Health inspection·April 21, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide drinking cups with cartons of milk for the breakfast meal on 04/19/22, for 32 residents on the [NAME] Unit. The findings included: Review of the approved breakfast menu for 04/19/22 documented that 8 ounces of milk was to be served. Review of the Production Count for the breakfast meal dated 04/19/22 documented that 98 residents received whole milk, 24 residents received skim milk, 4 residents received 2% milk, and 3 residents received lactaid milk. During an observation of the breakfast meal on 04/19/22 at 8:56 AM, it was noted that 32 residents on the [NAME] Unit who received a carton of milk with their meal did not receive a drinking cup. In an interview conducted on 04/20/22 at 7:43 AM, the Dietary Supervisor stated that most residents receive milk cartons with their breakfast meals. When asked why the milk cartons were not served with drinking cups, the Dietary Supervisor stated that most of the drinking cups were used to serve juice and that there were not enough drinking cups to serve with the milk cartons. He then acknowledged that the milk cartons should have been served with a drinking cup to promote residents' dignity. In an interview conducted on 04/20/22 at 8:04 AM, the Administrator stated that the kitchen did have drinking cups and that they were not provided with the milk cartons for the breakfast meal served to the residents on 04/19/22. Page 1 of 25 105506 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0583 Keep residents' personal and medical records private and confidential. 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 privacy for telephone communications for 1 of 1 sampled residents reviewed for privacy (Resident #12). Residents Affected - Few The findings included: Review of the facility's policy titled, Confidentiality of Information and Personal Privacy, dated 04/11/22, documented the following: The facility will strive to protect the resident's privacy regarding his or her written and telephone communications. Review of the facility's policy titled, Telephones, Resident Use Of, dated 04/11/22, documented the following: Designated telephones are available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily be reserved for staff use, unless no other alternative is available. Residents should use telephones at the nursing stations for as brief a period as possible. Telephones will be in areas that offer privacy and accommodate the hearing impaired and wheelchair bound residents. Review of the record showed that Resident #12 was re-admitted to the facility on [DATE] with diagnoses which included: Cerebral Infarction, Legal Blindness, and Recurrent Depressive Disorders. Review of Section C of the Minimum Data Set, dated [DATE] documented that Resident #12 had a Brief Interview for Mental Status of 09, which indicated that she was moderately cognitively impaired. During an observation conducted on 04/18/22 from approximately 12:30 - 1:00 PM, Resident #12 asked staff to make a phone call and was brought to the nursing station in the [NAME] Unit where she discussed private matters (family dynamics and specific family issues) on the facility's telephone. When asked, Staff G, Certified Nursing Assistant, stated that Resident #12 had a phone in her room. She further stated that Resident #12 required assistance with the phone and that it was easier to provide her with assistance at the nursing station rather than in her room. In an interview conducted on 04/21/22 at 7:38 AM, the Administrator stated that residents had telephones in their rooms that could be used to make private phone calls. Two surveyors informed the Administrator of the findings, and she acknowledged the findings. 105506 Page 2 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

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 observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that included the Central Supply Rooms (2), [NAME] Unit, [NAME] Unit , and Windsor Unit. The findings included: 1) During observation conducted on 04/18/22 at 2 PM of the central Supply Rooms (2) , accompanied by the Central Supply Supervisor, the following concerns were noted: room [ROOM NUMBER]: (a) The air-conditioning vent located on the ceiling in the middle of the room was noted to have the entire exterior and surrounding area covered in a black mold type substance. It was discussed with the supervisor that the vent was blowing the suspected mold onto nursing supplies located in the room. The supervisor stated she was aware of the condition of the vent but had not reported it to maintenance. (b) The entire floor area of the supply room was covered with dirt, dust, trash, and areas of black mold type matter. The supervisor stated that she has been in charge for 3 months and the floor area has never be cleaned. (c) The middle of the room contained a large wood pallet (8 X 3) that was covered with a rug. Further observation noted that the surface of the rug was heavily soiled with dirt, dust, and debris. Cases of supplies stored directly on the soiled rug included; Bathing Scrubs (4), Blue Masks (1), Incontinent Briefs (4), and Biotene (3). The supervisor stated that the rug has been in the room since her starting date and has never been cleaned. (d) Observation noted that 13 cases of supplies were stored directly on the soiled floor. The cases of supplies included: Glucose testing Strips (5), TB Syringes (2) , Nebulizer machines (2) , and Covid Immunization Syringes (4). The supervisor stated that many of the cases of supplies were stored directly on the soiled floor. (e) Numerous ceiling tiles (4) located in numerous areas of the room were noted to be soiled, stained, and molded. The supervisor stated that she never reported the tiles for replacement. Photographic Evidence Obtained. room [ROOM NUMBER]: (f) The room was noted to house nutritional supplements and gastric tube feedings. Observation noted that there were 6 soiled oxygen concentrators stored in the room and 4 soiled gastric feeding pumps. (g) The door to the bathroom located within the storage room was noted to open and a urine smell was noted. 105506 Page 3 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0584 (h) The supply room also had an office area with the door open. The office contained numerous bags of open foods and drinks. The floor area was heavily soiled and the office was unkept. Level of Harm - Minimal harm or potential for actual harm 2) First Floor - [NAME] Unit Residents Affected - Some room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair, sharp edges to bottom of bathroom entry door. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. peeling ceiling paint in main room. