Health inspection·February 28, 2020

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure the physician response to pharmacy recommendations were implemented as written by the physician for two (#125 and #151) out of seven residents reviewed for the task of unneccessary medications. Findings included: Resident #125 was admitted on [DATE] and readmitted [DATE]. The Face Sheet included diagnoses not limited to Parkinson's disease, unspecified dementia without behavioral disturbance, unspecified single episode major depressive disorders, and unspecified anxiety disorder. On 2/26/20 at 10:20 a.m., an interview was attempted with Resident #125. Resident #125 was upset, became tearful, and reported pain. A review of the pharmacy recommendation, dated 1/23/20, identified Resident #125 had an order for Clonazepam 0.5 milligram (mg) every 6 hours as needed (q6H prn) for anxiety. The recommendation included an order dated 2/4/20, to continue PRN use of this order for 30 days as the benefit outweighed the risk as Resident #125 had been on it for a long time. The review of Resident #125's physician order, indicated an order, dated 2/17/20, for Clonazepam Schedule IV tablet 0.5 mg oral every 6 hours as needed for anxiety. The order did not include an end date. The February Medication Administration Record (MAR) for Resident #125 indicated Clonazepam Schedule IV tablet 0.5mg oral every 6 hours prn, start 2/17/20 with no end date. On 2/28/20 at 4:27 p.m., the Director of Nursing (DON) reviewed the order for Clonazepam and shook her head in response to it not having an end date as written by the physician in response to the pharmacy recommendation. The DON changed the order to indicate an end date of 3/5/20, 30 days from the date of the physician response to the pharmacy recommendation. The care plan identified Resident #125 was at risk for developing adverse effects of psychotropic medications; receiving antidepressant and antianxiety medications for history (hx) of depression and anxiety. The interventions included administer medications as ordered. Resident #151 was admitted on [DATE]. The Face Sheet included diagnoses not limited to unspecified chronic obstructive pulmonary disease, pseudobnulbar affect, unspecified insomnia, mild recurrenct major depressive disorder, and vascular dementia with behavioral disturbance. Page 1 of 7 105515 105515 02/28/2020 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation on 2/25/20 at 12:23 p.m., indicated Resident #125 was sitting at an over-the-bed table eating lunch. A review of the Consultant Pharmacist recommendation, dated 1/21/20, identified Resident #151 was receiving Temazepam 15 mg every bedtime as needed (QHS PRN) and Alprazolam 0.5mg every 8 hours as needed (Q8H PRN). The Pharmacist recommended to discontinue the PRN use of the medication or reorder for specific number of days. The physician response was to continue PRN use for this order for 30 days as benefit outweighed the risk. The physician, on 2/4/20, indicated the following: - Temazepam 15 mg q hs. - Xanax (Alprazolam) q 8 hour prn The prescription order for Resident #151's Temazepam indicated a start date of 2/2/20 and was open ended. The residents' prescription order for Alprazolam indicated a start date of 2/14/20 and was open ended (no end date). The special instructions of the Alprazolam instructed staff to administer 0.5 mg oral (po) every 8 hours as needed for anxiety for 30 days. The February Medication Administration Record (MAR) revealed an order, dated 2/28/20, for Alprazolam 0.5mg po every 8 hours as needed for anxiety for 30 days, started 2/4/20 and stop 3/5/20. During an interview with the Director of Nursing, on 2/28/20 at 1:39 p.m., she confirmed the order for Alprazolam was written for 30 days and not open ended as it was put into the computer (electronic MAR). The policy titled Consultant Pharmacist Reports, dated 2006 and revised January 2018, indicated the findings are phoned, faxed, or emailed within 24 hours to the Director of Nursing or designee and the prescriber is notified if needed. 105515 Page 2 of 7 105515 02/28/2020 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

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 facility record review, the facility failed to ensure proper food storage and labeling of food items stored in the main kitchen area and a clean and sanitary nursing unit pantry on one of three nursing units. Findings included: An initial tour of the kitchen was conducted on 02/25/20 at 09:22 a.m. with the Certified Dietary Manager (CDM). She stated the facility had a full-time Registered Dietician (RD). Today, there are 8 staff members manning the kitchen details. A tour of the Walk-in refrigerator commenced at 09:42 a.m. with a registered temperature of 37 degrees Fahrenheit. The CDM asked Staff Member H, Dietary Aide, to observe the storage area. The tour revealed unwrapped heads of lettuce, cantaloupes, cucumbers, and cabbage stored in plastic baskets with no dates and no labels. Photo evidence was taken. An opened bag of green onions with an expiration date of 1/24/20 was observed. Photo evidence was taken. A bag of opened peppers revealed no dated opened and unlabeled. A loosely wrapped bag of shredded carrots revealed no label and no date opened. Photo evidence was taken. Further observation revealed leaking milk on floor of the walk-in refrigerator. Photo evidence was taken. The CDM stated, Milk delivery is on Mondays/Thursdays. Groceries are delivered on Tuesdays and Fridays. The CDM verified expired food items, loose vegetables, an undated bag of shredded carrots, and leaking milk on floor. The CDM asked Dietary Aide Staff Member H to discard the food and mop up the floor. She stated she expects her staff to follow the procedures for labeling and storing food after opening food and keeping the floor clean. At 9:58 