Health inspection·September 15, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. The findings included: Upon entering the facility, on 09/12/22 at 7:30 AM, there was an odor indicative of mold throughout the common areas of the facility. During an interview, on 09/12/22 at 10:27 AM, the concern of the mold like odor was brought to the attention of the Maintenance Director. It was noted that the air conditioning vents had an accumulation of dust and a black mold like substance, as did the vents over the nurse's stations. The ceiling tiles that were adjacent to the vents over the nurse's station were stained in a manner indicative of the tiles absorbing water. There was an area of the ceiling in the common area that appeared as though mold was painted over. The Maintenance Director stated that the facility would have an outside company come to the facility to clean the vents and dust and mold like substance. Upon returning to the facility, on 09/13/22 at 8:00 AM, the odor indicative of mold was still present, however not as pervasive and the air conditioning vents were clean throughout the common areas, although the ceiling tiles had not been replaced. In room [ROOM NUMBER], the wall inside of the entry way to the room was damaged. During an interview, on 09/12/22 at 1:57 PM, with the resident's family member, she stated that the air conditioning unit was blowing out warm air. During the interview, the resident was in bed with covers pulled back and only wearing an incontinent brief and a shirt. Resident's family member stated that she had uncovered him because the room was warm. In room [ROOM NUMBER], the wall by the window was damaged and the pull cord for the light over the window bed was fixed with a plastic bag and the bed frame for the door bed was missing caps on the ends leaving jagged edges with the potential for residents to obtain skin tears. In room [ROOM NUMBER], the wall at the head of the window bed was damaged. In room [ROOM NUMBER], parts of the bed frame near the foot of the window bed were damaged. In room [ROOM NUMBER], the wall at the head of the door bed was damaged. In room [ROOM NUMBER], the baseboard under the air conditioning was lying on the floor and had an Page 1 of 16 105492 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0584 accumulation of dust and a black mold like substance. Level of Harm - Minimal harm or potential for actual harm Outside of room [ROOM NUMBER], there was a portion of the wall that was damaged indicative of one of the dispensers being removed. Residents Affected - Some In room [ROOM NUMBER], the wall at the head of the window bed was damaged. The faucets at the hand sinks in the residents' restrooms showed signs of corrosion. The wall paper and walls at the entrance to the [NAME] and Canterbury units were damaged. During an environmental tour, on 09/15/22 at 1:13 PM, with the Maintenance Director, the Maintenance Director acknowledged the findings. 105492 Page 2 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

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** Residents Affected - Few Based on facility policy, record review, and interview, the facility failed to monitor and report lab results for 2 of 2 residents reviewed for Urinary Tract Infection (Residents #8 and #13). The findings included: A urinalysis is a test of the urine used to detect and manage disorders such as urinary tract infection, kidney disease and diabetes. A urine culture is a test to detect bacteria and organisms in the urine and which antibiotics will best treat it. Facility Policy titled Lab and Diagnostic Test Results- Clinical Protocol documents, The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. A nurse will review all results. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record. 1). On 09/12/22 at 12:10 PM Resident #8 stated she has had a urinary tract infection for a long time, and they do not seem to be doing anything more about it. Record review for Resident #8 documents an admission date of 12/08/21 with diagnoses that include Urinary Tract Infection and Paraplegia. A Minimum Data Set (MDS) Resident assessment dated [DATE] documented Resident #8 as cognitively intact. On 08/10/22 the physician ordered a urinalysis and urine culture. The urine culture was completed with results posted on 08/24/22. The urine culture results documented Organisms Isolated Indicative of Contamination, Please Resubmit. On 08/24/22 the physician ordered a repeated urinalysis and urine culture. A Nursing Progress Note by the Director of Nurses (DON) documented the resident refused collection of the repeat urine laboratory specimen. No documentation was noted of the physician being notified the urinalysis and urine culture was not done. On 09/13/22 the DON was unable to find documentation that Resident #8's physician was notified that the urinalysis and urine culture ordered on 08/24/22 were not done. On 09/13/22 at 7:10 PM, a progress note from the Infection Control nurse documents the physician for Resident #8 was notified the previous urine culture was contaminated and an order was received to send a repeat urine culture. 