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Numerous stains to hallway carpet in front of room entry door. room [ROOM NUMBER] - Numerous stains to hallway carpet in front of room entry door. 3) Second Floor - [NAME] Unit: Hallway #1 (Rooms 201-214): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. room [ROOM NUMBER] - Missing areas of room baseboards, large hole in wall (W-bed), room wall damage, areas of peeling room wall paper, and the arm rest of the over the toilet seat was broken and a large area of the arm was missing. room [ROOM NUMBER] - Missing areas of room base boards, and large hole in room wall. room [ROOM NUMBER] - Bathroom sink noted to have cracks throughout the entire base surface. room [ROOM NUMBER] - Poor TV reception. Resident requesting for repair. room [ROOM NUMBER] - Large scuff marks to walls located under room window, and missing areas of base boards to room. 4) Hallway #2 (Rooms 215-228): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. 105506 Page 4 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0584 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER] - Exterior of overbed table was peeling (W-bed), and peeling wood exterior to foot board of bed (A-bed). room [ROOM NUMBER] - Room walls noted to large scuff marks, and foot board bed exteriors were in disrepair, and overbed tables exteriors were worn (D & W Beds). Residents Affected - Some room [ROOM NUMBER] - Chipped exterior to overbed tables. room [ROOM NUMBER] - Peeling room wallpaper near window, and missing over bed light pull cord (W-bed). room [ROOM NUMBER] - Chipped exterior of bed. 5) Second Floor - Windsor Unit: Hallway #1 (Rooms #229-2241): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. Hallway #2: (Rooms #243-249): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. Following the environment tours all findings were again confirmed with the facility Directors. The Directors also reviewed the findings with the Administrator. 105506 Page 5 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

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 observation, interview, and record review, it was determined that the facility failed to provide necessary care and services to ensure that 1 (Resident #192) of 12 sampled residents ability to eat did not diminish. Residents Affected - Few The findings included: During the observation of the lunch meal on 04/18/22 at 12:30 PM, the [NAME] Unit, it was noted that the lunch meal was placed on the over-bed tray table in front of Resident #192, however the resident was not eating. Interview with Resident #192 at the time of the observation noted the resident to be very alert and orientated and stated that she is blind and requires extensive to total assist with meals. The resident further stated that she tells aides when delivering the meal that she needs help eating, but they never return. The surveyor inquired if she complained to Administration and stated I have been here 3 weeks without assistance and I am used to eating the foods cold. Resident #192 stated that she has total blindness in the left eye and blurred vision in the right eye. She further stated that she wants to receive therapy to be able to use eating skills for independent eating. An additional observation of Resident #192, conducted of the breakfast meal on 04/19/22 noted that the food transportation cart on the [NAME] Unit at 7:50 AM. Further observation noted that the breakfast food tray that was served on a disposable Styrofoam plate until 55 minutes latter at 8:50 AM. The resident requested the aide to set her up in a chair to assist eating independently. She was transferred and able to eat the meal which consisted of only cereal, and toast. It was also observed that the the son of Resident #192 was in the room during the 04/19/22 observation and confirmed that the resident is not receiving the assistance with meals that is required. A review of the clinical record of Resident #192 noted a date of admission to the facility on 4/4/22. The resident's diagnoses included, Acute Cholecystitis, ASHD (Arteriosclerotic Heart Disease), Laparoscopic Surgery, and CHF (Congestive Heart Failure). Review of Physician Orders included: No Added Salt Diet (4/4/22) Liquid Protein 30 ml BID (Twice per day) (4/10/22) Weekly Weights (4/4/22) The resident's weight history documented: 04/14/22 = 150 pounds 04/4/22 = 159.5 pounds (9.5 pound weight loss in 10 days) The Minimum Data Set (MDS) dated [DATE], documented the following: 105506 Page 6 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0676 Section B: Vision- Severely Impaired Level of Harm - Minimal harm or potential for actual harm Section C: BIMS (Brief Interview of Mental Status) score = 13, indicating intact cognition Section G: Supervision With Eating Residents Affected - Few Review of Physician's Progress Notes revealed the following: 04/18/22 - Resident is legally blind 04/14/22 - Resident is Legally Blind 04/12/22 - Extensive Assist with eating and drinking 04/11/22 - Resident is Legally Blind 04/10/22 - Resident requires total assist for eating and drinking 04/08/22 - Resident requires total assist for eating and drinking 04/07/22 - Resident is Legally Blind 04/07/22 - Resident requires extensive assist with eating and drinking A Nutrition assessment dated [DATE], documented that the resident has a fair meal intake of 50% and requires supervision with meals. Further review revealed there was no documentation indicating that the resident is Legally Blind and requires extensive to total assist with meals. Care Plan review noted that the the resident has a nutrition problem relating to Cholecystitis, however there are no interventions that includes the resident is legally blind and requires extensive to total assist with meals and fluids. The issues were discussed by the surveyor and confirmed with the Director of Nursing and Administrator on 04/20/22. 105506 Page 7 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

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, interview and record review the facility failed to ensure a midline intravenous (IV) catheter was assessed for 1 of 1 sampled residents reviewed for IV catheters, Resident #104, as evidenced by no documentation Resident #104's midline IV catheter was being assessed or checked for patency since the insertion date. Residents Affected - Few The findings included: Review of the facility policy titled Midline Dressing Changes states in part, 'Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter site dressings. General Guidelines: Change midline dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.' Review of the facility policy titled Central Venous and Midline Catheter Flushing states in part, 'Purpose: The purpose of this procedure are to maintain patency of midline and central venous catheters. Flushing Protocol: Flush catheters at regular intervals to maintain patency.' On 04/18/22 at 10:00 AM, an initial observation was conducted of Resident #104 in her room in bed. Observed to her right upper arm was a midline IV catheter with the insertion site covered with a transparent dressing. Resident #104 was unable to verbalize the reason for having the IV access site. Review of the clinical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses to include, Cerebral Vascular Accident with Left Sided Paralysis, Diabetes and Congestive Heart Failure. Further review of the clinical record revealed a Nursing Progress