Health inspection·February 8, 2024

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, record review, staff, resident and family interview, the facility failed to ensure 2 (Residents #12, #29) of 4 residents reviewed received care and services in accordance with professional standards, by failing to implement physician's orders for protective skin sleeves. Residents Affected - Few The findings included: 1. Clinical record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Dementia. The physician order effective 10/22/23 included to apply Geri-sleeves (protective sleeves) to both arms for protection. The Care Plan initiated 5/27/21 documented Resident #29, has the potential for impaired skin integrity r/t (related to) impaired cognition, impaired mobility, anorexia, incontinence, malnutrition. The resident needs assistance to apply protective garments; Geri-sleeves to BUE (bilateral upper extremities). On 2/5/24 at 1:56 p.m., 2:51p.m., and on 2/6/24 at 8:45 a.m., Resident #29 was observed in the activity area wearing a short sleeve shirt without Geri-sleeves as ordered by physician. On 2/6/24 at 11:30 a.m., Certified Nursing Assistant (CNA) Staff B removed the blanket revealing both arms for Resident #29 and verified she was not wearing Geri sleeves. On 2/6/24 at 2:08 p.m., Resident #29 was observed in the activity area wearing a short sleeve shirt without Geri-sleeves as ordered by physician. On 2/7/24 at 8:45 a.m., Resident #29 was observed without Geri sleeves on either arm. CNA Staff B verified resident was not wearing Geri-sleeves. On 2/7/24 at 10:23 a.m., CNA Staff B verified she was assigned to care for Resident #29 but said she did not know she was supposed to wear the Geri sleeves. On 2/7/24 at 10:25 a.m., Registered Nurse (RN) Staff O, verified Resident #29 was supposed to wear Geri sleeves. On 2/7/24 at 3:50 p.m., Unit Manager Staff L, said he was told today Resident #29 was not wearing the Geri-sleeves as ordered by the physician. Page 1 of 10 105538 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/7/24 at 4:11 p.m. the Director of Nursing (DON) said if the resident could tolerate the Geri sleeves, they would be on. He verified there was no documentation of refusal or taking them off. The DON said there was no policy related to following physician orders, that was the expectation. 2. Clinical record review revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included Congestive Heart Failure, Interstitial Pulmonary Disease, Chronic Obstructive Pulmonary Disease (COPD) and Chronic Pulmonary Edema. The physician order effective 11/10/23 included, Incentive Spirometer (a device used to improve air movement in the lungs) 10 X(times) hour every shift while awake. The Care Plan revised on 11/7/23 said Resident #12 has the potential for altered respiratory status/difficulty breathing related to interstitial pulmonary disease, pleural effusion, respiratory failure, pulmonary edema, Congestive Heart Failure, pulmonary hypertension, COPD and wheezing. The intervention as of 11/6/23 included incentive spirometer as ordered. On 2/6/24 at 8:31 a.m., Resident #12 was observed in bed with a private duty aide at the bedside. She said she stays with the resident throughout the day and has never seen anyone use the Incentive Spirometer with the resident before. On 2/6/24 at 9:35 a.m., Resident #12's Incentive Spirometer was noted at the bedside. Resident #12's daughter said she took the incentive spirometer out of the cabinet for staff to help her mother use it. The daughter said she has not seen staff using the Incentive Spirometer. She said, Do you hear her wheezing? On 2/7/24 at 3:00 p.m., Unit Manager Staff L, verified the resident was not able to use the Incentive Spirometer on her own, but nurses were signing off on the treatment record that was being done. On 2/7/24 at 3:10 p.m., Licensed Practical Nurse (LPN) Staff D said he does not recall if he assisted resident #12 with the Incentive Spirometer. On 2/8/24 at 9:20 a.m., Resident #12's private duty aid said she's been with the resident all morning and no one has come in to help Resident #12 with the incentive spirometry. On 2/8/24 at 9:29 a.m., Licensed Practical Nurse (LPN) Staff H, said Resident #12 can do the incentive spirometer once in the morning but verified it was not done 10 times per hour. On 2/8/24 at 11:03 a.m., The DON verified the order was revised to say, encourage to use Incentive Spirometer every hour while awake, every hour document refusal. The DON verified LPN Staff G documented on 2/7/24., every hour from midnight to 7:00 a.m., Resident #12 used the incentive spirometer. On 2/8/24 at approximately 11:10 a.m., in a telephone interview LPN staff G verified Resident #12 did not use the Incentive Spirometer every hour during the night of 2/7/24 as documented. The resident refused when he woke her up to use the spirometer. 