Health inspection·November 3, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide nail care to dependent residents for 2 of 6 residents sampled for Activities for Daily Living (ADL) residents, (Residents #309 and #46). Residents Affected - Few The findings include: Resident #309 An observation was made of resident #309 on 11/1/22 at approximately 12:10 PM. The resident was observed lying in bed, observed multiple long fingernails with brown matter under the nails. An additional observation was made on 11/1/22 at approximately 4:06 PM. The resident's family member was at the bedside and noted the fingernails continued to be long, and dirty, and stated she wants the nails to be trimmed, but doesn't know how to get that done. The fingernail on the forefinger of the right hand was broken to the quick. The family member lifted the sheet to expose the resident's feet. The toenails on both feet were long, thick and yellow and the nails on the left 2nd and 3rd toes were rolled under, embedded in the skin. The nail on the left 5th toe was long, thick, and yellow. Additional observations were made on 11/2/22 at 8:19 AM, 11/2/22 at 9:45 AM, which revealed continued long, dirty nails. A review of record revealed a brief interview for mental status (BIMS) score of 3, which indicates severely impaired cognition. On 11/2/22 at approximately 9:12 AM, an interview was conducted with staff O, certified nursing assistant, (CNA) who stated she was assigned to the resident for the day and stated when she notices a resident's nails are long, she will cut the nails, including the toenails if the resident is not a diabetic. She stated she was not aware of the resident's long nails. On 11/02/22 at approximately 10:00 AM, an observation of the resident and an interview with staff H, Licensed Practical Nurse, (LPN) was conducted. Staff H stated the expectation is that resident's nails are cleaned when they are given a bath, or when needed, and the fingernails should be trimmed to the tip of the finger, unless the resident is diabetic, then the nurse must trim the fingernails. She further stated the CNAs are not allowed to trim the toenails at all. Staff H observed the nails in the surveyor's presence and confirmed the 5th digit on the right hand had brown matter under the nail, and measured the nail as 0.5 centimeters (cm) past the tip of the finger, the left thumb nail had brown matter under the nail, was jagged and measured 0.5 cm beyond the tip of the finger, the forefinger of the left hand was greater than 0.5 cm beyond the end of the fingertip. Staff H confirmed the right great toe was greater than 0.5 cm beyond the tip of the toe, the nail on the 3rd digit on the right foot was curled under and was embedded in the skin at the upper back of the toe, the Page 1 of 7 105543 105543 11/03/2022 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few great toe on the left great toe was greater than 0.5 cm beyond the tip of the toe, and the nails on the 2nd and 3rd digits of the left foot were curled under and embedded into the upper back of the toe. An interview was conducted with the Director of Nurses, (DON) on 11/2/22 at approximately 11:01 AM, who confirmed resident's nails should be trimmed during the bath unless a diabetic, then the nurse should trim them. White, [NAME] Resident #46 An observation was made of resident #46 on 11/1/22 at approximately 12:15 PM. The resident was observed lying in bed, observed multiple long fingernails with brown matter under the nails. Additional observations were made 11/01/22 at 4:06 PM, 11/02/22 at 9:05 AM, and 11/02/22. A review of medical record revealed a diagnosis of psychoses and depression. The record also revealed a brief interview for mental status (BIMS) score of 9, which indicates moderately impaired cognition. On 11/2/22 at approximately 10:30 AM, an observation of the resident and an interview with staff H, Licensed Practical Nurse, (LPN) was conducted. She measured the fingernails and confirmed brown matter under the nails. Measurements included left thumb was 0.5 cm beyond the tip of the finger, left middle finger 0.5 cm beyond the tip of finger and the little finger or pinkie was 1.0 cm beyond the tip of finger. Right index finger was 1.0 cm beyond the tip of finger, right middle finger was 0.5 cm beyond the tip of finger and right pinkie was 1.0 cm beyond the tip of finger. Review of policy titled Nail care implemented on 5/1/21 revealed routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. The policy further states routine nail care, to include trimming and filing will be provided. Nail care will be provided between scheduled occasion as the need arises. 