Note dated 04/11/22 at 11:24 PM, documenting, 'Midline inserted to right upper arm, no complication noted to site, Normal Saline IV at 55 milliliters/hour initiated for dehydration.' Review of Physician Orders revealed an order dated 04/15/22 at 11:10 PM documenting, 'IV site check every shift.' Under Order Type is documented 'Other Treatment - (Treatment Administration Record (TAR).' Further review of the Physician Orders dated 04/15/22 documented 'IV Midline Catheter (Right Upper Extremity) Change catheter site dressing every week Thursday and PRN (as needed) with transparent dressing every night shift.' Review of the April 2022 TAR revealed no documentation of an order for the IV site checks every shift or IV catheter dressing changes to be done every week. Further review of the TAR revealed no evidence of documentation Resident #104's IV midline site was being assessed or flushed to ensure continued patency and no evidence of any dressing changes since the insertion date of 04/11/22. Review of the Nursing Progress Notes from 04/11/22 through 04/21/22, revealed no documentation of any assessment or flushing of the IV midline or any documentation of any dressing changes conducted. On 04/21/22 at 11:35 AM, Resident #104's right upper arm IV midline site was observed. Upon closer observation of the transparent dressing it was noted there was no date on the dressing of when the IV catheter was inserted or if the dressing had been changed since insertion on 04/11/22. 105506 Page 8 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident #104's Care Plans revealed no Care Plan addressing the resident was experiencing dehydration which required the insertion of an IV midline catheter and the administration of IV fluids. Further, there was no Care Plan addressing the need to assess the IV midline catheter for any signs of infection; the need to flush the IV midline to ensure continued patency; or change the IV midline catheter dressing weekly as ordered by the Physician. Residents Affected - Few On 04/21/22 at 12:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) Staff F, caring for Resident #104, and an inquiry was made how often they assess an IV midline to which she stated every day then stated every shift. An inquiry was made how often they change the dressing to which she stated weekly. An inquiry was made where they document their assessments and dressing changes to which she stated on the TAR. A request was made to look at Resident #104's TARs and show where she documented her assessment and dressing changes of the IV midline site. LPN Staff F checked the TAR and could not locate a place to document an assessment every shift or weekly dressing change since the insertion on 04/11/22. LPN Staff F then checked the Physician Orders revealing an order dated 04/15/22 to check the IV midline site every shift with dressing changes every week on Thursdays. LPN Staff F then went back to the TARs revealing the orders were not there to which she stated 'I guess it did not make it to the TAR.' A further inquiry was made if she has assessed the IV midline site or changed the dressing to which she had no comment. 105506 Page 9 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure splint devices were applied for 1 of 1 sampled residents reviewed for Position/Mobility, Resident #104, as evidenced by failing to apply a left hand splint, left elbow splint and bilateral lower extremity boots for Resident #104 to prevent further contractures. The findings included: Review of the facility policy for Restorative Nursing Services states in part, 'Residents will receive restorative nursing care as needed to help promote optimal safety and independence Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. physical, occupational or speech therapist). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.' On 04/18/22 at 10:00 AM, 12:20 PM and 2:40 PM, Resident #104 was observed in her room in bed in a hospital gown. Resident #104's left hand was observed to be very contracted in a clenched position. There was no splint in place. On 04/19/22 at 9:20 AM, 12:30 PM and 2:30 PM, Resident #104 was observed in her room in bed in a hospital gown. Resident #104's left hand was observed to be very contracted in a clenched position. There was no splint in place. On 04/20/22 at 10:12 AM, Resident #104 was observed in her room in bed in a hospital gown. Resident #104's left hand was observed to be very contracted in a clenched position. There was no splint in place. On 04/20/22 at 12:55 PM, Resident #104 was observed in her room in bed in a pink night gown. Certified Nursing Assistant (CNA) Staff L was at the resident's bedside assisting with feeding the resident her lunch meal. Resident #104 was observed with no splints on her left hand. Review of the clinical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses to include Cerebral Vascular Accident with Left Sided Paralysis, Diabetes and Congestive Heart Failure. Further review of the clinical record revealed Resident #104 had a hospital admission on [DATE] and was readmitted to the facility on [DATE]. Review of a Care Plan date initiated 04/01/22 documented, ' Potential for alteration in comfort related to decreased mobility, spasticity, contractures - Desired outcome- Left Upper Extremity will be positioned with appropriate orthotic devices for hemiplegic/contracture management. Interventions - Left elbow orthosis splint as tolerated. Left wrist/hand splint as tolerated. Restorative Nursing Program for BUE PROM (bilateral upper extremity passive range of motion) in all planes and BUE orthotic contracture management as tolerated.' Review of the April 2022 Physician Orders revealed an order dated 04/15/22 for a left elbow orthosis splint as tolerated; left wrist/hand splint as tolerated; and bilateral lower extremity padded calf board foot rest support board when up in wheelchair at all times as tolerated. All orders 105506 Page 10 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented to monitor for redness or skin breakdown. The Physician Orders did not provide a frequency or schedule for the number of hours the splints were to be worn daily. On 04/20/21 at 1:30 PM, an interview was conducted with Occupational Therapist (OT) Staff M who stated Resident #104 was picked up on their case load on 03/22/22 and discharged from their case load on 04/18/22 but the final discharge note had not been written yet. He stated the OT was for contracture management. He further stated the left hand splints should be on for 3-4 hours daily, off for 1 hour then put back on. At this time the Director of Rehabilitation arrived joining the conversation. She stated the resident will be transitioned to Restorative Nursing, but they have not done the paper work yet for the discharge. An inquiry was made what hand splints 'as tolerated' meant, and she then stated they have to take the splints off to make sure the skin is alright. An inquiry was made what the purpose of Resident #104's splints were and she stated for contracture management and prevention. The Director of Rehabilitation was