2). Record review revealed Resident #13 was admitted on [DATE] with diagnoses that include Stroke, Diabetes and Urinary Tract Infection. On 07/19/22 Resident #13 complained of burning when urinating and the physician ordered a urinalysis and a urine culture. On 07/22/22 the urinalysis results for Resident #13 documented white blood cells and bacteria in the urine and the physician ordered an antibiotic and antifungal to be started. On 07/23/22 the urine culture was completed documenting a multidrug resistant organism. No notation that the physician was notified of the culture results was noted in the chart. On 08/17/22 the lab reported an elevated white blood count of 17.8 (normal reference range 3.8-10.8) for Resident #13. No notation that the physician was notified of the elevated white blood count was noted in the chart. 105492 Page 3 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/13/22 at 2:58 PM the Assistant Director of Nurse (ADON) stated that there was no documentation in the chart of the physician being notified of the 07/23/22 urine culture results or the 08/17/22 elevated white blood count results for Resident #13. On 09/13/22 at 3:35 PM the Infection Control Nurse stated he was unable to locate documentation that the physician was notified of the 07/23/22 urine culture results or the 08/17/22 elevated white blood count results for Resident #13. On 09/14/22 at 5:15 PM, a Nursing Progress note by the DON regarding Resident #13 documents that the Advanced Registered Nurse Practitioner was informed of the previous elevated [NAME] Blood Count and prior drug resistant urine culture results. An order was received to repeat the urinalysis, urine culture and Complete Blood Count. 105492 Page 4 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

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 facility policy, observation, interview, and record review, the facility failed to ensure the environment was free from accident hazard and potential for injury. This requirement was not met due to hot water temperatures being above recommended range. This failure affected 4 of 8 residents sampled for bathroom water temperatures (#29, #41, #9, #38). The findings include: Facility Policy titled Water Temperature Monitoring review date 01/18/22 documented, It is the policy of Beach Breeze Rehab and Care Center to ensure the hot water temperature is maintained between 105 degrees - 115 degrees. (Fahrenheit) On 09/12/22 at 10:00 AM the surveyor noted water in the restroom to be uncomfortably hot. A TEL-[NAME] handheld thermometer was calibrated, and the following bathroom hot water temperatures were noted: room [ROOM NUMBER] and room [ROOM NUMBER]= 126 degrees Fahrenheit, room [ROOM NUMBER]= 124 degrees Fahrenheit, room [ROOM NUMBER]= 120 degrees Fahrenheit, room [ROOM NUMBER] and room [ROOM NUMBER]= 118 degrees Fahrenheit. On 09/12/22 at 10:10 AM the Director of Maintenance was notified of the elevated hot water temperatures in the resident rooms. He calibrated the facility handheld thermometer and verified the elevated hot water temperatures noted above. On 09/12/22 at 10:15 AM the Administrator was notified of the elevated hot water temperatures in the resident rooms. The Maintenance Director adjusted the hot water mixing valve to bring down the water temperatures in the resident rooms and stated a plumber was called to investigate. Record review of Resident #29 who resides in room [ROOM NUMBER], reveals a Minimum Data Set (MDS) assessment done 07/22/22 which documents moderate cognitive impairment with supervision needed for locomotion on and off the unit. Resident self-propels her wheelchair in and out of her room and throughout hallways. Record review of Resident #41 who resides in room [ROOM NUMBER], reveals a MDS assessment done 08/16/22 which documents cognitively intact with supervision only needed for activities of daily living. Record review of Resident #9 who resides in room [ROOM NUMBER], reveals a MDS assessment done 09/07/22 which documents cognitively intact with limited assistance needed for activities of daily living. Record review of Resident #38 who resides in room [ROOM NUMBER], reveals a MDS assessment done 08/11/22 which documents cognitively intact with limited assistance needed for activities of daily living. On 09/12/22 at 11:30 the Administrator stated that all residents were notified of hot water issues and instructed not to use the hot water. She