Health inspection·March 21, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was accurately completed for one (Resident #32) who was diagnosed with a mental disorder, from 21 residents in the total sample. Failure to accurately complete a Level I PASRR results in the facility's inability to determine whether a resident requires specialized services. Residents Affected - Few The findings include: A medical record review indicated that Resident #32 was admitted to the facility on [DATE]. Her diagnoses included traumatic subdural hemorrhage with loss of consciousness of unspecified duration, expressive language disorder, unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, depression and anxiety disorder. A review of a Quarterly minimum data set (MDS) assessment with an assessment reference date of 2/25/24, revealed that a Brief Interview for Mental Status (BIMS) score could not be obtained. The assessment further indicated that the resident had depression, a psychotic disorder (other than schizophrenia), dementia and a traumatic brain injury. She was also documented with hallucinations, delusions, and wandering behaviors. The Level I PASRR, dated 5/27/22, Section A, was incomplete as it did not indicate Resident #32's pertinent diagnoses. Section II indicated that the resident did not have a diagnosis of dementia. In an interview with the Director of Nursing 3/20/24 at 1:29 p.m., he was asked about the facility's process for PASRR review. He stated when residents were admitted , he reviewed all documentation including the PASRR. If the PASRR was incorrect for a new admission, he would have to send it back to the place the resident was admitted from to have it corrected. When he was asked the facility's process for review of new conditions for residents already in the facility that might require an update of the PASRR, he said, I have not had that happen while I was at the facility. He stated he would have to review that with Social Services. He added that the new psychiatric diagnosis would not warrant a new level one PASRR. He stated there was no one who reviewed the PASRR for residents who were already in the facility. He was then asked about Resident #32's PASRR. He confirmed that the resident had diagnoses including dementia, psychosis, and depression, and that these diagnoses were not checked on the Level I PASRR. He added that it was not a provisional admission and therefore it would not change anything. A review of the facility's policy and procedure titled PASRR (revised 6/2023), revealed that the facility admits only residents whose medical and nursing care needs can be met. The policy interpretation and implementation noted that all new admissions and readmissions were screened for mental Page 1 of 10 105526 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0645 Level of Harm - Minimal harm or potential for actual harm disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. a.) The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID or RD. Residents Affected - Few . 105526 Page 2 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that one (Resident #9) of three residents with pressure ulcers, from a total of 21 residents in the sample, received treatment and services consistent with professional standards of practice, to promote wound healing, by failing to follow the wound care physician's recommendations. Failure to follow physicians' recommendations could result in delayed healing. Residents Affected - Few The findings include: A medical record review indicated that Resident #9 was admitted to the facility on [DATE]. Her diagnoses included aftercare following joint replacement surgery, unspecified protein-calorie malnutrition, muscle weakness (generalized), difficulty walking, dysphagia, cognitive/communication deficit, elevated white blood cell count, fracture of unspecified part of neck of right femur, adult failure to thrive, Alzheimer's disease, and essential hypertension. A review of the resident's Physician's Orders revealed the following: 1/1/24: Weekly skin check on every day shift every Monday for skin care. 2/22/24: Wound care specialist may evaluate and treat as needed. 3/6/24: Cleanse wound to the right hip, left hip and left ankle with Dakin's solution. Apply skin prep to surrounding tissue, apply Santyl and calcium alginate to wound bed and cover with dry dressing daily. 3/11/24: Cleanse right ankle wound with normal saline, apply skin prep to surrounding tissue, apply Medi-honey and collagen powder to wound bed, and cover with dry dressing daily. A review of the 5-day admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/8/23, revealed that the Brief Interview for Mental Status (BIMS) score was left blank. The resident was documented as always incontinent of bowel and bladder and required extensive assistance for bed mobility, toileting and transfers. There were no pressure ulcers documented on this assessment. A review of the Significant Change MDS assessment with an ARD of 3/5/24, revealed that the resident had three stage IV pressure ulcers, one unstageable, one deep tissue injury (DTI), and moisture-associated skin damage, that were not present upon admission. The care plan updated on 3/12/24 read, Resident on hospice for end-stage dementia, eats 25% or less of meals, assist with all care, and at risk for new or