advised the resident's splints had not been observed on the resident for the past 3 days and they had not been observed in the resident's room. The Director of Rehabilitation stated they must be in the room. A request was made for her to go up to room and show where the splints are located. On 04/20/22 at 1:45 PM, Resident #104's room was observed with the Director of Rehabilitation who found the 3 splints on the resident's wheelchair pushed up against the wall. A request was made for her to put the left wrist splint on. She obtained the wrist splint and began attempting to unclench the resident's fingers which were very stiff. The resident complained of pain when the Director of Rehabilitation was trying to pry open her fingers. Resident #104 then stated to the Director of Rehabilitation to try putting on the elbow splint first as it might be easier to get the wrist splint on. The Director of Rehabilitation applied the left elbow splint. She then attempted again to put on the left wrist splint, still unable to pry open the resident's fingers. At this time the resident told her to put lotion on her fingers to make them unclench. The Director of Rehabilitation did this and she was then able to get the left wrist splint on. An inquiry was made to Resident #104 who puts her splints on for her to which she stated 'Nobody'. The resident then asked the Director of Rehabilitation to apply her boot splints. The Director of Rehabilitation pulled up the covers from the resident's legs to reveal both feet had foot drop. The Director of Rehabilitation applied the boots. During the application of the 3 splints the resident was compliant and did not refuse to have them applied. An inquiry was made to the Director of Rehabilitation for the reason for the boot splints to which she stated to prevent sores, prevent internal rotation and to prevent ankle contractures. An inquiry was made to Resident #104 if she was uncomfortable with the splints on to which she stated she was good. The resident looked very content. On 04/20/22 at 3:00 PM, Resident #104 was observed in her room in bed. All 3 splints remained in place. In an interview conducted with Resident #104, she expressed she did not mind wearing the splints. On 04/21/22 at 11:35 AM, Resident #104 was observed in her room in bed. The left wrist and elbow splints were in place and she was wearing the bilateral boots. Resident #104 stated she was pleased the splints were on and further stated I have the boots on too. She stated the therapist put the splints on and the aide put the boots on. On 04/21/22 at 1138 AM, an interview was conducted with CNA Staff L who had Resident #104 on her daily assignment. An inquiry was made who is responsible for applying the resident's splints to which she stated it is restorative nursing that puts on the splints, then quickly recanted stating it is all our jobs to put on splints. 105506 Page 11 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/21/22 at 12:30 PM, an interview was conducted with Restorative CNA Staff G and an inquiry was made about Resident #104 and if she was on her restorative nursing list. CNA Staff G stated Resident #104 is on restorative for the lower extremities as she is on case load with OT for the upper body. CNA Staff G confirmed prior to the resident's hospitalization in March, the 2 left arm splints were applied daily for 2-3 hours and the boots were applied. CNA Staff G stated she did the boots today and the OT did the splints. CNA Staff G confirmed the resident had been using the splints regularly prior to her hospitalization but could not state if the left hand splints have been applied since her return from the hospital. Review of an Interdisciplinary Team Referral to Therapy dated 04/20/22 for Occupational Therapy documented - Patient is currently on OT skilled services which is assessing LUE elbow and wrist hand splint as well as determining wearing tolerance in order to establish appropriate schedule and caregivers training. This additional OT referral was initiated after the discussion and observations conducted with the Director of Rehabilitation on 04/20/22 at 1:45 PM. On 04/21/22 at 12:35 PM, an interview was conducted with the Director of Rehabilitation who stated they put Resident #104 back on the OT case load to determine a schedule for the splints as a schedule had not been determined. The Director of Rehabilitation confirmed prior to the resident's hospital stay in March, she was wearing the splints for 3-4 hours a day. The Director of Rehabilitation also confirmed post the hospital stay, the splints have not been applied regularly, possibly due to a lack of a specified schedule so they will work with the resident now to determine the length of time the resident can tolerate wearing the splints. 105506 Page 12 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation and interview, it was determined that the facility's environment on the [NAME] Unit (first floor) which houses 40 residents, was not free of accident hazards. The findings included: During there environment tour of the [NAME] Unit located on the first floor on 04/20/22 at 2 PM, conducted with the Director of Maintenance and Director of Housekeeping, the following were noted: 1) Noted large areas (5) of cut up rolled up floor carpeting around North side of nurses station. Further observation noted the rolled carpeting to be protruded out and was a tripping hazard to resident and staff. The Director agreed with the surveyor's observation. 2) Observation of Community Shower #1 noted new floor tiles installed. Further observation noted that 4 floor tiles around the floor drain were raised and protruding sharp edges. It was discussed with the Mangers that the tiles were a hazard to residents feet and staff when utilizing the shower stall. The Managers agreed with the surveyors observation. 3) Observation of Community shower #1 noted that a new emergency call cord had been installed into the shower stall, however the emergency pull cord was still wrapped in tape and placed on a flat surface approximately 4 feet off the floor surface. It was discussed with the Directors that if the was an emergency in the shower stall the call bell could not be reached to activate the emergency call system. 4) Observation of the North Hallway noted a large hole (4 X 4 ) to the wall outside of room [ROOM NUMBER]. Further observation noted that electrical wiring could be seen in the hole. Interview with the Director's at the time of the observation revealed that the electrical wiring was love and could easily result in hazard to residents. Following the observations it was revealed that the [NAME] Unit was be remodeled by outside contractors, however the contractors had not been in the facility at least 10 days. It was further discussed that the contractor staff did not properly secure the unit from potential accident/hazards prior to leaving. A review of the facility census for 04/20/22 noted that there were 40 residents residing on the [NAME] Unit. Photographic Evidence Obtained of Example #1, #2, #3, and #4. 105506 Page 13 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

