Health inspection·October 9, 2023

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 observations, interviews and record review, the facility failed to provide toileting/incontinence care to 3 of 3 sampled residents (Residents #1, #2 and #3), reviewed for toileting / incontinent care and failed to follow the physician orders regarding blood glucose results for 2 of 3 sampled residents (Resident #1 and #2). Residents Affected - Few The findings included: 1) Review of Resident #1's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Cerebral Atherosclerosis, Diabetes Mellitus Type 2, Chronic Kidney Disease, Hypothyroidism, Dementia, Peripheral Vascular Disease and Anxiety. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was totally dependent on the staff for the activities of the daily living including toileting and bathing. The assessment documented under Bladder and Bowel that the resident was always incontinent of bladder and bowel. Review of the resident's care plan titled Resident #1 is at risk for complications associated with bladder incontinence. Risk of UTI (Urinary Tract Infection); Risk for skin breakdown initiated on 01/22/2018 and revised on 08/28/23 documented an intervention that read Check frequently for incontinent episodes. On 10/09/23 at 10:33 AM, an interview was conducted with Staff A, Certified Nursing Assistant (CNA) who stated that she has 10 residents assigned to her. Staff A stated that it was an ongoing job and there was always something to be done. Staff A stated that 8 out of 10 of her assigned residents were totally dependent on her for toileting/incontinence care. Staff A was asked how many of the eight (8) residents had she checked their brief or done incontinence care this morning. Staff A replied she had not touched any of the eight (8) residents that were dependent on her for incontinence care. Staff A stated that it takes a lot of time to provide a residents morning care. Staff A was asked if she had done Resident #1's incontinence care/morning care and stated she had not since she started her shift. Staff A stated that justly her total dependent residents were wet because they had not been changed since night shift. Staff A stated the residents are supposed to have their brief changed or checked every two (2) hours. Staff A stated it is not just passing meal trays, she has to make sure the residents are awake, give them water, reposition and change them, there is a lot to do. On 10/09/23 at 10:54 AM, a side by side review of Resident #1's adult brief was conducted with Page 1 of 5 105506 105506 10/09/2023 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 Residents Affected - Few Staff A, CNA. Staff A stated apart from checking the resident for safety this morning when she started her shift, Staff A reiterated she had not touched the resident this morning. Observation revealed the resident was wearing two adult briefs. Staff A stated the brief was wet, the resident needed to be washed and changed. Staff A stated that the resident was not supposed to have two briefs, only one. Staff A was asked why she had not done Resident #1's brief change and stated she started with the resident down the hall who had a morning appointment. 2) Review of Resident #2's clinical record documented an admission date to the facility on [DATE] with no readmissions. The resident's diagnoses included Cerebral Infraction, Diabetes Mellitus Type 2, Hypothyroidism, Neurologic Disorder in Lime Disease and Anxiety. Review of Resident #2's MDS quarterly assessment dated [DATE] documented a BIMS score of 9, indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff for the activities of the daily living including toileting and was totally dependent from the staff for bathing. The assessment documented under Bladder and Bowel that the resident was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #2's Wound Care Specialist note dated 10/04/23 documented that the resident had a stage 4 left buttock wound. On 10/09/23 at 11:09 AM, a side by side review of Resident #2's adult brief was conducted with Staff A, CNA. Staff A stated that she had not touched, checked or changed the resident's brief at the time of the review. Observation revealed the resident's adult brief was soaking wet and had a soiled dressing on her back that was partially covering an open wound. Staff A stated that the resident gets dressing changes to the sacrum by the nurse. Staff A stated the resident was her priority to get washed. 3) Review of Resident #3's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Atherosclerotic Heart Disease, Asthma, Depressive Disorders, Hypertension, Generalized Osteoarthritis and Hypothyroidism. Review of Resident #3's MDS significant change assessment dated [DATE] documented a BIMS score of 10, indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living including toileting. The assessment documented under Bladder and Bowel that the resident had an indwelling catheter and was always incontinent of bowel. Review of Resident #3's 2023 October Treatment Administration Record (TAR) documented cleanse blanchable redness to buttocks with soap and water, apply barrier cream every shift. On 10/09/23 at 11:23 AM, an interview was conducted with Resident #3 who stated her adult brief was changed last night. The resident was asked how she felt about having on a soiled brief since last night and replied, I don't like it, but what can I do. On 10/09/23 at 11:24 AM, a side by side review of Resident #3's adult brief was conducted with Staff A, CNA. The review revealed the resident had a stool soiled brief. The resident stated, I always 105506 Page 2 of 5 105506 10/09/2023 Encore at Boca Raton Rehabilitation and Nursing Ce 7300 Del Prado Circle South Boca Raton, FL 33433