stated staff education was done for safe water temperatures and hot water temperature audits/rounds had been instituted until repairs could be done. 105492 Page 5 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Resident # 47 was admitted to the facility on [DATE] with diagnosis to include unspecified protein-calorie malnutrition, open wound on left foot, gastrostomy status and schizophrenia. Residents Affected - Some The resident had a gastrostomy tube (feeding tube) and orders to received Jevity 1.5 at 45 ml for 20 hours through the gastrostomy tube. The resident also had orders for a dysphagia advanced texture, regular/thin liquid consistency diet. Review of the documented care plan (a written guide for the care of the resident) revealed residents potential for nutrition imbalance related to refusal to eat and failure to thrive. The goal of the care plan stated, the resident will maintain adequate nutritional status as evidenced by maintaining weight and no significant weight change. Interventions documented for this care plan include weigh as facility protocol. The facility policy documents, upon admission, residents are to be weighed every week for 4 weeks. Review of Resident #47 medical record revealed she was weighed one time since admission [DATE]). The documented weight was completed on 08/24/22. 5) Resident #20 was admitted to the facility on [DATE]. The resident had diagnosis to include unspecified severe protein-calorie malnutrition, diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, bipolar disorder, and schizoaffective disorder. The resident's care plan documents, the resident is at risk for nutritional problems, related to adult failure to thrive and underweight. The documented goal of the care plan was for the resident to improve weight. In review of the resident's record one weight was documented for the resident since admission to the facility on [DATE]. The weight for the resident was completed on 07/06/22. The facility policy documents, upon admission, residents are to be weighed every week for 4 weeks. 6) Resident #38 was admitted to the facility on [DATE]. The resident had diagnosis to include diabetes mellitus, dysphagia, urinary tract infection and muscle weakness. Review of the care plan revealed the resident had potential for imbalanced nutrition. The documented goal of the care plan for the resident to maintain adequate nutritional status as evidenced by maintaining weight. The interventions for the care plan included, provide food preferences and to weigh the resident per facility protocol. The facility policy documents residents are weighed every week upon admission for 4 weeks. In reviewing Resident #38 record the last documented weight was recorded on 08/11/22 on a MDS (Minimum Data Set) assessment sheet. Based on observation, interview, record review and facility policy review, the facility failed to monitor residents' weights per physician orders and facility policies and procedures for 8 of 10 residents reviewed for nutrition (Residents #29, 34, 27, 47, 20, 38, 5, 258). The findings included: 105492 Page 6 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0692 The facility's policy 'Weighing the Resident' documented: Level of Harm - Minimal harm or potential for actual harm Residents will be weighed unless ordered otherwise by the physician * Admission/re-admission x 3 days Residents Affected - Some * Weekly x 4 weeks * Monthly thereafter * As needed Procedure: * Weights will be completed as indicated and documented in the clinical record. * Identify the Resident. * Review prior month's weight and the scale that was used. Use same scale if possible. * When there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. * Record weight and alert nurse to any significant change. * Nurse to notify the physician of any significant weight change. * Consult with the Director of Dietary Services and/or dietitian. * Notify the Interdisciplinary Team in order to update the plan of care. During an interview, on 09/13/22 at approximately 9:00 AM, with Staff C, LPN, when asked how often residents are to be weighed, Staff C replied, they are weighed monthly. When asked who was responsible for weighing the residents, Staff C replied, whoever is able to do it. When asked about documenting the weights, Staff C replied, the weights are written in the record (referring to electronic health records). During an interview, on 09/14/22 at 1:07 PM, with Staff D, Registered Dietitian (RD), when asked who was responsible for weighing the residents, Staff D replied, Nursing is responsible for weighing the residents. We give a list to the DON (Director of Nursing). At the beginning of the month, we do monthly weights on everyone and then when we get the list of weights, we get re-weights and give nursing a list for the weekly weights. 