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** 3) On 04/19/22 at 11:19 AM, an interview was conducted with Resident # 125. Resident #125 was in bed with her breakfast tray on her overbed table with the breakfast dishes on it. Observation of the breakfast tray revealed she ate 90% of her breakfast. This surveyor asked the resident how breakfast was and she replied that she has been having a bad taste in her mouth which makes food taste metallic so she doesn't usually eat breakfast. She stated that she thinks she lost weight because of this. She was asked if she had seen a dietician and she replied that she had not seen a dietician recently. Residents Affected - Few Resident #125 was initially admitted to the facility on [DATE] with medical diagnoses of cerebral palsy, cerebral infarction, and type 2 diabetes. A Medicare 5 day Minimum Data Set (MDS) assessment was done with an assessment reference date of 03/23/22 which indicated in Section C that the resident has a Brief Interview of Mental Status (BIMS) of 14 indicating she is cognitively intact. A review of the resident's diet order revealed her diet as low concentrated sweets (LCS) and no added salt (NAS), regular texture, thin consistency. There were no supplements ordered. A review of the Resident #125's weights for 2022 revealed on 01/07/22 she weighed 189.5 pounds, on 02/04/22 she weighed 185 pounds, on 03/04/22 she weighed 176 pounds and on 04/12/22 she weighed 152.4 pounds. This was a 14% weight loss in 1 month and a 20% weight loss in 3 months. On 04/19/22 at 1:06 PM, an interview was conducted with Staff B, a Diet Tech. Staff B stated that at this time there is no Dietician in the facility and they have a remote Dietician. The previous Dietician abruptly left a few days ago. Staff B continued to state that she is doing assessments and any high risk assessments will be done by the Dietician. Staff B was asked who notifies her of a resident's weight loss or gain? She stated the Dietician will tell her. She was asked if a resident were weighed on 04/12/22 would you be aware of her weight yet. She stated that the weight list is given to the Director of Nurses (DON) who gives it to the restorative aide and the DON puts the weights in the computer. They run a weight report which was done by the remote Dietician. This surveyor asked for the weight report at 1:15 PM. At 3:05 PM she returned without a weight report for April and stated that she was not aware of the resident's weight loss in April. An interview was then conducted with the acting DON on 04/19/22 at 3:14 PM, who stated the nurses put the weights in the computer and should notify the Dietician if they see the weight is less than the previous month. The dietician will determine who to weigh monthly and weekly. The DON stated that she should have seen the weight loss by now for Resident #125. The surveyor asked for Resident #125 to be weighed the following morning. On 04/20/22 at 9:44 AM the resident was weighed by Staff C, a Certified Nurses Aide. The re-weigh was 154.8 pounds, a 2.4 pound gain since 04/12/22. Staff C stated she is given a list of residents to be weighed and gives the weights to the nurse because there is no Dietician now. Based on observations, interviews, and record review, the facility failed to address significant weight loss in a timely manner for 3 of 12 sampled residents reviewed for nutrition (Resident #12, Resident #25 and Resident #125). The findings included: 105506 Page 14 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy titled, Weight Assessment and Intervention, dated 04/11/22, documented the following: Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If they weight is verified, nursing will immediately notify the dietitian in writing. The dietitian will respond within 24 hours of receipt of written notification. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant, greater than 5% is severe; 3 months - 7.5% weight loss is significant, greater than 7.5% is severe; 6 months - 10% weight loss is significant, greater than 10% is severe. 1) Review of the record documented that Resident #12 was re-admitted to the facility on [DATE] with diagnoses which included: Cerebral Infarction, Type 2 Diabetes Mellitus, Mild Protein-Calorie Malnutrition, Atherosclerotic Heart Disease, and Hyperlipidemia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #12 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated that she was moderately cognitively impaired. Review of the Care Plan dated 02/26/22 documented that Resident #12 had nutritional problems with significant weight loss. Interventions were to assess weights and food intake as needed/indicated and for the Registered Dietitian (RD) to evaluate and make diet change recommendations as needed. Review of the weights documented that Resident #12 weighed 115 pounds on 03/22/22 and 109 pounds on 04/02/22. This showed that Resident #12 experienced a 5.2% significant weight loss within a 2 week timeframe. Review of all Dietary Progress Notes in PointClickCare (electronic charting system) showed that there were no progress notes addressing the 5.2% weight loss. Review of all Nutrition Assessments in PointClickCare showed that there were no assessments addressing the 5.2% weight loss. In an interview conducted on 04/20/22 at 8:06 AM, Staff B, Dietetic Technician, she stated that she was responsible for conducting initial assessments, quarterly assessments, annual assessments, and significant change progress notes for residents that were not at high nutritional risk. She further stated that the RD was responsible for conducting assessments for residents at high nutritional risk. According to her, residents at high nutritional risk were those with renal conditions, tube feeding, wounds, and significant changes in weight. Staff B stated that all assessments and notes were documented in PointClickCare. She further stated that residents were weighed upon admission, weekly for 4 weeks, and then monthly thereafter. When asked about re-weighs, she stated that if a resident experienced a weight loss greater than 3-5 pounds, she would ask for a re-weigh. She further stated that she would expect to obtain the re-weigh within 24 hours. According to her, weights were documented in PointClickCare. Staff B stated that a significant weight change would be 5% within 30 days or 10% in 90 days. She further stated that if a resident experienced a significant change in weight, she would follow up with them immediately. When asked about Resident #12, Staff B acknowledged that there were no assessments/progress notes addressing the 5.2% significant weight loss. When asked if an assessment addressing the weight loss should have been conducted, Staff B stated, Yes, there should have been. Staff B acknowledged that Resident #12's significant weight loss had been overlooked. 