worsening skin breakdown. A review of the Wound Care Specialist's notes dated 2/26/24, revealed the following: Stage IV right lateral ankle measuring 1.4 cm (centimeters) x 1.3 cm x 0.5 cm; Stage IV right hip 3.3 cm x 2.4 cm x 1.6 cm; Unstageable DTI left lateral foot 1.3 cm x 1.4 cm, and Stage IV left hip 1.5 cm x 1.7 cm x not measurable due to necrosis (dead tissue obstructing the wound bed). Recommendations included Zinc sulfate 220 milligrams (mg) for 14 days; Vitamin C, 500 mg two times a day (BID) and Multivitamin daily. On 3/11/24, the wound measurements were as follows: Stage IV right hip 3.3 cm x 1.6 cm x 1.6 cm, wound has decreased in size. Stage IV right lateral ankle 1.2 cm x 1.3 cm x 0.5 cm, unchanged 105526 Page 3 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in size; Stage IV left lateral foot 3/11/24: 0.7 cm x 0.7 cm, decreased in size; Stage IV left hip 1.2 cm x 1.4 cm x 1.7 cm, decreasing in size. Recommendations included Zinc sulfate 220 milligrams (mg) for 14 days; Vitamin C 500 mg two times a day (BID), and Multivitamin daily. On 3/20/24 at 3:43 p.m., Licensed Practical Nurse (LPN) C was observed providing wound care to Resident #9. She dressed the wounds to both of the residents hips and ankles per the orders. LPN C stated the resident was followed by a wound care physician weekly and the wounds had improved. LPN C was asked about the wound care physician's recommendations. She said, When the wound care recommendations are made, I notify the resident's attending physician and then add to orders to the Treatment Administration Record (TAR) and also document a progress note about the new recommendations. She added that she had never had the attending physician say no to any recommendations from the wound care physician. She was then asked about the recommendations for Resident #9. She confirmed that recommendations for Zinc sulfate 220 milligrams (mg) for 14 days; Vitamin C, 500 mg two times a day (BID), and a Multivitamin daily from the wound care physician had not been carried out since 2/26/24. She mentioned that she had just started rounding with the wound care physician and she was still learning the process. She mentioned that she would add the recommendations. A review of the facility's policy and procedure titled Pressure Ulcer Treatment (undated), revealed the following: 1. The pressure treatment program should focus on the following: a. Assessing the resident and the current status of the pressure ulcer(s). b. Current support surfaces. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Education and quality improvement. Interventions/care strategies - Pressure ulcer treatment requires a comprehensive approach including: 1. Debridement. 2. Managing infections. 3. Managing systemic issues ( edema, venous insufficiency etc). 4. Maximizing the potential for healing. 5. Pain control. . 105526 Page 4 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a staff interview, and record review, the facility failed to ensure that one (Resident #39) of four residents who required oxygen administration, from a total sample of 21 residents, received such care, consistent with professional standards of practice (Oxygen was administered without a physician's order.) Residents Affected - Few The findings include: On 3/18/24 at 3:19 p.m., Resident #39 was observed lying in bed. His oxygen flow rate was set at 2 liters per minute (L/min), his oxygen tubing was not dated, and the humidification bottle was on the floor. (Photographic evidence obtained) On 3/19/24 at 9:08 a.m., Resident #39 was observed lying in bed. His oxygen flow rate was set at 2 L/min, his oxygen tubing was not dated, and the humidification bottle was on the floor. There was no oxygen in use sign on the door. A review of the resident's medical record revealed that Resident #39 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) with exacerbation, acute and chronic respiratory failure with hypoxia, generalized anxiety disorder, and heart failure. A review of the active physician's orders revealed orders to change the resident's nebulizer tubing weekly and as needed every night every shift. Ipratropium - Albuterol solution 0.5-2.5 mg/ml (milligams per milliliter), inhale 3 milliliters (ml) orally three times a day for COPD was ordered. [NAME] Ellipta inhalation powder, breath-activated, 200-25 micrograms (mcg), 1 inhalation orally in the morning for COPD and rinse and spit after using to decrease the risk of infection was also ordered. There were no orders for oxygen. (Copy of the physician's orders obtained) A review of the admission Minimum Data Set (MDS) assessment, with an assessment reference date of 12/29/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 possible points, indicating severe congitive impairment. There were no behaviors documented. The resident required supervision with eating. He was dependent with bed mobility, transfers and toileting. He was documented with diagnoses including anxiety disorder, depression, COPD, acute and chronic respiratory failure with hypoxia, heart failure and he required oxygen use. A Care Plan initiated on 2/7/24, revealed that the resident required oxygen therapy related to COPD, chronic respiratory failure and heart failure. Interventions included administration of medication as ordered by the physician. In an interview on 