a.m., a tour of the walk-in freezer was conducted with the CDM. The freezer registered minus 8 degrees Fahrenheit. An observation was made of boxes of frozen foods on floor. CDM stated the food delivery just came in and the staff would be putting the items away. Further observation revealed a bag of opened chicken patties with no label and no date of when opened. Photo evidence was taken. A brief interview was conducted on 02/27/20 at 11:12 a.m. with Staff Member E, Dietary Aide for 5 years. She stated, When you open something, it has to have a date on it; wrap items and date. She stated other education in-services have been with hand sanitizing, hand washing, storage of food, and meal tickets. She stated the in-services are 2-3 times per month and as needed. A tour of the B wing pantry on 02/27/20 at 11:37 a.m. was conducted with the CDM. An observation revealed (3) Styrofoam water pitchers with plastic lids on the floor underneath and behind the ice machine. Photo evidence was taken. Further observation of the pantry room revealed garbage (napkins and crushed Styrofoam pieces) on the floor on the side of refrigerator. Photo evidence was taken. On 02/27/20 at 2:21 p.m., a second tour of the B-Wing pantry with the CDM revealed the 3 Styrofoam pitchers were removed from underneath the ice machine. Further review of the room revealed the garbage had not been picked up alongside of the refrigerator. The Housekeeping Supervisor verified and stated it was his expectation for his staff to clean behind the ice machines and refrigerators. He stated once a week on Mondays, the refrigerators are pulled out and cleaned. There was a person assigned to do this task. He stated the task was not on the housekeeper's task list/ assignment sheet. 105515 Page 3 of 7 105515 02/28/2020 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with the Administrator on 02/27/20 at 4:15 p.m. She verified and stated her expectation would be for dietary staff to label and date food items consistently and for the nursing unit pantries to be cleaned thoroughly by Housekeeping. 02/28/20 07:47 a.m., an interview was conducted with Staff Member F, Housekeeper for 1 year. She stated she goes to see if trash needs to be removed, wipes down cabinets, sweeps under the ice machines and behind the refrigerators. She stated she was a Floater and if she had the assignment to clean the pantry, You were responsible to clean the whole area. There was a lot of trash in the pantries and it had to be removed. A review of the facility policy and procedure for Food Receiving and Storage, revised date of 10/10/2018, revealed as Policy Statement, Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation #1. stated Food Services, or other designed staff, will maintain clean food storage areas at all times. #7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. #10. The freezer must keep frozen foods solid. Wrappers of frozen foods must stay intact until thawing. A review of the facility policy and procedure for Sanitization, dated 1/8/2020, revealed as Policy Statement, The food service area shall be maintained in a clean and sanity manner. The Policy Interpretation and Implementation #1 revealed, All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 105515 Page 4 of 7 105515 02/28/2020 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

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. Resident #280 was admitted on [DATE]. The Face Sheet included diagnoses but not limited to encounter for orthopedic aftercare following surgical amputation, acquired absence of right great toe, and unspecified site Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Residents Affected - Some On 2/25/20 at 9:58 a.m., an observation revealed a red and white magnetic sign attached to the upper right hand of the door frame. The sign was very similar to other signs noted on other resident door frames that read No Smoking, Oxygen in Use. The sign attached to the outside of Resident #280's room read Isolation See Nurse, the sign did not indicate what type of transmission-based precautions were being utilized. The observation revealed two bins; one yellow and one red, inside of the room with a small plastic drawers next to the bins. A review of Resident #280's physician order, dated 2/15/20, included an order for Contact Precautions, MRSA to wound on right foot. The Infection Control Preventionist stated, on 2/28/20 at 4:09 p.m., the facility was ordering new isolation signs due to realizing how similar they are to the No Smoking signs, but the isolation bins in the room should give people pause. Based on observations, record reviews, and interviews, the facility failed to ensure appropriate infection control measures were followed related to the usage of Personal Protective Equipment (PPE), signage for isolation rooms, and failed to use best practice measures for infection control during medication administration for three (# 1, #35, 280, and #324) of seven sampled residents. Findings included: 1. The policy provided by the facility Isolation- Categories of Transmission Based Precautions revealed the following: Policy Interpretation and Implementation 1. Transmission-Based Precautions will be used whenever measures are more stringent than Standard Precautions are needed to prevent or control the spread of infection. 2. Based on CDC definitions, three types of Transmission-Based Precautions (airborne, droplet and contact) have been established. Droplet Precautions 1. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. 4. Masks a. In addition to Standard Precautions, put on a mask when entering the room or cubicle. 