1) Resident #29 was admitted to the facility on [DATE]. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 11, indicating 'moderately impaired. The MDS documented that Resident #29 required 'Supervision' and 'Two + persons physical assist' for eating. Resident #29's diagnoses at the time of the assessment included: Orthostatic Hypotension, Non-Alzheimer's Dementia, Anxiety disorder, Depression, Dysphagia following Cerebral Infarction, Lack of Coordination, Muscle weakness, Deformity of musculoskeletal system, 105492 Page 7 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0692 Abnormal Posture, Cognitive Communication Deficit. Level of Harm - Minimal harm or potential for actual harm Resident #29's diet orders included: Residents Affected - Some Regular diet, Dysphagia Advanced texture, Regular/Thin Liquids consistency - Small Portion @ B/L/D for tolerance. - 06/30/22 and most recently revised on 08/19/22. Magic Cup - one time a day @ Lunch - 08/20/22. Enteral Feed - four times a day for poor oral intake Enteral: Tube Feeding - Bolus via syringe Jevity 1.5 237 ml - 06/14/21. Resident #29's care plan, initiated on 04/30/22 and most recently revised on 08/22/22, documented, The resident has nutritional problem or potential nutritional problem r/t dysphagia with enteral feeds and mechanically altered diet provided. 6/15: On PO feeding with poor oral intakes & bolus feeding via PEG. 8/19: Bolus feeding, magic cup, & small portion @ B/L/D. The goals of the care plan were documented as: o The resident will maintain adequate nutritional status as evidenced by maintaining weight within (5)% of (CBW), no s/sx of malnutrition. 04/30/21 with a target date of 10/13/22. o Res will tolerate enteral feeds and flush w/no s/s aspirations. 04/25/22 with a target date of 10/13/22. Interventions to the care plan included: o Monitor/document/report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. o Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: >5% in 1 month, >7.5% in 3 months, >10% in 6 months. o Provide and serve diet, SNP as ordered per RX and provide TF as ordered. o RD to evaluate and make diet change recommendations PRN. o Weigh per policy. On 05/06/2022, the resident weighed 132 lbs. On 08/19/2022, the resident weighed 122 pounds which is a -7.58 % Loss. During an interview with Resident #29, on 09/12/22 at 8:51 AM, Resident #29 stated that she received Bolus feeding. When asked of any concerns with weight loss or gain, Resident #29 replied, I have gained 1 pound. It was noted that Resident #29 had a breakfast tray on her over bed table that consisted of scrambled eggs and an intact cinnamon roll with beverages. On 09/15/22 at 8:29 AM, in the presence of this surveyor, Resident #29 was weighed by the ADON. The resident's weight was 119 pounds which is an additional 3 pounds weight loss. 105492 Page 8 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview, on 09/14/22 at 1:07 PM, with Staff D, the RD stated, I just did a note on her. She was weighed 08/19/22. Before 08/19/22, she was 129 (6 months before). I just wrote a note today, I talked with her today and she said she didn't want any intervention. Staff D further stated that she was not aware of any significant weight changes. 2) Resident #34 was admitted to the facility on [DATE]. According to a Medicare 5-Day MDS, dated [DATE], Resident #34 was not assessed for cognition due to 'resident is rarely/never understood' and was completely dependent upon staff for all Activities of Daily Living (ADLs). Resident #34's diagnoses at the time of the assessment included: Aphasia following cerebrovascular disease, Anemia, Hypertension, Seizure disorder, Depression, Psychotic disorder, Acute respiratory failure with hypoxia, Morbid (severe) obesity, Abnormal posture, Lack of Coordination, Muscle weakness, Mild cognitive impairment, Tracheostomy complication. The MDS documented that the resident had swallowing disorders that included: 'Loss of liquids/solids from mouth when eating or drinking' 'Holding food in mouth/cheeks or residual food in mouth after meals' 'Coughing or choking during meals or when swallowing medications' Resident #34's diet orders included: Nothing by Mouth diet, NPO - 08/05/22. Jevity 1.5 @ 55mls / hr X 20 hours(On at 5pm and off at 1pm - every day and evening shift OFF 1:00pmON 5:00PM; Until 1100cc is infused. - 08/24/22. Resident #34's care plan, initiated on 08/10/22, documented, The resident has potential for imbalanced nutrition r/t condition associated with obesity, acute CVA w dysphagia/ aphasia AEB Swallowing Problem , Obesity, abdominal PEG tube. The goals of the care plan were documented as: o The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. 