2) Review of the record documented that Resident #25 was admitted to the facility on [DATE] with 105506 Page 15 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0692 diagnoses which included: Protein-Calorie Malnutrition, Cerebral Infarction, and Dementia. Level of Harm - Minimal harm or potential for actual harm Review of Section C of the MDS dated [DATE] documented that Resident #25 had a BIMS score of 03, which indicated that she was severely cognitively impaired. Residents Affected - Few Review of the Care Plan dated 02/18/22 documented that Resident #25 had potential nutritional problems with weight loss. Interventions were for the RD to evaluate and make diet change recommendations as needed. Review of the weights documented that Resident #25 weighed 117 pounds on 09/01/21 and 108 pounds on 10/15/21. This showed that Resident #25 experienced a 7.6% severe weight loss within a 1 month timeframe. Review of the Dietary Progress Note dated 11/02/21 documented that Resident #25 had a current weight of 108 pounds, which was a 7.5% change in weight. This showed that Resident #25's severe weight loss was not assessed until 18 days after it was identified. In an interview conducted on 04/20/22 at 8:06 AM, Staff B confirmed that Resident #25 experienced a 7.6% severe weight loss between 09/01/21 - 10/15/21. Staff B further confirmed that the severe weight loss was not assessed until 11/02/21, which was 18 days after the weight loss was identified. Staff B acknowledged that the severe weight loss was not assessed in a timely manner and that an assessment should have been completed sooner. 105506 Page 16 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0759 Ensure medication error rates are not 5 percent or greater. 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, it was determined the medication error rate was 7 percent. 2 medication errors were identified while observing a total of 26 opportunities, affecting Resident #26. Residents Affected - Few The findings included: Review of the facility's policy titled Administering Medications published 04/11/2022 documented Medications are administered in a safe and timely manner and as prescribed. Review of Resident #26's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Dementia without behavioral disturbances, Type 2 Diabetes Mellitus, and Polyosteoarthritis. A quarterly Minimum Data Set (MDS) assessment was done with an assessment reference date of 02/07/22. Section C of the assessment included a Brief Interview for Mental Status of 9, which indicated the resident has moderate cognitive impairment. Review of Resident #26's physician orders for April 2022 documented Artificial Tears Solution 5-6 milligram (mg)/milliliter Instill 1 drop in both eyes three times a day for dry eyes. Additionally, Resident #26's physician orders for April 2022 documented Famotidine Tablet 20 mg give 1 tablet by mouth one time a day for acid indigestion. On 04/20/22 at 9:31 AM, observation of medication administration for Resident #26 was performed of Staff A, a Licensed Practical Nurse. Staff A pulled out a bottle of Famotidine 10 mg from the medication cart and proceeded to administer 1 tablet to Resident #26. Staff A also administered Artificial tears 2 drops to each eye of the resident during the same medication observation. An interview was conducted with Staff A after the medication observation. Staff A stated that he did not realize that he gave Famotidine 10 mg instead of 20 mg to Resident #26 and he will give her an additional 10 mg now. On 04/21/22 at 9:30 AM, an interview was conducted with the Director of Nurses regarding the medication observation on 04/20/22 for Resident #26. She acknowledged that the resident should have been given Artificial Tears 1 drop to each eye and Famotidine 20 mg per physician order. 105506 Page 17 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During a tour of the [NAME] Unit and Windsor Unit on 04/20/22 at 9:30 AM, it was noted that prescription medications and biological were being stored unsecured in utility drawers at the nurses station as per the following: (a) [NAME] Unit: Restasis (15 vials) with pharmacy label documented filled on 08/31/21. The resident currently residents at the facility, however no current physician order for administration of Retasis. (b) Windsor Unit: 8 vials = 0.9% Sodium Chloride Injection - 1 vial cap opened . Photographic Evidence Obtained Based on observations, interviews, and record review, the facility failed to secure and obtain an order for self-administration of prescription oral rinse for 1 of 1 sampled residents reviewed for self-administration of medications (Resident #84) and failed to secure medications in 2 of 2 nursing stations on the second floor. The findings included: Review of the facility's policy titled, Self-Administration of Medications, dated 04/11/22, documented the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. 1) Review of the record documented that Resident #84 was re-admitted to the facility on [DATE] with diagnoses which included: Anxiety Disorder, Bipolar Disorder, and Dysphagia. Review of Section C of the Minimum Data Set, dated [DATE] documented that Resident #84 had a Brief Interview for Mental Status score of 15, which indicated that she was cognitively intact. During an observation conducted on 04/18/22 at 12:56 PM, an opened prescription bottle of Chlorhexidine Gluconate 0.12% (oral rinse) was on top of Resident #84's bedside dresser. When asked about the prescription oral rinse, Resident #84 stated, This is a mouthwash for allergies. I do this by myself. A review of the Physician's Orders for Resident #84 was conducted on 04/19/22 at 1:43 PM, which showed that Resident #84 did not have a physician's order for Chlorhexidine Gluconate 0.12%. Review of the Care Plan dated 04/07/22 showed that there was no documentation to show that Resident #84 was able to self-administer medications. In an interview conducted on 04/19/22 at 2:28 PM, Staff H, Licensed Practical Nurse, stated, If a resident wanted to self-administer medications, the doctor would have to approve it and there would 105506 Page 18 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be an order for the resident to self-administer medications. When asked about Resident #84, Staff H stated that she did not know if Resident #84 had orders to self-administer medications. Staff H then looked through the electronic chart and stated that she needed to speak with her supervisor because she did not see any orders for Resident #84 to self-administer medications. Staff H returned from speaking with her supervisor and confirmed that Resident #84 did not have any orders to self-administer medications. Staff H then accompanied the surveyor to Resident #84's room where Resident #84 provided Staff H with the opened prescription bottle of Chlorhexidine Gluconate 0.12%. Resident #84 stated that she brought the prescription bottle with her upon her admission to the facility. Staff H stated that the prescription bottle should have been documented upon admission. 