F 0684 have a bowel movement when they check the diaper. Level of Harm - Minimal harm or potential for actual harm On 10/09/23 at 2:14 PM, an interview was conducted with Staff B, CNA who state 8 out of her 10 assigned residents assigned were total care. Staff B stated that sometimes she was not able to get to the residents every two (2), like they are supposed to. Residents Affected - Few On 10/09/23 at 5:05 PM, during an interview, the Director of Nursing (DON) was asked to state the facility's policy related to toileting/incontinence care/brief change and replied she did not know the policy from the top of her head. The DON stated that the residents should be turned, have their brief checked every 2 to 3 hour and as needed or twice a shift. The DON was apprised of the findings. 4) Review of Resident #1's clinical record documented an admission to the facility on [DATE], and a readmission on [DATE]. The resident diagnoses included Diabetes Mellitus Type 2, Chronic Kidney Disease, and Dementia. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3, indicating that the resident had severe cognition impairment. Review of Resident #1's active physician orders for October 2023 documented a physician's order dated 12/18/23 for Humalog G KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (millimeters) (Insulin Lispro) Inject 18 unit subcutaneously before meals for DIABETES, HOLD FOR BLOOD SUGAR LESS THAN 180. The physician's order was changed on 08/17/23. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 08/11/23 at 8:00 AM, the resident's documented blood sugar was 87 and a nurse's initial with a check mark, indicating that 18 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's active physician's orders for October 2023 documented a physician's order dated 08/19/23 for Humalog G KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (millimeters) (Insulin Lispro) Inject 12 unit subcutaneously before meals for DIABETES, HOLD FOR BLOOD SUGAR LESS THAN 180. The physician's order was changed on 08/23/23. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 08/19/23 at 8:00 AM and at 12:00 PM, the resident's documented blood sugar was 120 and a nurse's initial with a check mark, indicating that 15 units of insulin was administered. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 08/20/23 at 12:00 PM, the resident's documented blood sugar was 126 and a nurse's initial with a check mark, indicating that 12 units of insulin was administered. The insulin for 12:00 PM was to be held, as per physician's order. Review of Resident #1's active physician's orders for October 2023 documented an order dated 08/23/23 for Humalog G KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (millimeters) (Insulin Lispro) Inject 10 units subcutaneously before meals for DIABETES, HOLD FOR BLOOD SUGAR LESS THAN 180. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The 105506 Page 3 of 5 105506 10/09/2023 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 Residents Affected - Few review revealed that on 08/25/23 at 8:00 AM, the resident's documented blood sugar was 130 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/02/23 at 4:00 PM, the resident's documented blood sugar was 102 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/03/23 at 8:00 AM and 12:00 PM, the resident's documented blood sugar was 114 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/05/23 at 4:00 PM, the resident's documented blood sugar was 172 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/16/23 at 8:00 AM, the resident's documented blood sugar was 142 and a nurse initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/19/23 and 09/20/23 at 4:00 PM, the resident's documented blood sugar was 136 and 169 respectively and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/27/23 at 4:00 PM, the resident's documented blood sugar was 176 and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/29/23 at 12:00 PM, the resident's documented blood sugar was 122 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 12:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/30/23 at 8:00 AM, the resident's documented blood sugar was 174 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/01/23 at 8:00 AM and 12:00 PM the resident's documented blood sugar was 122 and 140 respectively with a nurse's initial and a check mark, indicating that 10 units of insulin was administered both times. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. 105506 Page 4 of 5 105506 10/09/2023 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 Residents Affected - Few Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/03/23 at 4:00 PM, the resident's documented blood sugar was 128 and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/07/23 at 4:00 PM, the resident's documented blood sugar was 151 and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/08/23 at 8:00 AM and 12:00 PM the resident's documented blood sugar was 122 and 178 respectively with a nurse's initial and a check mark, indicating that 10 units of insulin was administered both times. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. On 10/09/23 at 4:38 PM, a side by side review of Resident #1's August, September and October 2023's MAR was conducted with the Director of Nursing. The DON confirmed the findings and stated that the check marks indicated that the insulin was administered. 5) Review of Resident #2's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Cerebral Infraction, Diabetes Mellitus Type 2, Hypothyroidism, Neurologic Disorder in Lime Disease and Anxiety. Review of Resident #2's MDS quarterly assessment dated [DATE] documented a BIMS score of 9, indicating that the resident had moderate cognition impairment. Review of Resident #2's active physician's order documented an order dated 04/13/23 for Obtain and record accu-check blood sugar twice daily without coverage. Notify the MD (medical doctor) if blood sugar is less than 70 or greater than 300 two times a day for Diabetic monitoring before breakfast and dinner. Review of Resident #2's August and September 2023 MAR documented on 08/29/23 and on 09/20/23, the resident's blood sugar test result was 334 and 302, respectively. Further review revealed the lack of documentation of calling the physician related to a blood sugar greater than 300, as per physician's order. On 10/09/23 at 4:39 PM, a side by side review of Resident #2's August and September 2023's MAR was conducted with the Director of Nursing. The DON confirmed the findings and stated that there was no documentation related to calling the physician about the resident's blood sugar greater than 300. 105506 Page 5 of 5