Health inspection·December 21, 2023

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 observation, interview and record review, the facility failed to ensure that one (Resident #72) of three residents reviewed for activities of daily living (ADL), from a total sample of 32 residents, received adequate and appropriate nail care to maintain personal hygiene. Residents Affected - Few The findings include: On 12/18/23 at 11:45 AM, Resident #72 was observed resting in her room. The resident's fingernails extended approximately three quarters of an inch from the edge of the nail bed. The nails were yellow with dirt accumulated at the bottom edge of the nail bed. The resident explained that she did not like her nails so long and repeatedly asked members of facility staff to trim them. The resident could not recall a specific name of facility staff who she asked to trim her nails and said she asked several certified nursing assistants (CNAs) and licensed practical nurses (LPNs). (Photographic evidence obtained) On 12/21/23 at 10:00 AM, a second observation was made of the resident resting in bed with eyes her closed. The resident's fingernails extended approximately three quarters of an inch from the edge of the nail bed. (Photographic evidence obtained) On 12/21/23 at 10:30 AM, a third observation was made of the resident resting in bed with eyes her closed. The resident's fingernails extended approximately three quarters of an inch from the edge of the nail bed. (Photographic evidence obtained) A review of Resident #72's record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, history of transient ischemic attack and cerebral infarction, bipolar disorder, type II diabetes mellitus, hypertension and atrial fibrillation. The quarterly minimum data set (MDS) assessment, dated 09/23/23, documented the resident's brief interview for mental status (BIMS) score was 13 out of 15 possible points, indicating the resident's cognition was intact. The MDS further documented the resident had no potential indicators of psychosis; no indications of physical and/or verbal behavioral symptoms directed towards others; exhibited no rejection of care and no wandering behaviors. The resident's bed mobility was extensive assistance with a two person assist required. Transfer, walk in room, walk in corridor, locomotion on and off unit did not occur during the assessment. The resident's dressing required extensive assistance with a two person assist. Eating required supervision with set up only. Toilet use required extensive assistance with a one person assist. Personal hygiene required extensive assistance with a one person assist. The resident's quarterly MDS dated [DATE], revealed the same data as the MDS dated [DATE]. Page 1 of 10 105547 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #72's care plan dated 09/23/23, documented a focus area noting the resident required assistance with ADL functions related to weakness and debility. The care plan focus was initiated on 08/25/22 and revised on 03/23/23. The care plan goal projected the resident will have bathing, dressing and grooming needs met as evidenced by lack of unpleasant body odors, neat and clean appearance on a daily ongoing basis. The care goal was initiated 08/25/22 and revised 05/13/23. Interventions to the care plan documented assistive devices as ordered and/or indicated. Enablers as ordered to promote functional bed mobility. Encourage and assist with all activities of daily living (ADL) tasks as indicated, as tolerated by resident, including locomotion, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. On 12/21/23 at 10:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) A. She reported she had worked at the facility for a little over 22 years. She explained that she was familiar with the resident and the resident's needs. She said she had not been asked by the resident to have her fingernails trimmed. She expressed that the process while providing activities of living care was to observe residents' fingernails. If the fingernails appearred long, the expectation was to trim the resident's fingernails at bedside. She described the definition of excessively long nails, which have the potential of scratching a resident's skin, as a minimum of a quarter inch beyond the edge of the nail bed. The CNA pulled back the resident's blanket and observed the resident's fingernails. On 12/21/23 at 11:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) B. She reported she had worked as an Agency employee at the facility for approximately one month. She explained the process for a resident needing a fingernail trim started with the CNA while the care was provided. If she administered medication to a resident and noticed a resident's fingernails exceeded a half an inch beyond the nail bed, she should report it to the CNA who was responsible for trimming the resident's fingernails. She only gave the CNAs verbal notice and did not document a resident's excessive fingernail length in the facility's electronic medical records. On 12/21/23 at 12:40 PM, an interview was conducted with the facility's Director of Nursing (DON). She reported she had worked at the facility for approximately three years. She explained that