105538 Page 2 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to ensure 1 (Resident #29) of 1 dependent resident received the appropriate assistance to apply corrective lenses as per the physician's orders and care plan to maintain vision. Residents Affected - Few The findings included: Review of the clinical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Dementia and unspecified age-related cataract. The physician's orders dated 6/30/21 included for the nurse to verify the resident's glasses were on in the morning and remove the glasses at bedtime. The Care Plan revised on 7/1/2021 noted Resident #29 had impaired visual function related to cataracts and used glasses. The interventions included to remind the resident to wear glasses when up. Assist with placing glasses on in the morning, remove at bedtime. The Quarterly Minimum Data Set (MDS) assessment with a target date of 12/7/23 indicated the resident's vision was adequate with corrective lenses. The care plan summary meetings dated 2/15/23, 4/11/23, 5/18/23, 12/14/23 noted the resident wears glasses. Review of the Treatment Administration Record (TAR) for February 2024 noted on 2/5/24 (Day, evening, and night shift), on 2/6/24 (Day, evening, and night shift), and 2/7/24 (Day shift) Resident #29's glasses were on. On 2/5/24 at 1:53 p.m., and 2:50 p.m., Resident #29 was observed sitting in the activity area in front of nursing station. Resident #29 was not wearing glasses. Resident #29 was not able to respond to interview questions. On 2/6/24 at 1:05 p.m., Resident #29 was observed sitting in front of the nursing station without glasses. On 2/6/24 at 1:07 p.m., Certified Nursing Assistant (CNA) Staff K said everything you need to know about the resident can be found on the care plan. On 2/7/24 at 2:51 p.m., Unit Manager Licensed Practical Nurse (LPN) Staff L verified the resident should be wearing glasses. On 2/7/2024 at 6:04 p.m., A nursing progress noted documented by the unit manager said, Pt eye glass is missing room was searched. Pt husband was notified and was offered to have glasses replace . 105538 Page 3 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

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** Based on observations, resident and staff interviews, clinical records review and facility policy review the facility failed to follow physician's ordered fluid restrictions for 1 (Resident #14) of 2 residents reviewed for hydration management. Residents Affected - Few The findings included: Review of facility policy titled Encouraging and Restricting Fluids, revised October 2010 which stated, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Preparation: 1. Verify that there is a physician's order for this procedure . General Guidelines: 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. 3. Record fluid intake on the intake side of the intake and output record. Record fluid intake in ml (milliliter) . 8. Be sure an intake and output record is maintained in the resident's room . Documentation: . 6. The amount (in mLs) of fluids consumed by the resident during the shift. 7. The type of liquids consumed (i.e., tea, milk, coffee, soup, etc.) . 9. The signature and title of the person recording the data. Review of facility policy titled, Dietary Tray Card, revised 9/4/18 which stated, Policy: The Food and Nutrition Services Department should maintain a tray card system in order to record dietary information necessary to use on resident's tray card . Update any changes in the diet order; change the tray card, production count and nourishment list when applicable. Review of facility policy titled, Fluid Restriction, revised 5/20/20 which stated, Policy: To provide residents who have a written physician order for fluid restriction an appropriate amount of fluid each day while allowing nursing adequate fluid to supply medication, etc. each shift . Procedure: 2. For a diet with fluid restrictions, the following distribution may be used by nursing and dietary. Recommend dietary put ml allowed on tray card, and nursing note the ml allowed on the MARs. Review of clinical records revealed Resident #14 was admitted to the facility on [DATE] for short term rehabilitation. Primary admitting diagnosis was Chronic Obstructive Pulmonary Disease (COPD) with secondary diagnoses including acute and chronic respiratory failure, pleural effusion, chronic pulmonary edema, weeping edema both lower extremities and heart failure. Review of physician's order dated 2/1/24 documented, Fluid Restriction 1200cc/24 hrs:11-7 provide 60 ml; 7-3 Nursing provide 120 ml, dietary breakfast 420 ml, lunch 240 ml, 3-11 nursing provide 120 ml, dinner 240 ml every shift. Resident #14 care plan dated 2/2/24 documented the resident had altered cardiovascular status with intervention of restricted fluids as ordered by the physician. The Certified Nursing Assistant (CNA) [NAME] (Provides instructions for care) for Resident #14 documented restricted fluids as ordered by the physician. On 2/5/24 at 10:00 a.m., in an interview, when asked about meals at the facility, Resident #14 said, They put me on water restrictions last week. 105538 Page 4 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0692 Level of Harm - Minimal harm or potential for actual harm Observed Resident #14 with two juice six ounce (360 cc) cups on bedside table. Resident #14 said, Yeah, there is no reason, I get my other drinks but water is restricted. I will need to talk with the doctor. On 2/6/24 at 8:40 a.m., observed Resident #14 eating breakfast. Resident #14 had six ounces of orange juice, eight ounces of coffee, six ounces of water and eight ounces of milk on the breakfast tray. Residents Affected - Few CNA Staff B verified Resident #14 had six ounces of orange juice, eight ounces of coffee, six ounces of water and eight ounces of milk on the breakfast tray. During the observation, Registered Nurse (RN) Staff C provided Resident #14 with an additional eight ounces of chocolate (brand name) supplement. The total