105543 Page 2 of 7 105543 11/03/2022 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, record review, staff interviews, and policy review the facility failed to provide physician ordered treatment to prevent complications of enteral feeding tubes for 1 of 2 sampled residents with enteral feeding tubes. (resident #62) The findings include: Observations of resident #62's Percutaneous Endoscopic Gastrostomy (PEG) tube insertion site were conducted on 10/31/22 at 2:45 PM and 4:21 PM. The dressing on the tube site was observed to be dated 10/27/22 and the resident stated it was supposed to be changed daily. The Director of Nursing (DON) observed the tube site dressing on 10/31/22 at 4:21 PM, and confirmed the dressing on the tube site was dated 10/27/22. A PEG tube is a tube surgically placed into the stomach through the abdominal wall that allows for liquid food to be given. Review of resident #62's electronic medical record revealed a current physician treatment order dated 10/26/21 stating cleanse peg tube site with warm, soapy water once daily and pat dry, apply split sponge to site and secure with tape every day and as needed every night shift. Review of the treatment administration record (TAR) for October 2022 revealed the treatment was signed as completed by nursing staff on October 28, 29, and 30, 2022 and no refusals were documented. The TAR revealed employee B, Licensed Practical Nurse (LPN) signed the treatment was completed on 10/28/22 and employee C, LPN signed the treatment was completed on 10/29/22 and 10/30/22. A telephone interview was conducted with employee B, LPN, on 11/1/22 at 2:52 PM. Employee B, stated the treatment was overlooked and an error. A telephone interview was conducted with employee C, LPN, on 11/1/22 at 3:10 PM. Employee C verified her initials on the treatment record and stated she did not complete a dressing change for resident #62. Review of the facility policy regarding Care of Feeding Tubes (implemented 5/1/21) revealed it is a policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Direction for staff on how to provide the following care will be provided examination and cleaning of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection. 105543 Page 3 of 7 105543 11/03/2022 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review the facility failed to ensure staff serve food in a sanitary manner during 1 of 2 dining observations. (lunch 10/31/22) Residents Affected - Few The findings include: An observation of the lunch meal was conducted on 10/31/22 at 11:40 AM. Employee A, Certified Nursing Assistant (CNA) was observed to serve a resident a bowl of soup, and touched the eating end of a spoon before handing the spoon to the resident. At 11:45 AM, Employee A, CNA, touched her surgical face mask with her bare hand and pulled it down while speaking to a resident. Employee A then used the same bare hand to serve soup to a resident and did not wash or sanitize her hands after touching her face. An interview was conducted with Employee A on 10/31/22 at 2:30 PM. She stated she had received training regarding safe food handling and should not touch the end of the utensil the resident eats with. She also confirmed she should wash or sanitize her hands after touching her face or mask before serving food. Review of the facility policy regarding Dietary/Food Handling (revised April 2001) revealed food handlers must wash their hands after personal body functions and before handling any food surfaces. 105543 Page 4 of 7 105543 11/03/2022 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents who required assistance with eating/dining received restorative dining services for 1 of 1 resident sampled for weight loss. (Resident #38) Residents Affected - Few The findings include: An observation on 11/01/22 at approximately 8:45 AM, revealed that Resident #38 was observed in her room sitting up in the wheelchair with a sling under her. There was a breakfast tray sitting in front of the resident still covered. She was not eating her breakfast. The bedside table and food were not near the resident. A follow up observation was conducted on 11/01/22 at 9:11 AM, during which staff member Q, Certified Nursing Assistant (CNA) was in the room and brushing the resident #38's hair. The breakfast tray and bedside table were still sitting in the same position as the earlier observation. The surveyor lifted the lid to the breakfast tray to identify what food had been eaten. No food had been consumed from the plate. The CNA then reached over to the bedside table and handed the resident a glass of what appeared to be the ordered vanilla shake. The CNA stated, She will not eat if we give her the shake. A record review was conducted for resident #38 which revealed she had a 29-pound weight loss over the last 4 months, per the facility's weight documentation on 6/22/22 the resident weight 129 pounds, there was no weights for July, on 8/23/22 - 101.2 pounds, on 9/8/22 - 101 pounds, 9/15/22 - 99 pounds, 9/22/22 - 99.4 pounds, 10/4/22 - 98 pounds, 10/18/22 - 99.4 pounds, and on 10/25/22 - 100 pounds. A review of Resident #38's care plan dated 4/22/22 and revised on 10/24/22 revealed a focus area regarding risk for weight variance related to therapeutic diet, mechanically altered diet, gastroesophageal reflux disease and thickened liquids. The resident was to have her trays set up with supervision and cueing and to assist with meals as needed. The resident was to participate in Restorative Dining and needed to be up and in dining room before 11:30. She required extensive assist with eating dated on the 10/24/2022 care plan. Further review of the care plan revealed the goal for Resident #38 was to have no significant weight loss of 5% in 30 days or 7.5 % in 90 days (revised 5/5/22). Care plan interventions dated 8/26/22 restorative dining as ordered. The resident was to have her trays set up with supervision and cueing and to assist with meals as needed. A review of the resident's dietary orders dated 5/24/22 revealed she was to be on a consistent carbohydrate diet with pureed texture, nectar consistency, and fortified foods for additional calories. An order dated 10/21/22 added supplements that included a vanilla house shake two times a day. She was referred to speech therapy on 8/17/22 with documented concerns of takes two hours to feed and will not open mouth wide enough to eat. