Health inspection·December 15, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review. the facility failed to identify and maintain 1 of 17 shared patient bathrooms on the 200 unit out of a total of 33 shared patient bathrooms (rooms 228-230). Residents Affected - Few Findings: On 12/12/22 at 9:25 AM, 12/12/21 at 3:12 PM, 12/13/21 at 9:06 AM, and 12/14/21 at 9:57 AM, observations revealed approximately 12 inches of baseboard molding had separated from the wall in the shared bathroom for rooms 228-230. On 12/14/21 at 4:04 PM, the Maintenance Director stated he conducts resident room rounds daily to make observations of areas that need repair. He stated there is a book on each nursing unit for staff to document any issues they identify that need repair, and said, I check the book every morning and then complete the repairs. On 12/14/21 at 4:09 PM, an observation in the shared bathroom for rooms 228-230 was conducted with the Maintenance Director. The Maintenance Director explained he had just been in the bathroom earlier that morning and he had not seen the baseboard molding separating from the wall. He said, The molding should not be coming off the wall and it should have been fixed. Review of the facility's Physical Environment Policy and Procedure, dated January 1, 2020, read, A safe, clean, comfortable, and home-life environment is provided for each resident/patient. Page 1 of 9 105539 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #29 was re-admitted to the facility on [DATE], from an acute care hospital with diagnoses that included multiple sclerosis, diabetes, and kidney failure. Residents Affected - Few Resident #29's Order Summary Report, dated 9/08/21, revealed a physician's order for dialysis every Tuesday and Saturday at 5:45 AM. The resident's medical record revealed Dialysis Consultation forms, dated 9/11/21 through 12/02/21. The documentation showed resident #29 had dialysis treatment in place, as ordered by the physician starting on 9/11/21. The MDS Significant Change Assessment, with assessment reference date of 9/21/21, showed resident #29 had an active diagnosis of renal insufficiency, but did not list dialysis as a special treatment, procedure or program performed in the past 14 days. On 12/15/21 at 11:24 AM, the MDS Coordinator stated the MDS Significant Change Assessment was performed for resident #29 because she started dialysis. She explained the O section of the MDS was where special treatments like dialysis were indicated. She confirmed that a mistake was made when she did not indicate resident #29's dialysis treatment in her MDS Significant Change Assessment. On 12/15/21 at 11:33 AM, the Director of Nursing said, The MDS is a reflection of what the level of function the resident is currently exhibiting. She explained the information flowed into the care plan and [NAME] for staff to provide the appropriate care, and therefore she expected it to be accurate. The Center for Medicare & Medicaid Service's (CMS) Resident Assessment Instrument Version 3.0 Manual, dated October 2019, revealed that Reevaluation of special treatments and procedures the resident received or performed . during the 14-day look back period is important to ensure the continued appropriateness of the treatments, procedures or programs. Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for oxygen use for 1 of 5 residents reviewed for respiratory care (#22), and for 1 of 1 resident reviewed for dialysis (#29) out of a sample of 44 residents reviewed. Findings 1. Review of resident #22's medical record documented she was admitted to the facility on [DATE] with diagnoses including Anxiety and Chronic Obstructive Pulmonary Disease (COPD). Observations conducted on 12/01/21 at 1:58 PM, 12/13/21 at 8:59 AM, 12/14/21 at 9:41 AM, 12/14/21 at 12:30 PM, and 12/15/21 at 9:50 AM revealed resident #22 had been on oxygen at 2 liters per minute via nasal cannula. On 12/12/21 at 1:58 PM, resident #22 stated she had a diagnosis of pulmonary fibrosis, was on oxygen, received breathing medications, and had seen a pulmonary physician for her lung problems. Review of resident #22's care plan for oxygen initiated on 05/06/2016 with revision on 06/20/20 reflected that the resident had oxygen therapy related to respiratory illness, and that the resident's oxygen saturations were within parameters, but the resident demands to continue to wear oxygen at 105539 Page 2 of 9 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