105506 Page 19 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and policy review; the facility failed to provide a resident with snacks to consume at dialysis for 1 of 1 sampled residents (Resident #20) reviewed for dialysis. The findings included: The facility's policy titled Dialysis created on 2/2019 states Dietician will be made aware to provide meals/snacks as needed. Resident #20 was admitted to the facility on [DATE] with recent readmission post hospitalization on 04/01/22. Medical diagnoses include end stage renal disease, anemia, type 2 diabetes and dependence on renal dialysis. He is on a Renal diet, regular texture, thin liquids consistency. The Medicare 5 day Minimum Data Set assessment with an assessment reference date 04/04/22 reveals a Brief Interview of Mental Status (BIMS) score of 7, indicative the resident has severe cognitive impairment. The chart review revealed the resident goes to the Dialysis Center for dialysis on Tuesday, Thursday, and Saturday approximately 5:00 AM with a chair time of 5:40 AM and he returns to the facility between 10:30-10:45 AM. An interview was conducted on 04/20/22 at 10:55 AM with Staff F, a Licensed Practical Nurse, who works with the resident on the day shift. She stated he has breakfast when he returns from dialysis. The facility sends food with him to dialysis. He takes medication before he goes to dialysis. An interview was then conducted with Resident #20 on 04/20/22 at 11:00 AM who stated that he eats great but gets hungry at dialysis because he does not have any food to eat at dialysis. An interview was then conducted with Staff B, a Diet Tech. Staff B stated she was not sure what the facility was giving to Resident #20 to eat at dialysis so we should find out from the kitchen. Staff B and this surveyor went to the kitchen and interviewed Staff E, a cook, on 04/20/22 at 11:14 AM who stated the dialysis residents get a breakfast tray sent to them in the morning and if they don't want to eat it then they can eat it when they come back because it will be in nursing. It was further stated that Dialysis residents get a sandwich, apple sauce, graham crackers and a ginger ale to take with them. The person who accepts the bag from the kitchen will sign for it. On 04/20/22 at 11:31 AM, an interview was conducted with Staff D, a Corporate Food Service Director. Staff D stated they don't provide the food bag for dialysis residents anymore. They provide a breakfast tray before they go and provide food when they return. He added that since COVID, the facility stopped providing food because the Dialysis Center would not allow it, but he will check with the Administrator regarding what they are allowing now. Staff D never provided additional information to this surveyor. 105506 Page 20 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, it was determined that the approved menu was not followed for 6 residents (including Resident #26) receiving physician ordered pureed diets and 8 residents (including Resident #141) receiving physician ordered Mechanically Altered Ground Diet. The findings included: During follow-up visits to the kitchen to observe the food tray line on 04/19/22, 04/20/22, and review of the approved facility menu, the following were noted: (a) Observation of the breakfast tray line on 04/19/22 at 7:30 AM noted that 2 Turkey Sausage Links were being served as a standard sized portion for Regular, No Added Salt, and Low Concentrated Sweets Diets. At the request of the surveyor, the standard portion of the Sausage Links were weighed utilizing the facility's portion scale. It was noted that 2 Sausage Links were weighed at 1 ounce. A review of the approved breakfast menu for 04/19/22 documented that 2 ounces of Sausage Links to be served, as a standard portion size. Interview conducted with the Kitchen Supervisor at the time of the observation noted to state that he was not aware that the sausage link portion being served was not following the approved menu. (b) Observation of the breakfast tray line on 04/20/22 at 7 AM noted that a #16 scoop (2 ounces) was being utilized as a standard portion of Pureed Eggs. A review of the approved breakfast menu for 04/20/22 documented that the standard for pureed eggs was a 3 ounce portion. Interview with the Kitchen Supervisor revealed the he was unaware of the menu portion size and unaware that an incorrect scoop was being utilized. (c) Observation of lunch tray line on 04/20/22 at 11:30 AM noted that a standard serving of a Hot Dog was 1 each. At the request of the surveyor a standard portion of a Hot Dog (1) was weighed utilizing the facility's portion scale and the portion was recorded at 2 ounces. A review of of the approved breakfast menu for the 04/20/22 documented that a 3 ounce standard portion to be served to Regular, No Added Salt, and Low Concentrated Sweet Diets. Interview conducted with the Kitchen Supervisor at the time of the observation noted that he was unaware of the portion issues. It was revealed during the interview that a 4 ounce Hot Dog should have been purchased to ensure that a 3 ounce cooked portion was served. The supervisor stated that a 3 ounce Hot Dog portion was being purchased. (d) Observation of the lunch tray on 04/20/22 at 11:30 AM noted that a 4 ounce portion of Regular Baked Beans was being served to Mechanically Altered Diets. A review of the approved menu for the lunch meal of 04/20/22 documented that a Mechanically Altered Ground Baked Beans be served to Mechanical Altered Ground Diets. Interview with the Kitchen Supervisor conducted at the time of the observation revealed that he was not aware that the Mechanically Altered Menu documented a Mechanically Altered portion of Baked beans and further stated that they were not prepared as per the menu. The facility's Diet Census Report for 04/19/22 documented that there were 6 residents with physician ordered pureed diet Including Resident #26) and 8 residents with physician ordered Mechanically Altered Ground Diet (including Resident #141). 105506 Page 21 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents receiving a Puree Diet, Resident #64, did not have access to food items not recommended for residents on a Puree Diet. The findings included: Review of the facility policy for Therapeutic Diets states in part, 'Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences A therapeutic diet is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.' Review of the facility definition of Puree Diet states 'The puree diet is for residents who have difficulty chewing and/or swallowing. Foods allowed on this plan must be pureed, pudding like food that is in the form of an easy to swallow bolus with moist, pudding-like consistency without particles. Foods to Avoid include under the category Solid Fats and Added Sugars - any food that is stringy, chunky and cannot be completely pureed.' On 04/18/22 at 10:10 AM, an initial observation and interview was conducted with Resident #64 in her room. Observed next to her bed was a feeding pump and an inquiry made if she received tube feedings to which she stated she gets the tube feedings at night. A further inquiry was made if she is allowed to eat anything by mouth to which she stated she can have a puree diet but she does not like the puree texture. Observed on her overbed table was a container of thickened lemon water and cranberry