08/10/22 with a target date of 11/15/22 o The resident will tolerate TF order with no s/sx of intolerance/ inadequacy, no S/S of malnutrition. 08/10/22 with a target date of 11/15/22. Interventions to the care plan included: o Administer medications as ordered. Monitor & report for side effects and effectiveness. o Monitor & report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. o Provide and serve TF/Water flush as ordered. 105492 Page 9 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0692 o RD to evaluate and make TF/Water flush change recommendations PRN. Level of Harm - Minimal harm or potential for actual harm o Weight as per facility protocol. On 08/10/22, Resident #34 weighed 186 pounds. Residents Affected - Some There were no other weights documented in the resident's record. The facility could not produce any evidence that Resident #34's weights were taken and documented since 08/10/22. 3) Resident #27 was admitted to the facility under Hospice care on 05/31/22 and discharged from Hospice on 07/06/22. According to a Significant Change MDS, dated [DATE], Resident #27 had a BIMS score of 03, indicating 'severe impairment'. Resident #27's diagnoses included: UTI, Benign prostatic hyperplasia, Diabetes, Non-Alzheimer's Dementia, Malnutrition, Anxiety disorder, Depression, Psychotic disorder, ESBL, Deformity of musculoskeletal system, abnormal posture, lack of coordination, Cerebral atherosclerosis, metabolic encephalopathy. Resident #27's care plan, initiated on 07/03/22 and most recently revised on 07/06/22, documented, Resident has a nutritional problem r/t vascular dementia, dysphagia AEB functional decline, significant weight loss, altered texture, & hx of Hospice care. The goal of the care plan was documented as, Will maintain adequate nutritional status as evidenced by improving weight toward IBW , no s/sx of malnutrition, and consuming at least (75%)% of at least (2-3) meals daily through review date. - 07/06/22 with a target date of 10/30/22. Interventions to the care plan included: o Encourage PO fluid intake. o Encourage PO Intake. o Monitor labs and intakes; appetite stimulant in place. o OT to screen and provide adaptive equipment for feeding as needed. o Provide and serve diet, mechanically altered texture as ordered. o Provide fortified food, SNP as ordered: weight management. Resident #27's dietary order was documented as, Regular diet, Dysphagia Puree texture, Nectar Thickened Fluids consistency - 07/11/22. On 05/31/2022, the resident weighed 160 lbs. On 07/06/2022, the resident weighed 146 pounds which is a -8.75 % Loss. On 07/06/2022, the resident weighed 146 lbs. On 09/15/2022, at the request of this surveyor, the resident weighed 134 pounds which is an additional -8.22 % Loss. 105492 Page 10 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0692 There were no other weights documented in the resident's record. Level of Harm - Minimal harm or potential for actual harm 7) Resident #5 was admitted to the facility on [DATE]. Review of Resident #5's electronic health record revealed that Resident #5 was not weighed upon admission. On 06/15/2022, the resident weighed 141 lbs. On 07/06/2022, the resident weighed 133 pounds which is a -5.67 % Loss. There were no other weights documented in the resident's records. Residents Affected - Some During an interview, on 09/13/22 at 1:10 PM with Resident #5, who has a BIMS score of 14, the resident stated that she did not like the food and sometimes the staff does not offer her an alternate meal. Record Review revealed that the Resident is on a Regular NAS diet, Dysphagia Advanced texture, Regular/Thin Liquids consistency. A record review of Nurse Progress Notes dated 8/20/22 in the electronic medical records (EMR), Nutrition Note, states, Oral intakes supplemented with Fortified foods with breakfast and lunch (448kcal, 13gm pro), and Prostat AWC 30ml 1x/day (100kcal, 17gm pro, vit C/zinc). Appetite stimulant in place with improving appetite. PLAN: Will recommend MVI (Multivitamins) 1x daily. Obtain monthly weight. 8) On 09/12/22 at 8:35 AM, during an interview, Resident #258 stated that he thinks he has lost weight and does not get the food he orders sometimes. Record review for Resident #258 documented an admission date of 09/01/22 with diagnoses that include Heart Disease, Depression and Adult Failure to Thrive. A Minimum Data Set assessment dated [DATE] documented the resident as being cognitively intact requiring extensive assistance for all activities of daily living except eating which needs supervision. A Physicians order on 09/02/22 reads Regular Diet with an order revision on 09/09/22 to include large portions with meals. Two weights were recorded for Resident #258. On 09/04/22 a weight was documented as 0. On 09/10/22 a weight was documented as 140 pounds. An Initial Nutritional Evaluation