F 0641 all times. Level of Harm - Minimal harm or potential for actual harm On 12/15/21 at 12:27 PM, the MDS Coordinator stated that all MDS assessments are required to be accurate and reflect the resident's medical care needs. She explained that to complete an accurate MDS assessment she needed to conduct an observation and interview with the resident, interviews with the nursing staff providing care to the resident, interview with the resident's family/responsible party, review of the nursing progress notes, physician orders and progress notes, hospital information and all consults completed. She confirmed that resident #22 had a care plan for her oxygen use which had been initiated in 2016 and then updated in 2020. She confirmed resident #22's 06/12/20 Quarterly MDS, the 09/12/21 Significant Change in Status MDS, the 12/13/2021 Quarterly MDS, the 03/15/21 Quarterly MDS, the 06/15/21 Quarterly MDS and the 09/11/21 Annual MDS had not been completed correctly for the resident's oxygen use. She explained that since resident #22 had been on oxygen therapy, there should have been a check in the Section O, Respiratory Treatments, C. Oxygen therapy While a resident box. Residents Affected - Few On 12/15/21 at 1:20 PM, Licensed Practical Nurse (LPN) A stated that resident #22 used her oxygen at 2 liters via nasal cannula at all times. 105539 Page 3 of 9 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to for 1 of 5 sampled residents reviewed for respiratory care (#92). Findings: Resident #92's Medical Record reflected that she was admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, dementia with behavioral disturbances, Arteriosclerotic Heart Disease, (ASHD), and Atrial Fibrillation. Observations conducted on 12/12/21 at 9:25 AM, 12/12/21 at 3:04 PM, and 12/13/21 at 9:04 AM, revealed resident #92 was on oxygen at 3 liters per minute via nasal cannula (nc). Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/17/21, documented she had received oxygen. On 12/14/21, resident #92's physician ordered oxygen 1 liter via nasal cannula for shortness of breath as needed (PRN) from 9 PM to 9 AM. The Physician's Progress Note, dated 11/10/21, reflected a diagnosis of Hypoxemia, that the resident was on continuous oxygen via nasal cannula, that a chest x-ray would be ordered, and that oxygen was to be decrease to 1 liter. On 12/14/21 at 12:53 PM, Certified Nursing Assistant (CNA) B stated, She [resident #92] does wear her oxygen, and sometimes she will take it off, so I have to help her put it back on. On 12/15/21 at 1:46 PM, Licensed Practical Nurse (LPN) A indicated that resident #92's oxygen was off during the day and was on during the night. She explained the resident had an order for oxygen at 2 liters per minute via nasal cannula, however, the order had changed on 12/14/21 to oxygen at 1 liter per minute via nasal cannula. Resident #92's plan of care did not reveal a care plan for oxygen use. On 12/14/21 at 3:39 PM, the MDS Coordinator said resident #92 had been receiving oxygen, but she did not have a care plan to address her medical needs, goals and interventions for her oxygen use. She stated, She should have had an oxygen care plan. 105539 Page 4 of 9 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

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 observation, interview, and record review, the facility failed to obtain a physician's order for the use of oxygen for 2 of 5 sampled residents reviewed for respiratory care (#22 & #36), and failed to ensure the oxygen concentrator's external filter was clean to promote proper flow of oxygen for 1 of 5 sampled residents reviewed for respiratory care (#92) of 11 residents receiving oxygen therapy. Residents Affected - Few Findings: 1. Resident #22's medical record reflected she was admitted to the facility on [DATE] with diagnoses including Anxiety and Chronic Obstructive Pulmonary Disease (COPD). Observations conducted on 12/01/21 at 1:58 PM, 12/13/21 at 8:59 AM, 12/14/21 at 9:41 AM, 12/14/21 at 12:30 PM, and 12/15/21 at 9:50 AM revealed resident #22 had been on oxygen at 2 liters per minute via nasal cannula (nc). On 12/12/21 at 1:58 PM, resident #22 stated she had a diagnosis of pulmonary fibrosis, was on oxygen, received breathing medications, and had seen a pulmonary physician for her lung problems. Resident #22's care plan for oxygen, initiated on 05/06/2016 with revision on 06/20/20, reflected that the resident used oxygen therapy due to respiratory illness. The resident's oxygen saturations were within parameters, but the resident demanded to continue to use oxygen at all times. On 12/15/21 at 1:20 PM, Licensed Practical Nurse (LPN) A said that resident #22 uses oxygen at 2 liters nnasal cannula at all times. Resident #22's December 2021 physician's orders did not reveal any order for oxygen therapy. The facility's Oxygen Administration and Therapeutics Policy and Procedure, dated November 2013, read, Oxygen Administration Policy: The facility requires that a physician's order be obtained prior to the administration of oxygen . 2. Resident #92's medical record reflected that she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, dementia with behavioral disturbances, Arteriosclerotic Heart Disease, (ASHD), and Atrial Fibrillation. Observations conducted on 12/12/21 at 9:25 AM, 12/12/21 at 3:04 PM, 12/13/21 at 9:04 AM, 12/14/21 at 9:49 AM, and 12/14/21 at 12:36 PM revealed an oxygen concentrator with the Hospice name. The oxygen concentrator's external filter was covered with a gray dust-type substance. On 12/04/21, resident #92's physician ordered oxygen at 1 liter via nasal cannula from 9 PM to 9 AM. On 12/14/21, the physician ordered oxygen at 1 liter via nasal cannula for shortness of breath as needed (PRN). The resident's Quarterly Minimum Data Set (MDS) assessment, dated 11/17/21, reflected that she had received oxygen. 