Health inspection·January 6, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure foods in the refrigerator/freezer were covered, dated, labeled, and shelved to allow circulation, failed to ensure the equipment was in good condition, and failed to ensure the kitchen and food service equipment were clean. Findings include: On 1/3/2023 at 8:46 AM, during a tour of four nourishment rooms including C-1, C-2, C-3, and post-acute areas with the Registered Dietician (RD), there were outdated or undated open products of juices, milk, nutritional drinks, and thickened water (Photographic evidence obtained). On 1/3/2023 at 9:16 AM, during an initial tour of the refrigerator, freezer and stock-room located in the kitchen with the RD, the following were observed: 1. a buildup of what appeared to be food particles and spills in the microwave, 2. dust and grease build up under the stove hood vent and on the light covers, 3. open boxes of raw cookie dough with open flaps exposing food items and a buildup of ice on the back wall and floor in the freezer, 4. food items with no use by date or identifier labels in the walk-in cooler, 5. an opened container of jelly with no opened date and a label reading refrigerate after opening in the dry storage area, and a large plastic scoop stored in the sugar storage bin, 6. a dark, moist, and slimy substance surrounding the door of the ice machine, and 7. dirty rags stored on the bottom shelve in the pot and pan sink area (Photographic evidence obtained). During an interview on 1/3/2023 at 9:30 AM, the RD stated that all dirty clothes should be in a sani-bucket and not stored or placed on a shelf or table, and all foods should be labeled and dated in the refrigerators, coolers, and stock room. The RD verified the food items that were outdated or expired in 4 of 4 nourishment rooms. During an interview on 1/4/2023 at 7:19 AM, the Dietary Manager (DM) confirmed that all foods in the freezer and/or cooler should be closed properly to ensure the safety and protection of the food items and a use-by-date should be on the items according to the policy for first-in, first out in the kitchen and nourishment rooms. The DM stated that the opened jar of jelly should have been in the cooler as labeled, the scoops should not be stored in the food bins, and all vents, walls, and equipment including the ice machine should be cleaned according to policy. Review of the facility policy and procedure titled Storage dated January 201 reads, Procedure . 6. Store baking ingredients and cereal in original containers or plastic containers with lids. a. Never store scoops in ingredient bins or ice machines. Always place in separate container . Refrigerator Storage: 1. Store perishable foods in refrigerator and/or foods marked Keep Refrigerated by the Page 1 of 6 105512 105512 01/06/2023 Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711

F 0812 manufacturer. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled Sanitation dated September 2021 reads, Procedure . The Food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. Walls, floors, ceilings, and equipment and utensils are clean and/or sanitized and in good, working order . 20. Maintain clean and sanitary kitchen facilities and equipment by following cleaning instruction procedures and Nutritional Services Cleaning Schedule. Residents Affected - Some Review of the facility policy and procedure titled Nourishment Rooms/Pantries dated February 2022 reads, Procedure: 1 . c. Items will be discarded after 72 hours of storage (perishable), 30 days (non-perishables) or per expiration date . 3. Food and Nutrition Services and the Nursing departments will inspect food items daily to meet above standards and discard any expired foods. Review of Daily/Weekly Kitchen Sanitation Checklist revised on 11/4/20 reads, Main Kitchen . walk-insnothing on floor or above red line on top shelves, floor clean, door clean, + all food labeled and dated. No scoops stored in ingredients bins, ice machine or any other food container. Ice machine clean regular as scheduled . Microwave and toasters clean in and out. Hoods/vents cleaned and free of grease build-up . Sanitizer buckets in use and filled with clean sanitizing water. 105512 Page 2 of 6 105512 01/06/2023 Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 3 sampled residents, Resident #32. Findings include: Review of the medical records for Resident #32 revealed the resident was admitted on [DATE] with the diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, immobility syndrome, unspecified severe protein calorie malnutrition, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infections as the cause of disease classified elsewhere, chronic obstructive pulmonary disease, emphysema, pressure ulcer of sacral region, stage 4 pressure ulcer of left hip, other lack of coordination, dislocation of thoracic 12 lumbar 1 vertebra sequela, paraplegia, polyneuropathy, neuromuscular dysfunction, hyperlipidemia, anemia, other injury of unspecified body region, sepsis due to methicillin resistant staphylococcus aureus, obstructive and reflux uropathy, colostomy, resistance to multiple antibiotics, stage 4 pressure ulcer of left buttock, unstageable pressure ulcer of left heel, unstageable pressure ulcer of right heel, essential hypertension, presence of neurostimulator, and depression. During an observation on 1/3/2023 at 9:45 AM, Resident #32 had a midline on left arm with the dressing dated 12/27/2022. Review of Resident #32's physician order dated 12/13/2022 reads, Change IV [intravenous] dressing every 7 days as well as PRN [as needed] for soiling and/or dislodgement every evening shift every 7 day(s). Review of Resident #32's physician order dated 1/2/2023 reads, Cleanse wound to the sacrum with NS [normal saline] pat dry and apply AquaCell Ag Cover with ABD [abdominal] pads and tape in place. Three times daily, one time a day every Mon, Wed, Fri. Review of Resident #32's Medication Administration Record (MAR) for December 2022 revealed staff initials as completing the dressing change on 12/14/2022, 12/21/022 and 12/28/2022. Review of Resident #32's MAR for December 2022 and January 2023 reads, Cleanse wound to the sacrum with NS pat dry and apply AquaCell Ag Cover with ABD pads and tape in place. Three times daily, every day shift every Mon, Wed, Fri. The MAR revealed staff initials as completing the wound care on 12/21/2022, 12/23/2022, 12/26/2022, 12/18/2022, 12/30/2022, 1/4/2023 only. During an interview on 1/5/2023 at 1:55 PM, the DON stated, It was an error of data input. It should say weekly not daily. During an interview on 1/6/2023 at 8:30 AM, the Director of Nursing (DON) stated she spoke to both staff members involved, and the staff stated she noted the dressing was dated 12/27/2022 and checked off on 12/28/2022 that it had been done already even though she did not do the dressing change herself. During an interview on 1/6/2023 at 10:30 AM, the DON stated staff were expected to accurately 105512 Page 3 of 6 105512 01/06/2023 Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711