fluid provided to the resident with breakfast was 1080 cc. While interviewing Resident #14, RN Staff C came into room to administer medications to the resident. RN Staff C offered six ounces of water with medications. While RN Staff C was administering the medications, Resident #14 was observed taking a pair of pliers which he said was to open the milk bottle. RN Staff C opened the eight-ounce milk container for the resident. RN Staff C did not comment on the multiple drinks on the resident's breakfast tray. Review of the meal ticket failed to reveal instructions for the fluid restriction. On 2/6/24 at 12:53 p.m., observed Resident #14 finishing lunch with six-ounce cranberry juice partially consumed and six ounce orange juice partially consumed half on bedside. Lunch tray reviewed with CNA Staff B who confirmed resident drank eight ounces of milk and eight ounces of coffee with lunch. Review of the lunch meal ticket failed to show documentation of fluid restrictions. The total amount of fluids offered with the meal was 840 cc. On 2/7/24 at 8:23 a.m., in an interview Resident #14 said his dinner meal on 2/6/24 included regular fluids. The Resident said, I got juice, water and coffee. They are only restricting my water. I need to talk with the doctor about that. On 2/7/24 at 8:52 am., in an interview CNA Staff A confirmed Resident #14 was on fluid restrictions. When asked how much fluid resident is allowed each day CNA Staff A replied, 1400 cc I think. When asked if the1400 cc were for the shift or the entire day, CNA Staff A replied, 1400 cc for my shift. The CNA said she does not chart the fluid intake. She tells the nurses, and the nurses chart the amount. On 2/7/24 at 9:06 a.m., in an interview CNA Staff B who had cared for resident 2/6/24 confirmed she knew resident was on fluid restrictions. She said Resident #14 was allowed 1200 cc of fluids per day. CNA Staff B said, He had about 500 cc in the morning. I might have calculated it wrong; I knew he 105538 Page 5 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was on a fluid restriction that's why I only provided him with the juice. He did not get any Styrofoam cups of water. CNA reviewed drinks provided for both breakfast and lunch. CNA Staff B said, I should have been more aware of what he was supposed to have. The nurse tells me. I was told 1200cc for the day shift. On 2/7/24 at 11:07 a.m., in a phone interview RN Staff C confirmed she was aware of Resident #14 physician ordered fluid restriction was for 1200 cc over a 24 hour period. RN Staff C said she had communicated to the CNAs about the fluid restrictions. When shared the observed fluids provided to the resident for breakfast and lunch, RN Staff C said, Wow, I don't know what to say. RN Staff C said she did not notice the fluids on the breakfast tray on 2/6/24 when she administered the medications to the resident. On 2/7/24 at 11:39 a.m., in an interview Unit Manager Staff E said the nurses are the only ones who are supposed to provide the fluids with meals and medication pass. When shared the observation of the fluids provided to the resident at breakfast and lunch on 2/6/24, RN Staff E said, It's obvious the fluid restriction is not being followed. On 2/7/24 at 12:01 p.m., in an interview the Director of Nursing (DON) confirmed Resident #14 was on 1200 cc daily fluid restriction, as ordered on 2/1/24. The DON said the process for providing fluids when on restriction is for nursing not dietary to provide the fluids. CNAs can provide fluids based on the nurse's instructions. The DON confirmed staff did not follow the physician's order for fluid restriction for Resident #14. The DON said not following the fluid restriction could lead to complications of the congestive heart failure or the COPD. On 2/7/24 at 12:31 p.m., in an interview, the Registered Dietitian (RD) verified the meal tickets should reflect the fluid restriction for Resident #14. The RD said the meal tickets should have been reprinted when the fluid restriction was ordered and they were not. The RD said the supervisor needs to check the preprinted meal tickets to ensure they are correct and the menus handed to the residents are correct, especially when a change in orders occurs. On 2/7/24 at 1:00 p.m., in a telephone interview Resident #14's physician said she expects staff to follow orders, including orders for fluid restriction. She said they will need to work as a team to improve and not let it happen again. 105538 Page 6 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure they posted and updated the nurse staffing information with the facility name and an updated census per shift. The facility further failed to maintain the nursing staffing information for 18 months. Residents Affected - Some The findings included: On 2/5/24 at 9:10 a.m. via observation, the nurse staffing information form dated 2/5/24 located in the main lobby did not have the facility's name and the current census. On 2/5/24 at 4:00 p.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/05/24. On 2/06/24 at 10:10 a.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/06/24. On 2/06/24 at 4:10 p.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the updated resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/06/24. On 2/07/24 at 9:10 a.