105539 Page 5 of 9 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/14/21 at 12:53 PM, Certified Nursing Assistant (CNA) B stated, She does wear her oxygen and sometimes she will take it off, so I have to help her put it back on. On 12/14/21 at 3:53 PM, the Director of Nursing (DON) indicated that the Maintenance Director is responsible for cleaning the external concentrator filters. The DON said, The external filters are kept clean to ensure the air entering the resident's lungs is free of dust, and the oxygen concentrator is working properly to administer the correct oxygen liter flow to the resident. The DON confirmed the external [NAME] was covered with gray dust-type substance. The DON then washed the filter with water and brown water was observed flowing from the filter. On 12/14/21 at 4:04 PM, the Maintenance Director stated he was responsible for cleaning the facility's oxygen concentrator's external filters. He explained that he checked the external filters once a month, and if the filter was dirty, he removed and changed the filter. The Maintenance Director revealed that if the oxygen concentrator belonged to Hospice, the hospice staff are responsible for cleaning the equipment. He said, Hospice does not want me performing maintenance on their equipment but if the staff inform me that the filter is dirty, I will clean the filter. On 12/15/21 at 1:46 PM, Licensed Practical Nurse (LPN) A said resident #92's oxygen was off during the day and on during the night. She explained the resident had an order for oxygen at 2 liters per minute via nasal cannula, but the order had changed on 12/14/21 to oxygen at 1 liter per minute via nasal cannula. Review of the facility's Oxygen Concentrator Policy and Procedure, not dated, read, Purpose: To provide oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration level of oxygen . Precautions and Hazards 1) DO NOT operate the oxygen concentrator without the filter or with a dirty filter . Procedure . 5) Check the inlet filter pad and ensure that it is in place and clean . Daily Maintenance . 3) Clean the air inlet filter as needed and weekly . Review of the facility's Competency Review for Nurses, completed during Nursing Skills Fair in September 2021, listed required competency for types of delivery equipment for oxygen which included concentrator. Review of the Facility Assessment, dated 11/19/2021, documented staff competency is required for residents with Congestive Heart Failure, COPD, Tracheostomy and Oxygen Concentrators. 3. Resident #36 was readmitted to the facility on [DATE] with diagnoses including pneumonia unspecified organism, unspecified diastolic (congestive) heart failure and hypoxemia. On 12/14/21 at 9:56 AM, resident #36 was lying in bed. The resident was not interviewable. She used oxygen via nasal cannula attached to an oxygen concentrator. The regulator was set at 2.5 liters per minute (LPM). On 12/14/21 at 10:08 AM, Licensed Practical Nurse (LPN) C acknowledged the regulator was set at 2.5 LPM. LPN C stated resident #36 had pneumonia and was using oxygen at that time. On 12/14/21 at 10:08 AM, LPN C checked the physician's orders and stated she could not find a physician's order for resident #36's oxygen. On 12/14/21 at 10:28 AM, the 100 Unit Manager (UM) checked the physician's orders. She acknowledged 105539 Page 6 of 9 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there were no current orders for oxygen for the resident. The UM stated that the resident's oxygen level should reflect the order. She stated, Any nurse who sees a resident with oxygen without an order should call the doctor and confirm that the resident should or should not be on oxygen and obtain orders. She said a physician's order is required to administer oxygen. She said oxygen was considered a medication. A review of physician's orders Summary Report from 9/21/2021 through 12/14/2021 did not indicate any orders for oxygen therapy for resident #36. The Medication Administration Record from 9/23/21 through 12/14/2021 did not reveal any orders for oxygen therapy for resident #36. A nurse's Admission/readmission note, dated 9/23/2021 at 7:15 AM, reflected that resident #36 resident used oxygen. Resident #36's quarterly Minimum Data Set (MDS) assessment, with assessment reference date of 10/01/2021, revealed that the resident was cognitively impaired and required assistance of 2 staff for activities of daily living. Review of the facility policy and procedure for Medication Administration read, . 3. Prior to Administration, review and confirm medication orders for each individual resident on the Medication Administration Record. 105539 Page 7 of 9 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