F 0842 document and only document when they performed the task. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled Documentation revised on 1/5/22 reads, Policy . 2. Documentation should be accurate, complete, chronological, and objective, legible and timely. Residents Affected - Few 105512 Page 4 of 6 105512 01/06/2023 Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical records for Resident #32 revealed the resident was admitted on [DATE] with the diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, immobility syndrome, unspecified severe protein calorie malnutrition, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infections as the cause of disease classified elsewhere, chronic obstructive pulmonary disease, emphysema, pressure ulcer of sacral region, stage 4 pressure ulcer of left hip, other lack of coordination, dislocation of thoracic 12 lumbar 1 vertebra sequela, paraplegia, polyneuropathy, neuromuscular dysfunction, hyperlipidemia, anemia, other injury of unspecified body region, sepsis due to methicillin resistant staphylococcus aureus, obstructive and reflux uropathy, colostomy, resistance to multiple antibiotics, stage 4 pressure ulcer of left buttock, unstageable pressure ulcer of left heel, unstageable pressure ulcer of right heel, essential hypertension, presence of neurostimulator, and depression. Residents Affected - Few Review of Resident #32's physician order dated 1/5/2023 reads, Cleanse right lateral lower leg wound with NSS [normal saline solution], pat dry, apply santyl cover with ABD [abdominal]/gauze, secure with roll and tape every day shift. Review of Resident #32's physician order dated 1/5/2023 reads, Cleanse right ankle NSS, pat dry, apply santyl, cover with ABD, secure with roll gauze and tape every day shift. On 1/5/2023 at approximately 10:10 AM, during an observation of Resident #32 receiving wound care from Staff B, RN, and Staff C, Licensed Practical Nurse (LPN), Staff B placed a towel under Resident #32's feet. Staff B removed the soiled wound dressing from Resident #32's right foot and placed the resident's right foot with the wound back on the towel. Staff C elevated Resident #32's right foot and Staff B cleansed the wound. Once the wound was cleansed, Staff C placed the resident's right foot down on the soiled towel. Staff B stated to Staff C to hold the resident's right foot up and not to place it on the towel. Staff B applied the clean wound dressing to the resident's right foot without re-cleansing the wound. During an interview on 1/5/2023 at 10:45 AM, Staff B, RN, stated that Resident #32's foot should not have been placed down on the towel after the wound had been cleansed. During an interview on 1/5/2023 at 1:50 PM, the DON stated, Nurses are expected to follow infection control practices. Review of the facility policy and procedure titled Infection Prevention and Control Program dated May 2020 reads, Procedure . d. Prevention of Infection and Communicable Disease. Staff, volunteers, visitor, those individuals providing services under contractual bases and resident education is done to focus on risk of infection and practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections during medication administration for 1 of 2 residents receiving intravenous (IV) medications, Resident #36, and during wound care dressing change for 1 of 2 residents, Resident #32. 105512 Page 5 of 6 105512 01/06/2023 Clermont Health and Rehabilitation Center 151 E Minnehaha Ave Clermont, FL 34711

F 0880 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical records for Resident #36 revealed the resident was admitted on [DATE] with diagnoses including asthma, diabetes, dementia, paranoid schizophrenia, noninfective colitis and anxiety. Residents Affected - Few Review of Resident #36's physician order dated 12/29/2022 noted Ertapenem 1 gram IV daily for 10 days. During an observation on 1/4/2023 at 3:00 PM, Staff A, Registered Nurse (RN), proceeded to administer Ertapenem 1 gram to Resident #36. Staff A connected and flushed with normal saline to the resident's IV catheter without scrubbing the needleless connector on the resident's catheter with an antiseptic wipe. Staff A connected the medication IV line to Resident #36 without scrubbing the needleless connector on the resident's catheter. During an interview on 1/4/2023 at 3:10 PM, Staff A, RN, stated, I should have scrubbed the resident's needleless connector of the IV catheter for 30 seconds. No, I did not. During an interview on 1/4/2023 at 3:55 PM, the Director of Nursing (DON), stated her expectation for the nurses was to follow infection control standards and do the right thing. Review of the facility policy and procedure titled Administration of IV Fluids and Medications. Setting Up a Primary Infusion (Hydration or Medication) reads, Procedure . 8. Scrub needleless connector on resident's catheter with antiseptic wipe. 105512 Page 6 of 6