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 had a brief interview for mental status (BIMS) score of 06, indicating severe cognitive impairment. She required supervision and assistance for eating. The resident was non-ambulatory and used a wheelchair for mobility. The resident was to have a mechanically and therapeutic altered diet. Resident #38 had a Significant Change MDS assessment dated [DATE]. The Significant Change MDS indicated weight loss and a current weight of 99 pounds, had lost 10% of her body weight. And that she was a Restorative Dining participant. 105543 Page 5 of 7 105543 11/03/2022 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 10/31/22 at approximately 12:11 PM, staff member P, CNA. She stated, It is hit or miss when the food gets here and when the residents are brought down to us. Sometimes everyone is here for meals and sometimes they are not. It is hit or miss. An interview was conducted on 11/01/22 at approximately 9:00 AM, with the Restorative Manager. The Restorative Manager stated she did ask staff S, Licensed Practical Nurse (LPN) to make sure the residents were up this morning for breakfast and brought to the restorative dining area. She stated that no residents were brought to restorative dining. She stated she had approximately six residents in restorative dining. The Restorative Manager stated, She just did not bring them down there like I asked her. An interview was conducted on 11/01/22 at approximately 9:38 AM, staff member T, LPN, who stated, The Restorative Dining residents are supposed to be up by 7 AM daily. The night shift is supposed to have them up. We do have a problem with them doing that. An interview was conducted on 11/02/22 9:51 AM, with the Director of Nursing (DON). She stated there are approximately 6-7 in Restorative Dining. I was just made aware that none of them were up for restorative dining this morning. Our restorative program for Resident # 38 is to cue her to eat. We want to keep our residents as independent as possible, as far as eating. The DON stated that the night shift staff were to get the restorative residents up by 7 AM and that a recent staff meeting had been conducted regarding the need for the Restorative Dining residents to be up and in the dining area by the specified time. The DON stated, I will be addressing this on a different level as far as getting the residents up for restorative dining. An interview was conducted on 11/02/22 at approximately 3:30 PM, with staff member V, Dietician. Staff member V stated there was a list of residents with weight loss and that Resident #38 was to participate in Restorative Services and be supervised by the staff during her meals. 105543 Page 6 of 7 105543 11/03/2022 St Andrews Bay Skilled Nursing and Rehabilitation 2100 Jenks Ave Panama City, FL 32405

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interviews, and policy review the facility failed to ensure resident personal hygiene items were stored in a sanitary manner for 1 of 20 sampled residents (resident #60) and failed to maintain the main dining room glass exterior door in a safe manner. The findings include: Resident #60 Observations of resident #60's shared bathroom were conducted on 10/31/22 at 12:51 PM, 11/1/22 at 2:32 PM, 11/3/22 at 9:01 AM, and 11/3/22 at 11:20 AM. A blue toothbrush was observed to be in an open emesis basin on top of the sink and was not labeled or in a storage container and a urine collection hat was observed in the floor. The urine collection hat was not labeled or stored in a bag or storage container. (Photographic evidence obtained.) An interview was conducted with Employee D, Certified Nursing Assistant (CNA) on 11/3/22 at 11:20 AM. She observed the toothbrush and urine collection hat. She stated resident #60 had indicated the blue toothbrush was her toothbrush. Employee D stated she had worked in the facility for about 2 months and she did not know how the items were supposed to be stored. An interview was conducted with the Director of Nursing (DON) on 11/3/22 at 11:32 AM. The DON stated resident #60 was not care planned for refusals to properly store personal items. Review of the facility policy regarding Resident Personal Belongings (implemented 5/1/21) revealed the facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room. Main Dining Room Glass On 10/31/22 at 11:40 AM, an observation of the dining room glass exit door revealed the glass was cracked the entire length of the 2 window panes. (Photographic evidence obtained.) An interview was conducted with the Administrator on 11/3/22 at 10:23 AM. The Administrator stated this must have happened last Thursday when the yard maintenance was being done. 105543 Page 7 of 7