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 20 nutritional supplement cartons were discarded prior to the use by date listed on the container in 1 of 2 nourishment rooms (200 Unit), and failed to ensure employee food items were not stored in 1 of 2 nourishment room (100 Unit). Findings 1. On 12/13/21 at 9:18 AM, an observation of the 200 Unit nourishment room revealed in the cabinet twenty 8 ounce cartons of Novasourse Renal 18% 2.0 calorie Nutritionally Complete formula with the use by date of June 2021. The 200 Unit Manager (UM) explained that the 11 PM -7 AM nurse was responsible to check the nourishment room every night to ensure any out dated items were discarded and not available for resident consumption. The 200 UM stated, The 20 cartons of Novasourse Renal had expired and should have been discarded. On 12/13/21 at 9:21 AM, the Registered Dietitian (RD) confirmed the 20 cartons of Novasourse Renal had expired in June 2021, and said, The cartons should have been discarded. 2. On 12/13/21 at 9:38 AM, an observation of the 100 unit nourishment room was conducted. The 100 UM confirmed two employee lunch bags containing food were on the nourishment room counter. She stated. Employees have a refrigerator in the employee break room to store their food. They should not be storing their lunch bags in the nourishment room which contains food provided to the residents. On 12/13/21 at 9:42 AM, the Director of Nursing (DON) stated, the expired Novasource Renal should have been discarded in June 2021 to ensure the residents do not receive expired products. She said, The employees have a refrigerator in the break room for their food so they should never be storing their personal items from home in the nourishment rooms. Review of the facility's Safe Handling, Storage, and Reheating of Food from Visitors or Outside Source Policy and Procedure, dated January 2021, read, . Storage . 3. Shelf stable items may be retained up to the listed expiration date . 105539 Page 8 of 9 105539 12/15/2021 Healthcare and Rehab of Sanford 950 Mellonville Ave Sanford, FL 32771

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to implement and monitor the Performance Improvement Plan (PIP) developed by the Quality Assurance & Assessment (QA&A) committee to ensure continued accuracy with all resident Minimum Data Set (MDS) assessments and Development/Implementation of Comprehensive Resident Care Plans. Findings: On 12/15/21 at 12:27 PM, the MDS Coordinator stated that all MDS assessments are required to be accurate, reflect the resident's medical care needs and completed in a timely manner In order to complete an accurate MDS assessment, she needed to conduct an observation and interview the resident, interview the nursing staff providing care to the resident, interview the resident's family/responsible party, review the nursing progress notes, physician orders and progress notes, hospital information and all consultations completed. The MDS Coordinator confirmed that current resident MDSs were not correct for their oxygen use, a resident MDS had not correctly identified her dialysis treatments, a resident discharge MDS had not been completed in a timely manner (overdue 120 days), and two residents did not have a care plan for their oxygen use. The facility's Quality Assurance and Performance Improvement (QAPI) Plan did not contain data for analysis and planning, developing a plan, identifying teams to implement the plan, presentation from teams for activity/results to the QAPI Committee, summary plans with updates, changes, and completion/resolution. On 12/15/21 at 3:30 PM, an interview was conducted with the Administrator and the Director of Nursing (DON). The Administrator acknowledged the facility had previous non-compliance related to the accuracy with MDS assessments for Hospice and development/implementation of resident care plans. The Administrator stated the goal of the facility's QAPI Program was to identify issues, develop a plan, determine the root cause for the non-compliance, analyze interventions, and change the plan with the goal to be in compliance. The Administrator explained the QAPI Program addressed the non-compliance back in March 2020, and the facility determined compliance as of 04/13/20. Audits of the MDS specific to Hospice residents and Care Plans were conducted by the Regional MDS Consultant and then the audits were discontinued. The Administrator did not present a PIP for the identified issues related to the Development/Implementation of Comprehensive Care Plans. The Administrator stated that the Corporate MDS Coordinator had completed audits which were conducted remotely. On 12/15/21 at 4:44 PM, the Clinical Reimbursement Specialist stated that she had completed audits monthly and quarterly for only the Hospice and Hemodialysis residents. 105539 Page 9 of 9