Health inspection·December 2, 2021

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to follow up on voiced medical concerns for 1 of 1 sampled residents (Resident #36) who voiced concerns to both nursing staff and physician staff, of possible skin cancer, and requested to be seen by an outside physician for removal of the skin cancers. The facility failed to follow through with the resident's request. Residents Affected - Few The findings included: During an interview on 11/29/21 at 9:48 AM, Resident #36 was asked if he was receiving the care and services he expected from the facility. Resident #36 stated he was concerned about the skin cancer on his right hand and left ear, further explaining that he had had other skin cancers removed previously. Resident #36 showed the surveyor a prominent growth on the top of his right hand and another on the top of his left ear. His left ear had an obvious indentation and Resident #36 stated that was where a previous dermatologist had removed skin cancer. Resident #36 stated he spoke with a lady who he believed was a Nurse Practitioner about three days ago, who agreed it was skin cancer and walked away. When asked if he had spoken with any other facility staff about his concerns, Resident #36 stated he spoke with the Unit Manager about a month ago. Record review revealed Resident #36 was admitted to the facility on [DATE], with his most current readmission on [DATE]. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14 on a scale of 0 to 15, indicating he was alert and oriented. Review of the record lacked any mention of skin cancer or referral to a dermatologist. Review of the progress notes by the Nurse Practitioner from 11/22/21, 11/24/21, and 11/26/21 all lacked any mention of skin cancer or issues, or any mention of a referral for dermatological services. During an interview on 12/01/21 at 9:39 AM, Staff B, a Licensed Practical Nurse (LPN)/Unit Manager stated she was unaware of any skin issues for Resident #36. The Unit Manager stated she would speak with the resident and call the VA (Veterans Administration) for an appointment. On 12/01/21 at 10:08 AM, Resident #36 came up to the nurse's station and spoke to the Unit Manager. Resident #36 was overheard stating, I told the lady . the Nurse Practitioner, and she said 'yea, those are skin cancers and walked away.' During an interview on 12/01/21 at 10:59 AM, Staff G, a Certified Nursing Assistant (CNA) confirmed Resident #36 was very alert and oriented and was able to make his needs known. When asked if the resident had a good recall of things, she stated he did. Page 1 of 9 105485 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/01/21 at 11:05, Staff H, a Nurse Practitioner, was asked if she was aware of the skin cancers on the hand and ear of Resident #36. Staff H stated she was not a dermatologist but confirmed the resident had pointed them out to her recently. The Nurse Practitioner explained the resident had a lot of sun damage. The Nurse Practitioner stated she told Resident #36 the areas were probably skin cancers, and he should probably be seen (by a dermatologist) at some point in time. When asked if she followed up with anyone or told staff at the facility about the voiced concerns from Resident #36, the Nurse Practitioner stated she had not. The Unit Manager was at the nurse's station during the conversation and stated she had now called the VA and was awaiting a return call from the resident's social worker. The Unit Manager agreed the interventions were done after surveyor intervention. During a subsequent interview on 12/01/21 at 3:30 PM, Resident #36 stated he wanted to clarify something. The resident stated he never pointed out his skin issues to the Unit Manager. Resident #36 stated the only persons who knew about it were that Nurse Practitioner and another floor nurse, whose name he could not recall. 105485 Page 2 of 9 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 11/30/21 at 2:34 PM, the specialty air mattress for Resident #74 was set on static mode and at 325 pounds (photographic evidence obtained). Residents Affected - Few During a subsequent observation on 12/02/21 at 10:30 AM, the Wound Care Physician was in the room of Resident #74. An observation of the specialty air mattress revealed it remained on the static mode at 325 pounds. The Wound Care Physician then looked at the specialty air mattress, looked in the record to obtain resident's weight, and lowered the settings on the specialty air mattress to match his current weight. The physician stated sometimes the settings get accidentally changed, but confirmed it should be set to the resident's weight. When asked if the physician would prefer the setting to be on the static or alternating mode, the physician stated it should be on the alternating mode. Review of the most current weight for Resident #74 was 154 pounds as of 11/29/21. Based on observation, interview and record review, the facility failed to provide and maintain specialty air mattress and ensure proper settings to prevent the worsening of pressure ulcers for 1 of 1 sampled residents (Resident #74) reviewed for Pressure Ulcers. The findings included: Review of the facility policy Pressure Ulcer Preventive Measures revised 04/25/17 documented, 18. For residents in bed, who are completely immobile, use devices that relieve