3/20/24 at 9:54 a.m. with Licensed Practical Nurse (LPN) A, she stated Resident #39 was receiving oxygen at 2 L/min PRN (as needed) for COPD. She was accompanied to the resident's room and confirmed that the resident was receiving oxygen. She also confirmed that the humidification bottle was on the floor. She said, The humidification bottle should never be placed on the floor. She picked it up and attached it to the oxygen concentrator. When she was asked to review the resident's orders for oxygen administration, she confirmed that there were no orders for oxygen. A review of the facility's policy and procedure titled Oxygen Administration and Use (revised 8/2022), revealed that the facility will ensure that oxygen therapy will be administered in compliance 105526 Page 5 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0695 with current standards of practice. Level of Harm - Minimal harm or potential for actual harm The policy interpretation and implementation indicated that: 1. Oxygen should be administered in accordance with the physician's order. Residents Affected - Few 2. Oxygen will be administered by physician's order; however, in an emergency situation, oxygen may be applied and the physician will be contacted as soon as possible to obtain appropriate directions. 3. An Oxygen in Use sign should be placed outside of the room on the entrance door or door frame. . 105526 Page 6 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5%, based on 37 opportunities for error with three errors identified, resulting in an error rate of 8.11%. Two (Residents #31 and #23) of six residents observed during medication administration were involved. Failure to administer medications as ordered could result to side effects leading to serious harm to residents. Residents Affected - Few The findings include: During medication administration observation on 3/18/24 at 11:34 a.m., Registered Nurse (RN) B was observed preparing medications for Resident #31. She gathered supplies for blood glucose monitoring. She performed hand hygiene and donned gloves. She cleansed the resident's right ring finger with alcohol, obtained a drop of blood on the test trip and received a blood glucose reading of 160 milligrams per deciliter (mg/dl). She reviewed the Medication Administration Record (MAR) and stated Resident #31 required three units of Novolog insulin coverage. She obtained the Novolog Flex Pen, opened 3/12/24. She dialed the pen to three units, donned gloves and administered the insulin in the resident's right lower abdomen. RN B did not prime the pen before dialing the dosage. An interview was conducted with RN B on 3/18/24 at 11:52 a.m. When she was asked about the proper way to use insulin Flex Pens, she stated, I should have primed the pen with two units then dialed per sliding scale. On 3/20/24 at 9:28 a.m., Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #23. She reviewed the MAR, obtained medications one at time and put them in a medication cup. She then poured the contents of the cup into a pill crushing pouch and crushed the medication. She mixed all of the medications with pudding and administered them to the resident. In an interview on 3/20/24 at 9:35 a.m., LPN A confirmed that this resident had no order to crush medication. A review of the facility's policy and procedure titled Administering Medication (reviewed on 02/2024), revealed: Medications shall be administered in a safe and timely manner and as prescribed. According to the National Library of Medicine at www.Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations - PMC (nih.gov) (Accessed on 4/9/24 at 9:05 a.m.): Mixing multiple crushed medicines may also be unsafe or make them less effective. People in hospitals and long-term care settings who have a hard time swallowing pills should have an individual plan in place for taking medicines. Physicians, pharmacists, speech-language pathologists, and front-line care staff should work with patients and caregivers to make the plan. The plan should be written down in their patient record. Although medication crushing is common, prescribing information may not include details on acceptability of crushing medications or how to administer once crushed, and inappropriate medication crushing can have unintended or adverse effects. According to the American Association of Post-Acute Care Nursing at www.Avoiding a Citation When Crushing Medication - AAPACN (Accessed on 4/9/24 at 9:00 a.m.): 105526 Page 7 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Best practice for administering crushed medication is to crush and administer each medication separately. Crushing and combining medication may result in physical and chemical incompatibilities, leading to an altered therapeutic response; it can also cause a feeding tube occlusion. There may be times when crushing and administering each medication separately is not appropriate for a resident. When this is the case, facility staff should actively involve the resident, the resident's representative, the attending physician, the consultant pharmacist, and the medical director, as needed, to ensure that there is a person-centered, individualized approach to administering each medication. . 105526 Page 8 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