juice. Review of the clinical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, right sided paralysis, dysphagia (difficulty swallowing) and diabetes. Further review of the clinical record revealed a Physician Order dated 03/23/22 for a low concentrated sweets, no added salt, puree texture, nectar thickened liquids consistency. Further, Resident #64 had feeding tube feeds to be infused via a feeding pump from 7:00 PM to 7:00 AM for a total of 12 hours daily. Review of a Care Plan last reviewed 03/16/22 documented 'Resident has swallowing problem related to dysphagia. On enteral feedings as the primary route of nutrition and hydration. She is on oral diet with pureed consistency and thickened liquids. Intervention to include: All staff to be informed of resident's special dietary and safety needs. Diet to be followed as prescribed.' On 04/18/22 at 12:55 PM, Resident #64 was observed with her lunch meal consisting of puree chicken and potatoes, chicken gumbo soup, ice cream, yogurt, thickened water and juice. Resident #64 reiterated she does not like the consistency of the puree diet. On 04/20/22 at 10:12 AM, Resident #64 was observed in her room, in bed with numerous red jelly beans sitting loose on her overbed table in front of her, in addition to 4 wrapped hard candies. An inquiry was made to her if she is allowed to have these candies while being on a puree diet to which she stated she did not know. Also observed on the overbed table were 2 juices left over from her breakfast meal. 105506 Page 22 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/20/22 at 12:45 PM, Resident #64 was observed in her room in bed with the jelly beans and hard candies still on the overbed table. An inquiry was made to the resident where she obtained these candies to which she stated a family member from out of state sent them to her. Resident #64 was observed eating her puree soup for lunch, with the bowl sitting right next to the jelly beans indicating her lunch meal was delivered to her with the jelly beans on the table, with no staff member identifying jelly beans are not an appropriate food for a resident on a puree diet. On 04/20/22 at 12:50 PM, an interview was conducted with Licensed Practical Nurse (LPN), Staff F and an inquiry was made about Resident #64's diet. Not knowing off the top her her head she referred to the electronic record and stated LCS (low concentrated sweets) NAS (no added salt) puree solids, nectar thick diet. Staff F was advised Resident #64 has jelly beans and hard candy on her overbed table. An inquiry was made if that was an appropriate food for a resident on a puree diet, to which she stated no, she will take them away. Staff F proceeded to go to Resident #64's room to deal with the issue. On 04/20/22 at 1:00 PM, an interview was conducted with Speech Therapist (ST) Staff K and an inquiry made about Resident #64's swallowing ability, to which she stated the resident has had many swallow studies and from the results it has been determined there is no potential for improvement; she has structural deficits and vocal paralysis and is not able to maintain a patent airway. Staff K further stated the resident is a high risk for aspiration, as her airway is compromised. An inquiry was made about the resident's ability to chew and swallow a jelly bean to which Staff K stated a jelly bean is hard outside and soft inside, it could stick to the roof of the mouth and the resident may not be able to remove it depending on her tongue action. Staff K confirmed eating jelly beans would not be a safe practice for Resident #64 and could lead to aspirating or choking on the jelly bean. 105506 Page 23 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that include, proper storage of foods to prevent contamination, maintenance of ceiling air-conditioning vents to prevent contamination, maintain floor cleanliness, proper cleaning of ice machine filters to prevent contamination, and ensure sanitation buckets contain required levels of chemical sanitizing agents. The findings include: 1) During the initial kitchen observation conducted on 04/18/22 at 9 AM, accompanied with the Kitchen Supervisor, the following were noted: (a) Observation of the walk-in kitchen noted that there was a large pan of raw chicken (30 pounds) in a large commercial mixing bowl ,that was located on the second shelf on a food storage rack. Further observation noted that there was a pan of individual juice portions (20) and individual yogurt portions (20). It was discussed with the supervisor that there was a potential that spillage from the raw chicken could contaminate the portions of juice and yogurts resulting in food borne illness. The surveyor requested that the juices and yogurt be discarded and all raw meats, etc be placed on the lower storage shelves at all times. (b) Observation of the walk-in refrigerator noted that the refrigeration fan covers were heavily soiled with dust and black mold like substance. Further observation noted that the ceiling area around the fan covers also had a layer of dust and mold like sustance. It was discussed with the supervisor that there was a potential for the dust and mold to reach and cover foods being stored within the unit. (c) Observation of the kitchen floor noted that the area in font of the two walk-in refrigerators had large areas of peeling paint. It was discussed with the supervisor that the pieces of peeling paints could be transferred around the kitchen area and possible become a source of food contamination. (d) Observation of the commercial ice machine noted that the 4 filters located on the front of the machine were dust/dirt laden. (e) A test of the chemical solution concentration of the 3 cleaning cloth buckets was requested by the surveyor and performed by the kitchen supervisor. The test revealed that 2 of the 3 buckets failed to have the minimum required level of Quaternary chemical, as per regulation. (f) Observation of food preparation equipment noted that 2 of 2 commercial skillets were covered with carbon and the inside Teflon coating was being rub off during repeated uses. 2) During a second tour of the kitchen conducted on 04/19/22 at 7 AM, accompanied with the Dietary Manager, it was noted that there was a commercial air-conditioning vent located directly over the steam table and clean dish storage area. Further observation noted that the entire area surface of the vent was full of condensation and mold like matter. It was noted that the condensation was dripping directly down onto the right side of the steam table, onto clean dishes, and staff working directly under the vent. The surveyor requested the facility's Administrator and Director of Maintenance to 105506 Page 24 of 25 105506 04/21/2022 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0812 Level of Harm - Minimal harm or potential for actual harm come to the kitchen and view the vent issues. It was discussed with the Administrator that there was potential for foods, clean dishes, and staff to become contaminated and possible result in food borne illness . Residents Affected - Many 105506 Page 25 of 25