pressure on the heels, most commonly by raising the heels off the bed. Use pillows under the length of the lower leg, suspending the heels. When using a specialty support surface, follow manufacturer's instructions. Review of the Operation Manual for the Signa Relief Alternating Pressure System with Low Air Loss specialty air mattress documented, 7.0 Program Settings: 1. Place the patient in the center of the mattress. Adjust the mattress' internal pressure according to the patient weight by using the weight button on the control panel of the power unit. 1) Record review revealed Resident #74 was admitted to the facility on [DATE] and most recently readmitted for current stay on 11/26/21. According the resident's most recent complete assessment, a Quarterly Minimum Data Set (MDS), completed on 11/08/21, Resident #74 had a Brief Interview for Mental Status (BIMS) score of 15, indicating 'cognitively intact'. The Assessment documented that Resident #74 was dependent upon staff for all Activities of Daily Living (ADLs). Resident #74's diagnoses at the time of the assessment included: Malnutrition; Pressure ulcer of sacral region, Stage 4 Pressure ulcer of right ankle, Stage 3; Pressure ulcer of left heel unstageable; Hemorrhage of anus and rectum; pressure ulcer of right buttock, unstageable and Pressure ulcer of left buttock unstageable. An 'admission Evaluation' dated 11/27/21, documented that the resident's pressure ulcers were present upon re-admission. Resident's orders included: [Name of the equipment company] Air Mattress for Wounds to buttocks 11/27/21. QSM Wound Care Consult for Evaluation and Treatment for open area to right buttock - 11/27/21. 105485 Page 3 of 9 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The list of Active diagnoses on Resident #74's Baseline Care Plan, dated 11/26/21 (date of readmission), included: Pressure Ulcer of Right Ankle, Stage 3; Pressure Ulcer of Left Heel, Unstageable; Pressure Ulcer of Left Ankle, Stage 3; Pressure Ulcer of Sacral Region, Stage 4; Pressure Ulcer of Left Buttock, Unstageable; Pressure Ulcer of Right Buttock, Unstageable; End Stage Renal Disease; Hemorrhage of anus and Rectum and Malnutrition. The Baseline Care Plan documented that the resident was dependent upon staff for all Activities of Daily Living and was 'Always incontinent' of urine and bowel. A Skin wound note, dated 11/18/21 at 14:07, documented, Resident seen by Wound Physician. Treatment continued to apply calcium alginate with medi-honey to right buttocks, right ankle, left posterior medial heel, left posterior medial heel, left lateral ankle, sacrum, right Ischium, and scrotum. No signs of infection noted. Documentation in the resident's Medication Administration Record (MAR) in the resident's electronic health record documented Resident #74's compliance with intake of supplement to promote wound healing. Further review of Resident #74's electronic medical records revealed no documentation of the resident having or receiving an air mattress per physician's orders. During an interview, on 11/29/21 at 10:45 AM, with Resident #74, when the resident was asked of any skin issues, Resident #74 replied, I've got sores on my backside on my rear end and a little on the lower back. Before I went to the hospital last Friday, I had a air mattress. Since I got back, I don't have the air mattress. I guess they never put me in it. I used to be in [room #] and that is where the bed is. During the interview, it was noted that the resident was positioned on a standard mattress at the time of interview, as evidenced by there not being any controls at the resident's foot of his bed that would control the firmness of the air mattress, should one had been on the resident's bed. During a follow up interview, on 11/30/21 at 3:40 PM, with Resident #74, it was noted that there was an air mattress in place on the resident's bed. When asked about the air mattress, Resident #74 replied, I got it yesterday, late in the afternoon. Resident #74 further stated that the mattress was comfortable and felt better During an interview, on 12/01/21 at 3:11 PM, with Staff A, RN, when asked about Resident #74 having an air mattress, Staff A replied, He always had an air mattress. Whenever we have a patient transfer, we call maintenance to get the mattresses and get the room ready and to move the mattress. When he first came here it was worse (pressure ulcers.) when asked if the resident received an air mattress upon his return from the hospital into a different room from his previous stay, Staff A was not able to recall. During an interview, on 12/01/21 at 3:15 PM, with Staff B, LPN/UM, Staff B stated, He came in the middle of the night on the weekend. The nurses that work on the weekend should have tried to get him one. Maintenance should have had one in storage. During an interview, on 12/01/21 at 3:28 PM, with the Maintenance Director, when asked about getting an air mattress for a resident when ordered, the Maintenance Director stated, I started this job on Monday (11/22/21). I was here on Saturday and there was nobody asking for an air mattress, (Staff C) was here on Sunday. The request would have been put into TELLS (maintenance requisition system) 105485 Page 4 of 9 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 12/01/21 at 3:40 PM, with Staff C, Maintenance Assistant, when asked