Richey, FL 34653

F 0698 Level of Harm - Minimal harm or potential for actual harm assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documention include, but are not limited to: a. Documentation shall be factual, objective and resident centered. i. False information shall not be documented. e. Record dated and time of entry. Residents Affected - Some 105438 Page 9 of 9