every resident was different, and some residents did not like their fingernails trimmed. She further explained that fingernail trimming should be included with activities of daily living (ADL) care. She informed CNAs that they should only file fingernails and not clip them. Clipping fingernails was the responsibility of the nurses. Fingernail filing and trimming or requests for filing or trimming were not documented in the facility's electronic medical records. If a resident requested to have their nails trimmed, the expectation was to have the resident's nails filed or clipped within the same day. She explained that if a nurse noticed nails were long during medication administration, they would initiate the trim right there and then. A review of the facility's Activities of Daily Living (ADL) policy documented. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, nail care and oral care. . 105547 Page 2 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure that one (Resident#33) of four residents receiving enteral feedings received adequate nutrition as prescribed. There were 32 residents in the total sample. Failure to provide enteral nutrition as prescribed could result in caloric deficit and eventual malnutrition. The findings include: During a tour on 12/19/23 at 10:12 am, Resident #33 was observed lying in bed. He was receiving tube feeding Jevity 1.5 cal at 60 milliliters per hour ml/hr. (Photographic evidence obtained) Another observation was made on 12/19/23 3:27 pm. Resident #33 was observed receiving Jevity 1.5 cal at 60 ml/hr. On 12/20/23 at 9:08 am, Resident #33 was observed in bed lying supine with the head of the bed elevated at 30 degrees. Jevity 1.5 was running at 60 ml/hr. (Photographic evidence obtained) In an interview on 12/20/23 at 9:28 am, Licensed Practical Nurse (LPN) C stated she was assigned to Resident #33. When asked about the resident's tube feeding times, she reviewed the physician's orders and stated the order read Jevity 1.5 cal at 70 ml per hour on at 2:00 pm and off at 10:00 am. She confirmed that the order was changed from 60 ml to 70 ml on 12/11/23. She was accompanied to the resident's room and confirmed that the resident was receiving the feeding at 60 ml/hr. She added that she would adjust the rate to 70 ml/hr. A review of the medical record indicated that Resident #33 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction, gastrostomy status, dysphagia, severe protein calorie malnutrition, pneumonitis due to inhalation of food and vomit. Physician orders dated 12/11/23, revealed Jevity 1.5 cal at 70 ml/hr x 20 hours (1400 - 1000 o'clock). Additional orders dated 9/6/23, indicated to provide hydration 125 ml of free water flush every 4 hours for hydration. Encourage resident to remain NPO (nothing by mouth). Check residual every shift. If 60 ml hold feeding for one hour. If residual remains greater than 60 ml, continue to hold and notify the physician. Change tube feeding set/bag every night shift. A review of the care plan dated 9/5/23, indicated that the resident required tube feeding related to dysphagia, a history of aspiration, cardiovascular accident, severe calorie malnutrition, and low BMI (body mass index)/low weight. Interventions included to follow physician's orders regarding nutrition orders and flushes. Check tube placement and gastric content/residual volume per facility protocol and record. Turn off G-tube (feeding tube) while providing care and when head of bed is down. Encourage resident to keep head of bed elevated. A review of the 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/05/23, revealed that the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3 out of 15 possible points, indicating severe cognitive impairment. He was dependent on staff for toileting, bed mobility and hygiene care. The resident was dependent on a feeding tube for nutritional support. 105547 Page 3 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Nutrition Note dated 12/11/23, indicated that the resident was reviewed for a quarterly assessment. He was tolerating tube feedings well and his weight was trending down some. Recommended increasing the tube feeding regimen to help combat further weight loss. Continue NPO. Increase tube feeding to Jevity 1.5 70 ml/hr x 20 hrs 2 pm - 10 am, 200 ml free water flush QID (four times daily) to provide 1400 ml formula, 2100 kcal, 89 grams of protein and 1864 ml free water meeting 100% kcal, 95 % protein and 99% free water needs. The tube feeding regime meets 90-110% estimated nutritional needs. A review of the Nursing Progress Notes for 12/12/23-12/19/23 revealed that the resident was receiving Jevity 1.5 at 60 ml/hr. (Copies obtained) A review of the resident's recorded weights revealed that the resident weighed 126.2 pounds on 9/5/23 and 117.0 on 12/6/23. In an interview on 12/20/23 at 9:45 am, LPN D stated she was covering for the unit manager. When asked about Resident #33's enteral feeding orders, she stated when the dietician made any changes, he updated the new orders in the computer and also notified the nurses of the new changes. She confirmed that Resident #33's orders for tube feedings were changed on 12/11/23 to Jevity 1.5 Cal at 70 ml/hr and the nurses had documented providing the feeding at 60 ml/hr. She added that the nurse's night note had adjusted the pump setting. A review of the facility's policy and procedure titled: Enteral Nutrition (Revised January 2014), revealed the following: The policy statement indicated that adequate nutritional support through enteral feeding will be provided to residents as ordered. The policy implementation and interpretation read: 3. The Dietitian, with input from the physician and Nurse will: a. Estimate calorie, protein, nutrient ad fluid needs; b. Determine whether the resident's current intake is adequate to meet his or her nutritional needs; c. Recommend special food formulation and d. Calculate fluid to be provided ( beyond free fluid in formula). 