Assessment completed on 09/09/22 documented the diagnosis of Failure to Thrive and reported weight loss. The Ideal Body Weight was recorded as 166 pounds with 10 percent variance. Included in the assessment was the most recent weight dated 09/04/22 documented as 0 with a plan to give large portions with meals and follow weights weekly. A Food Preference Assessment was documented completed on 09/13/22. On 09/14/22 at 10:45 AM the Assistant Director of Nursing stated that new admissions must be weighed within three days and refusals to be weighed must be documented in the chart. She stated that no documentation of weight refusals was noted for Resident #258. On 09/14/22 at 11:00 AM Resident #258 stated that he has not refused to be weighed since he was admitted to the facility. On 09/14/22 at 12:32 PM Staff D, Registered Dietician stated the dietician creates a list of residents who need to be weighed, updates it weekly and gives it to the Director of Nurses. She stated that if a resident had a diagnosis of Failure to Thrive and did not have a weight, she would have the nurse weigh them. She stated that Food Preference Assessments should be done within three days of admission. 105492 Page 11 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide enteral feeding as ordered for 1 of 6 residents reviewed for tube feeding, Resident #34. The findings included: Resident #34 was admitted to the facility on [DATE]. According to a Medicare 5-Day MDS, dated [DATE], Resident #34 was not assessed for cognition due to 'resident is rarely/never understood' and was completely dependent upon staff for all Activities of Daily Living (ADLs). Resident #34's diagnoses at the time of the assessment included: Aphasia following cerebrovascular disease, Anemia, Hypertension, Seizure disorder, Depression, Psychotic disorder, Acute respiratory failure with hypoxia, Morbid (severe) obesity, Abnormal posture, Lack of Coordination, Muscle weakness, Mild cognitive impairment, Tracheostomy complication. The MDS documented that the resident had swallowing disorders that included: 'Loss of liquids/solids from mouth when eating or drinking'. 'Holding food in mouth/cheeks or residual food in mouth after meals'. 'Coughing or choking during meals or when swallowing medications'. Resident #34's diet orders included: Nothing by Mouth diet, NPO - 08/05/22 Jevity 1.5 @ 55mls / hr X 20 hours(On at 5pm and off at 1pm - every day and evening shift OFF 1:00pmON 5:00PM; Until 1100cc is infused. - 08/24/22. Resident #34's care plan, initiated on 08/10/22, documented, The resident has potential for imbalanced nutrition r/t condition associated with obesity, acute CVA w dysphagia/ aphasia AEB Swallowing Problem , Obesity, abdominal PEG tube. The goals of the care plan were documented as: o The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. 08/10/22 with a target date of 11/15/22. o The resident will tolerate TF order with no s/sx of intolerance/ inadequacy, no S/S of malnutrition. 08/10/22 with a target date of 11/15/22. Interventions to the care plan included: o Administer medications as ordered. Monitor & report for side effects and effectiveness. 105492 Page 12 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0693 o Monitor & report to MD PRN for s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Level of Harm - Minimal harm or potential for actual harm o Provide and serve TF/Water flush as ordered. Residents Affected - Few o RD to evaluate and make TF/Water flush change recommendations PRN. o Weight as per facility protocol. Resident #34's care plan, initiated on 08/17/22, documented, The Resident is at risk for complications related to G-tube. The goal of the care plan was documented as, The resident will maintain adequate nutritional status as evidenced by maintaining weight with no S/S of malnutrition thru the next review date. 08/17/22 with a target date of 11/15/22. Interventions to the care plan included: o Check for tube placement and gastric contents/residual volume per facility protocol and record. o Keep HOB elevated as ordered. o Monitor weights per facility protocol. o Observe for and report to MD s/s of Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, and Dehydration. o Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. o Provide local care to G-Tube site as ordered and monitor for s/sx of infection. o Provide tube feeding and water flushes. See MD orders for current feeding orders. o RD to evaluate quarterly and PRN. Monitor caloric intake as indicated, estimate needs. Make recommendations for changes to tube feeding as needed. o ST evaluation and treatment as ordered. On 09/12/22 at 9:15 AM, Resident #34 was observed in bed sleeping with tube feeding initiated at 50 milliliters per hour (ml/hr). On 09/13/22 at 11:48 AM, Resident #34 was observed in bed sleeping with tube feeding initiated at 50 ml/hr. On 09/14/22 at 10:12 AM, Resident #34 was observed in bed sleeping with tube feeding initiated at 50 ml/hr. 105492 Page 13 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/15/22 at 7:04 AM, Resident #34 was observed in bed sleeping with tube feeding initiated at 50 ML/hr. The facility could not provide evidence of Resident #34's weights being appropriately monitored. During an interview, on 09/15/22 at 8:14 AM, with Staff B, RN, when asked of Resident #34's orders for tube feeding, Staff B confirmed the order and stated that the 11-7 shift was responsible for initiating the tube feeding. 