of any orders for an air mattress for Resident #74, Staff C stated that there were no orders received. During an interview, on 12/01/21 at 4:29 PM, with Staff D, RN via telephone, when asked about Resident #74 having an air mattress, Staff D replied, He came after I left, I worked with him on Saturday (11/27/21) I didn't see an order in his MAR (Medication Administration Record) or TAR (Treatment Administration Record) for an air mattress. Staff D further stated that a traditional mattress had the potential to worsen the pressure sores that the resident had. During an interview, on 12/02/21 at approximately 9:10 AM, with Staff C and Staff E, Maintenance Assistant, both stated that the facility does not keep air mattresses on site. The Administrator stated that the facility orders air mattress when needed. During an interview, on 12/02/21 at 9:42 PM, with Staff F, LPN, via telephone, when asked about Resident #74 having an air mattress, upon re-admission, Staff F replied, He came in late at night, I know the order was there. I left that morning at around 730 and was off for the weekend and wasn't in the building again until Monday night. I assumed that the mattress was delivered. I was not aware. Before he went out, he had one because of his condition. He had an order for one when he came back, I assumed that they would have delivered one on Saturday from the company. During an interview on 12/02/21 at 10:22 AM, with representative from the equipment supply company that mattresses and equipment are ordered and received, when asked about an order for an air mattress for Resident #74, the representative replied, there was one ordered on October 25th and the order is still in place. When asked about the process for ordering an air mattress, the representative stated, Our office is open 8:00 AM to 7:00 PM and we have a 24-hour answering service so whenever we are closed, one of our associates will call back right away. When asked about the timing between ordering and receiving an air mattress, the representative stated, Within 24 hours if not on the same day, depending on the location and scheduling. On 12/02/21 at 11:12 AM, the Administrator stated, We have air mattresses on site, we have some that are our own, we mostly rent, but we have used our own. 105485 Page 5 of 9 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to ensure a timely assessment for removal of an indwelling urinary catheter for 1 of 3 sampled residents reviewed for catheters (Resident #327). The findings included: Review of the policy Indwelling Urinary Catheter Removal Protocol not dated documented two potential pathways to follow. Either the physician chooses to follow nurse driven removal protocol that is imbedded in the orders, or the physician will place a discontinue order when the indwelling catheter should be removed and the nurse will continue to assess catheter necessity daily. During an observation on 11/30/21 at 2:26 PM, Resident #327 was lying in bed, with an indwelling urinary catheter noted in use. Further observations revealed clear yellow urine was noted in the tubing. Resident #327 explained he had been unable to urinate while a patient in the hospital, a bladder scan was done with 800 ml (milliliters) of urine noted in his bladder, so an indwelling catheter was placed. When asked if the facility had addressed removing the catheter, Resident #327 stated they had not. When asked if he was told he has or had any type of obstruction, the resident stated he had not. An observation on 12/01/21 at 9:33 AM revealed Resident #327 still had the indwelling urinary catheter. Review of the record revealed Resident #327 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #327 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was alert and oriented. This same MDS also documented the resident had an indwelling urinary catheter. Further review of the record revealed an order dated 11/19/21 for a Foley (indwelling urinary) catheter for obstructive uropathy. The record lacked any imbedded orders for the nurse driven removal protocol and lacked any daily catheter necessity assessment, as per their indwelling catheter removal protocol. Review of the 11/02/21 admission hospital record revealed Resident #327 did have acute kidney failure during that hospitalization that was resolved. The hospital record lacked any attempt to remove the indwelling urinary catheter. During an interview on 12/02/21 at 1:34 PM, Staff B, the Licensed Practical Nurse (LPN)/Unit Manager was asked about the indwelling catheter for Resident #327. The Unit Manager explained as she was leaving the facility the previous evening, and she spoke with Resident #327, who did not know why he had the urinary catheter. The Unit Manager stated the resident told her that he was urinating without any issues prior to his recent hospitalization. The Unit Manager stated she suggested a voiding trial (removal of the indwelling urinary catheter with monitoring of urine output), spoke with the restorative nurse, who was responsible for the voiding trials, and spoke with the Nurse Practitioner who stated he would write an order to discontinue the Foley and do a voiding trial. The Unit Manager looked in the electronic medical record (EMR) and an order had not been written as of yet. Staff I, the Restorative Nurse, joined the conversation at this