105515 Page 5 of 7 105515 02/28/2020 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. Signs- The facility will implement a system to alert staff and visitors to the type of precaution the resident requires. A review of the Resident Face Sheet for Resident #324 revealed that he was admitted into the facility on [DATE] at 4:15 p.m. with a primary diagnosis of pneumonia due to Methicillin resistant Staphylococcus aureus (MRSA). The admission Report Sheet dated 02/26/20 revealed isolation: sputum MRSA droplet. The form also indicated that Resident #324 was on the antibiotic, Doxycycline two times per day. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated and signed by the phsycian/designee on 2/25/20, revealed that the resident had MRSA in the sputum and isolation precautions included contact and droplet. A review of the Physician Order Report dated 2/26-2/28/20, revealed that the resident had an order for droplet precautions. A review of the care plans revealed that Resident #324 had a care plan initiated on 02/27/20 related to respiratory infections: Pneumonia with MRSA in the sputum. The approaches included but were not limited to isolation/precautions as ordered. On 02/27/20 at 9:32 a.m., the surveyor observed the Registered Dietitian (RD) in Resident #324's room The RD was not wearing PPE. The Surveyor stopped and asked the RD from the doorway if the resident was on contact isolation and she stated, Yes. The surveyor asked her how she knew the resident was on contact isolation. The RD stated because the box with the PPE was on the wall inside the room. There was no signage observed on the door or outside the door (photographic evidence obtained). At 9:34 a.m., the Director of Nursing (DON) confirmed that there should be signage on the door. The DON stated that she would have to talk to the nurse that admitted him last night to see why signage was not posted. On 02/27/20 at 1:12 p.m., the surveyor observed from the hallway, a staff member in the room assisting Resident #324. The staff member was not wearing PPE. The staff member walked Resident #324 into the restroom and closed the door. At 1:13 p.m., the staff member came out of the restroom, took off gloves, and used the sanitizing dispenser near the door. The surveyor verified the staff member's name as she stood in the doorway of the room. Staff A, Occupational Therapist Assistant, stated that she saw the call light on and Resident #324 stated that he needed to go to the restroom really bad, so she helped him go to the restroom. On 02/27/20 at 1:19 p.m., the Surveyor observed a staff member go into the room. When the staff member exited the room, the Surveyor verified the staff member's name. Staff B, Certified Nursing Assistant (CNA), reported that the resident was on droplet precaution. Staff B stated that a gown, gloves, and a mask must be worn when entering the room. Staff B then stated she did not wear the gown or mask because she did not touch him. 3. Resident # 35´s active medication orders included blood glucose monitoring before meals and at bedtime with insulin coverage using an insulin delivery pen. During the administration of a subcutaneous injection on 02/27/20 at 11:33 a.m. for Resident # 35, Staff C, Licensed Practical Nurse (LPN) was observed to bring the injection supplies into the room. The supplies included the injection pen and a plastic baggie that was used to store the pen in the medication cart. When preparing the 105515 Page 6 of 7 105515 02/28/2020 Solaris Healthcare Plant City 701 N Wilder Rd Plant City, FL 33566

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pen for the injection, Staff C removed it from the plastic baggie, placed the baggie on the resident´s overbed table, and placed the primed pen on the foam tray that she used as a barrier. After delivering the injection, Staff C, LPN returned the pen to the baggie and the baggie to the medication cart. During a medication administration observation on 02/28/20 at 12:10 p.m. Staff D, LPN stated that she had two residents that she would be performing glucose testing for. Review of Resident # 324´s active medication orders included blood glucose monitoring before meals and at bedtime. The nurse entered the first room with two glucometers (# 1 and # 2) on a foam tray along with testing supplies, one meter was wrapped (# 2) with a disinfecting wipe, and the other meter was unwrapped (# 1). The nurse performed hand hygiene, donned the appropriate Personal Protective Equipment (PPE) for the droplet isolation room, and performed resident # 324´s test using meter # 1. After removing her PPE and performing hand hygiene, she unwrapped the other meter (# 2) to let it air dry. She cleaned the meter she had just used (# 1), wrapped it in a disinfecting wipe, and placed it in a cup. Staff D, LPN then proceeded to the second resident´s room. Resident # 1´s active medication orders included blood glucose monitoring before meals and at bedtime. Staff D, LPN entered the room with both glucometers on her foam tray. She performed hand hygiene and donned the appropriate PPE for the contact isolation room. Staff D, LPN then performed the test for resident # 1 using the second meter (# 2). After the test, she removed her PPE, performed hand hygiene and returned to her medication cart. She obtained a new disinfecting wipe to clean and wrap meter # 2 and then placed it in a cup. Staff D, LPN then unwrapped meter # 1 and returned it to the drawer in her cart. The DON was interviewed on 02/28/20 at 4:06 p.m. and she stated that only the supplies needed should be brought into the resident rooms, she stated that the staff was trained on infection control measures and that medication was prepared, including removing its wrapping, at the cart and only the medication should be brought into the room. The DON also stated that a nurse should not enter a resident room with two glucometers for the performance of a glucose test, the nurse should return to the medication cart to clean the used meter and to exchange it for another before performing another test. 105515 Page 7 of 7