105492 Page 14 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2) During an observation of meals that were packed for residents to take to dialysis, on 09/14/22 at 8:24 AM, the following were noted. Residents Affected - Many a. Resident #109's meal consisted of an egg salad sandwich, juice and assorted crackers. The meal was contained in a soft sided cooler. It was noted that there was no means to keep the items, including potentially hazardous food at or below 41 degrees Fahrenheit (F) to prevent the growth of pathogens that cause foodborne illness. b. Resident #158's meal consisted of pureed cereal, pureed egg, apple sauce, and juice. The meal was contained in a soft sided cooler. It was noted that there was no means to keep the items, including potentially hazardous food at or below 41 degrees (F) to prevent the growth of pathogens that cause foodborne illness. During an interview, on 09/14/22 at 9:05 AM, the Certified Dietary Manager (CDM), when asked about keeping the potentially hazardous items at or below 41 degrees F, the CDM replied, I have never seen an ice pack in here. Based on observation, interview and record review, the facility failed to provide foods prepared, served and stored in a manner to prevent the potential growth of pathogens that cause foodborne illness and in accordance with professional standards for food safety. The findings included: 1) During the initial kitchen tour, on 09/12/22 at 8:15 AM, accompanied by the Certified Dietary Manager, the following was observed. a. The blade of he the can opener was encrusted with food residues. b. There was an accumulation of dust on the air conditioning vents over the food preparation area. c. There was an accumulation of dust on the sprinklers for the fire suppression system over the food preparation area. d. There was an accumulation of food residue on the gasket inside of the door to the walk in cooler. e. The waste dumpster that was located behind the facility was left open and was noted to be dirty. f. Brooms that were kept in the Janitor's closet were stored on the floor. During an interview, on 09/15/22 at 2:38 PM with the Certified Dietary Manager, she was informed of the findings and acknowledged understanding of the concerns. 105492 Page 15 of 16 105492 09/15/2022 Beach Breeze Rehab and Care Center 1626 Davis Rd West Palm Beach, FL 33406

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on facility policy, record review and interview, the facility failed to maintain accurate resident records. This failure affected 1 of 15 sampled residents (Resident #8). Residents Affected - Few The findings include: Facility Policy titled Physician's Orders dated 04/01/22 documents, It is the policy to write physicians' orders to establish a plan of care to follow for the care of the patient. Purpose: To ensure that the plan of care is followed in accordance with the orders established by the physician and/or nurse practitioner. Vital signs definition is clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions. Record review on 09/12/22 for Resident #8 revealed an active Physicians Order for Vital Signs every Friday initiated 02/13/22. Review of Blood Pressure Summary Record for Resident #8 documented a Blood Pressure of 124/69 on 05/05/2022 with no further entries. Review of Pulse Summary Record for Resident #8 documented a Pulse of 80 on 05/05/2022 with no further entries. Review of Medication Administration Records for July 2022 through September 12, 2022, documented Vital Signs as being taken every Friday. Skilled nursing notes dated 07/09/22, 08/09/22 and 09/02/22 all reference current vital signs as Blood Pressure 124/69 and Pulse 80 taken on 05/05/22. Interview with the Regional Director 09/14/22 at approximately 12 noon confirmed there was no documentation of Blood Pressure or Pulse readings for Resident #8 after 05/05/22 on the chart although the Medication Administration Record documents it is being done every Friday. On 09/14/22 at 11:10 AM Resident #8 stated that she has not refused to have her blood pressure taken and they have not taken it in a long time. 105492 Page 16 of 16