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the updated resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/07/24. On 2/07/24 at 1:45 p.m. in an interview with the Director of Nursing (DON), he confirmed the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the facility's name, the current resident census, the current number of staff, and the actual hours worked by the licensed and unlicensed nursing staff working 2/07/24. On 2/07/24 at 2:00 p.m., in an interview with the facility's Scheduler, she said she was responsible for posting the nurse staffing information form every morning. She confirmed the nurse staffing information form did not contain the facility's name and resident census. She further said she was unaware the nurse staffing information needed to be updated daily with the resident census, the current number of staff, and the actual hours worked by the licensed and unlicensed nursing staff. She also said she would throw away the nursing staffing information form the next day because she was unaware the facility was required to retain the nurse staffing information form for 18 months. 105538 Page 7 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and staff interview the facility failed to ensure its medication error rate remained below 5%. Four licensed nurses with 27 opportunities were observed. Two medication errors were identified resulting in a 7.41% error rate. Residents Affected - Few The findings included: Policies and Procedures titled Administering Medications (reviewed/revised April 2019), specified Medications are administered in a safe and timely manner, and as prescribed. The policy states 4. Medications are administered in accordance with prescriber orders, including any required time frame. On 2/7/24 at 9:01 a.m., Licensed Practical Nurse (LPN) Staff D was observed administering two medications to Resident #23, including Entresto and metoprolol. The physician's orders specified to hold the medications if the systolic blood pressure was less than110 or the heart rate was less than 65 beats per minute. Resident #23 had a heart rate of 60 beats per minute. This indicates the medication should be held per the physician order parameters. On 2/7/24 at 10:50 a.m., in an interview LPN Staff D verified the physician's orders for the Entresto and Metoprolol specified to hold if systolic blood pressure was less than110 or the heart rate was less than 65 beats per minute. He stated he gave the medication and should have held it due to the parameters. On 2/7/24 at 10:52 a.m., the Director of Nursing reviewed the Medication Administration Record for Resident #23 and verified the medications should have been held per the specified physician ordered parameters. 105538 Page 8 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

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. Based on observation, and staff interviews, the facility failed to administer and store medications in accordance with professional practice and standards for 1(Resident #14) of 1 resident observed with unsecured medications at the bedside. The findings included: On 2/7/24 at 8:39 a.m., observed Registered Nurse (RN) Staff D enter Resident #14 room with glass of water and medicine cup of pills. Observed RN leave medicine cup on bedside table next resident. RN did not stay with the resident to ensure medications were taken as ordered. On 2/7/24 at 8:42 a.m., interviewed RN Staff D who confirmed he had left resident #14 with pills in medicine cup on bedside table. RN Staff D said, I was looking for an iron pill when I left the room. I know I'm not supposed to do that. RN confirmed it was against medication administration policy to leave medication unattended. On 2/7/24 at 8:48 am., interviewed unit manager Staff E who confirmed it was not acceptable to leave medications at the bedside and to not wait for the resident to take medication when administering medications. On 2/7/24 at 12:01 p.m., interviewed Director of Nursing (DON) who confirmed medications are not to be left at bedside and the nurse is expected to stay with the resident until the medications have been taken. On 2/06/24 10:08 a.m. the medication storage room C wing checked with the Assistant Director of Nursing (ADON). During the observation a large white oval pill was found in the sink. Internet search shows it is Metformin (a pill to control blood sugar). Photographic evidence obtained. During an interview on 2/6/24 at 10:09 a.m. ADON stated that she did not know what the large white pill was and she acknowledged that it should not be in the sink in the medication room. On 2/06/24 at 11:25 a.m., LPN Staff Q's medication cart C left was checked and found to have opened over the counter (OTC) liquid medication not labeled with the open date. LPN staff Q confirmed 3 of the bottles did not have an open date on them and she could not know how long they had been in the drawer open. The following medication bottles were observed not dated with open date. -Geri-tussin DM -Liquid pain relief acetaminophen -Iron supplement During an interview on 02/07/24 at 11:45 a.m. the Director of Nursing (DON) stated that her expectation was for nurses when opening OTC liquid medication is to place an open date on the bottle. They 105538 Page 9 of 10 105538 02/08/2024 Harbour Health Center 23013 Westchester Blvd Port Charlotte, FL 33980

F 0761 dispose of the medication when the expiration date is reached. No policy of labeling open date on the bottle. Just a higher standard they want the nurse to practice. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105538 Page 10 of 10