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 kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility, by failing to 1) Seal and date mark open food products in the walk-in freezer, walk-in refrigerator, and open bundles of bread on the bread rack, and 2) Properly clean and sanitize the kitchen mixer, convection oven, fryer, oven tray lines and can opener pixel. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 3/18/24 at 10:45 a.m. During the tour, no date markings were observed on three open bags of French fries and one open bag of carrots in the freezer. The walk-in refrigerator had one open box of white potatoes, one open box of sweet potatoes, one open box of oranges, one open box of lemons, one open bag of onions, one open box of melons, one open box of cabbage, one open box of cantaloupe, one open package of strawberries, one open box of pineapples, one open box of tomatoes, one open box of parsley, one open box of squash, and one open package of shredded cabbage with no date marking. Four open bundles of bread with no date marking were observed on the bread rack located next to the prep table. At the time of the observations, the Certified Dietary Manager (CDM) was notified that one package of rolls was taken off the shelf and discarded by this surveyor due to an observation of mold. (Photographic evidence obtained) An interview was conducted with Dietary Aide D on 3/18/24 at 10:55 a.m., who reported opened and unused bread was used for puree and was not to be placed back on the bread rack. The CDM confirmed staff were to properly close and date all unused bread. A follow-up tour of the kitchen was conducted on 3/19/24 at 11:01 a.m. The mixer, located next to the bread rack and covered with clear plastic, had food debris stuck on and around the safety guard; the convection oven top and bottom doors were filled with grease buildup; the inside floor of the top and bottom convection oven was covered with food debris and dirty grime; grease buildup was observed on both sides of the fryer; the oven trays were filled with grease substances and food debris; and the can opener pixel holder was greasy and filled with food debris. During this time, the same observations were made in the walk-in refrigerator as were made on 3/18/24 at 10:45 a.m. of the open white potatoes, sweet potatoes, oranges, lemons, cabbage, onions, melons, parsley, and shredded cabbage with no date marking. New observations were made in the walk-in refrigerator of one open box of lettuce, one open package of tomatoes, and one open bag of mushrooms sealed with no date marking. Also, the same observations were made in the walk-in freezer of the three open bags of French fries with no date marking. (Photographic evidence obtained) An interview was conducted with [NAME] E on 3/19/24 at 11:01 a.m., who reported that she used ovens to prepare a la carte food items for the long-term care nursing home residents on the 2nd floor. During a second interview at 1:45 p.m., [NAME] E reported that each staff member was responsible for cleaning their area at the end of each shift. She confirmed that the facility policy for date marking food items was to wrap, date, and label once the food item was opened. An interview was conducted on 3/19/24 at 1:57 p.m. with Dietary Aide F, who reported that the staff 105526 Page 9 of 10 105526 03/21/2024 Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many member who used the kitchen equipment was responsible for cleaning the equipment. All open food was to be wrapped with plastic wrap, dated using a white sticker, or date marked on the actual product wrapping before placing the food item back on the shelf or in the freezer or refrigerator. An interview was conducted with the Dining Services Director on 3/19/24 at 2:04 p.m., who confirmed that all open food should be covered and labeled with a date. Each staff member was responsible for their station. Individual stations were wiped and sanitized each night; fryers were cleaned weekly; steamers and ovens were degreased and delimed monthly, and oven trays were cleaned monthly. The Dining Services Director was unable to provide cleaning schedules. A review of the facility's policy and procedure titled Labeling and Dating (undated), revealed: 1. Raw Foods . b. Once the raw package is open, it must be placed in a sealed container; c. Raw food package must be labeled and dated within 3 days of opening the package; d. Raw food can only be refrigerated for 3 days; and e. If the raw food is not completely used and needs to be put back into the freezer, the food must wrapped, sealed, labeled and dated . 3. Perishable Foods . b. If any perishable food is opened or cut, it must be sealed, labeled and dated 3 days from being used . 5. Bread . b. Once bread is opened, it must be used within 7 days. c. Once bread is opened, it must be placed in the original package or a sealed container, labeled and dated 7 days from the original date of being used. A review of the facility's policy and procedure titled Cleaning and Sanitizing Dietary Areas and Equipment (undated), revealed: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary food service that meets state and federal regulations. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 2/20/24) Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 11/13/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. . 105526 Page 10 of 10