time. Staff I stated Resident #327 105485 Page 6 of 9 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0690 Level of Harm - Minimal harm or potential for actual harm came to the facility with the Foley catheter. The Restorative Nurse stated that today the resident asked why he had the Foley. The Restorative Nurse stated she spoke with the Nurse Practitioner who said he would put the order into the EMR. When asked why the possible discontinuation of the indwelling urinary catheter was not addressed prior to today, the Restorative Nurse stated they were awaiting an MD (physician) order. The Unit Manager then stated, He never asked to get it (the indwelling catheter) removed. Residents Affected - Few During a phone interview on 12/02/21 at approximately 2:00 PM, Staff J, a Nurse Practitioner, was asked about the indwelling urinary catheter for Resident #327. The Nurse Practitioner stated he had spoken with the Restorative Nurse that morning and told her to remove the catheter, and that he was waiting on the nurse to enter the order so that he could sign it. When asked why the possible removal of the indwelling urinary catheter was not addressed prior to today, the Nurse Practitioner stated he was waiting on the Infectious Disease physician to clear him. The Nurse Practitioner also stated the urinary volume had not been good enough and the urine was a little brown last week. The Nurse Practitioner stated he spoke with the doctor who said to wait (to discontinue the catheter). Further review of the record lacked any documented evidence the possible removal of the indwelling urinary catheter was discussed or assessed. Further review of the Nurse Practitioner's progress note dated 11/24/21, the only time the Nurse Practitioner had seen the resident, documented the resident had an indwelling urinary catheter that was draining clear yellow urine. The note lacked any documentation of brown or discolored urine or a low urinary output. During an interview on 12/02/21 at 2:21 PM, Staff K, a Registered Nurse (RN), stated the urine for Resident #327 had been clear with adequate output throughout his stay. 105485 Page 7 of 9 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and policy review, the medication error rate was 8 percent. Two medication errors were identified while observing a total of 25 opportunities, affecting 1 of 6 residents observed (Resident #38). The RN also failed to follow their policy to ensure the five rights of administration of medications, by failing to ensure the right resident, and nearly administered the wrong medication. Residents Affected - Few The findings included: Review of the policy Medication Administration - General Guidelines dated April 2018 documented, Procedures: Preparation . 4. FIVE RIGHTS - Right resident, right drug, right dose, right route an right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: . A medication pass observation was made with Staff K, a Registered Nurse (RN), for Resident #38 on 11/30/21 beginning at 9:42 AM. Staff K pulled the following tablets/pills for Resident #38: One 100 mg (milligram) tablet of Stool Softener. One 500 mcg (microgram) tablet of Vitamin B12. One 1000 IU (International Unit)/25 mcg tablet of Vitamin D3. One 20 mg tablet of Escitalopram (an antidepressant). One 2 mg tablet of Tolterodine (for overactive bladder symptoms). One 600/400 mg tablet of Calcium with D3. During this observation, Staff K also obtained one 20 mg tablet of Citalopram (an antidepressant) and poured it into the medication cup with the other pills for Resident #38. The surveyor noted the medication was for a different resident. After the RN pulled all the medications for Resident #38, the surveyor asked to look at the pill card for the Citalopram again. The RN pulled the card back out of the medication cart, looked at his eMAR (electronic Medication Administration Record), and looked at the card again and stated the medication was not due at this time. The RN started to put the card back into the medication cart when the surveyor asked the RN to look again at the medication card to ensure the five rights of administration. The RN then noticed the medication that he had obtained for administration to Resident #38, that he thought was just not due at that time, was actually for another resident. Before administration of the medication and after disposal of the Citalopram, the RN verified he had six pills to administer to Resident #38. Review of the physician orders after the administration of the medications revealed the following: Cyanocobalamin (Vitamin B12) 1000 mcg to be given once daily. Vitamin D3 1000 IU/25 mcg, give two tablets daily. 105485 Page 8 of 9 105485 12/02/2021 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0759 Both of these medication orders were written with a start date of 07/02/21. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/30/21 at 10:43 AM, Staff K was asked to pull up the eMAR for Resident #38 and obtain the Vitamin B12 bottle from the medication cart. Staff K immediately noticed the 500 mcg (wrong dose) on the bottle and agreed the order was for 1000 mcg. The RN stated, last week we had the 1000 mcg tablets. Upon review of the order for the Vitamin D3, Staff K also agreed the dosage was for two tablets, and that he administered just one tablet. Residents Affected - Few 105485 Page 9 of 9