4 . Enteral nutrition will be ordered by the physician based on the recommendation of the Dietitian. If a feeding tube is ordered, the physician and interdisciplinary team will document why enteral nutrition is medically necessary. 5 . Some examples of possible benefits of using a feeding tube include : a. Addressing malnutrition and hydration c. 105547 Page 4 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

F 0693 Allowing a resident to gain strength that may allow him or her to return to oral feeding. Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few 105547 Page 5 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

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. The facility failed to ensure that the dietary staff practiced the proper procedures for hand hygiene, disposable glove use, food storage and proper sanitation practices in the kitchen. Hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. This had the potential to impact any resident receiving food from the facility. The findings include: During the first tour of the facility kitchen on 12/18/2023 at 10:12 AM one of the reach-in freezers located in a back hallway of the kitchen, had large blocks of frozen ice built up on the inside of the unit covering packages of food products. The walk-in cooler had black biological growth and food debris on the shelving where food was stored. Cheese wrapped in plastic food storage wrap had black magic marker dates written on the plastic that was not legible. Sandwiches were stored in a plastic bag with no date mark. The floor of the cooler had dirt, food particle debris and food wrappers. The walk-in freezer had food stored on the floor. The floor had dark black dirt, food debris, paper and cardboard food containers particles on the floor. The gaskets on the reach -in coolers and freezers had a black build up of biological substance in the creases. The ceiling and walls in the dry storage room had a buildup of dust debris. Previously unsealed packages of sugar product were stored in plastic resealable bags that were left open with no date mark. There was a buildup of dust covering the drink machine filter. The dispensers were sitting in a red liquid in a plastic container on the counter top. The Certified Dietary Manager (CDM) pulled them up out of the liquid and stated they need to be allowed to drip. The sanitizer buckets tested at 500+ parts per million (ppm) quaternary ammonium. The CDM stated that it was a toxic level and instructed the staff to change the water out. The kitchen walls and floors had a buildup of dark brown grease, dust and food debris. There was a buildup of grease and debris under the fryer and the stove. The walls of the dish room were covered with a buildup of black food debris and water that had run down the wall and dried. There was a plastic bowl with no handle down in the bulk flour bin. The can opener had a buildup food debris. There were missing tiles from the floor of the dish room and the kitchen wall (Photographic evidence obtained). During a tour of the kitchen on 12/19/2023 at 9:15 AM, the walls and floors of the kitchen and the coolers had not been cleaned. The shelves of the walk-in cooler had not been cleaned. The gaskets had not been cleaned. There was a buildup of grease and debris under the fryer and the stove (Photographic evidence obtained). During a tour of the kitchen on 12/20/2023 at 11:15 AM Employee H, Cook, Employee E, Cook, and Employee G, dietary aide, Employee F and other unsampled dietary staff were present. The walls were dirty under dish machine and under ware washing sink. Preparation tables were dirty with food debris under the drink machines and under preparation table next to the fryer. The table was rusting. The tiles under the warewashing sink had little to no grout. Food debris and dirt were stuck between the tiles. Broken tiles were observed in the kitchen. Food debris, grease and dirt was observed under the stove and fryer line (Photographic evidence obtained). Observed new ice beginning to form on the 105547 Page 6 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

F 0812 inside of the reach in freezer in the back hallway of the kitchen. Level of Harm - Minimal harm or potential for actual harm The tray line was set up and the meal service started at 11:48 AM. Employee H, Cook, started plating food. At 11:52 AM she changed gloves without washing her hands. She then continued to plate food. Residents Affected - Many At 12:07 PM Employee E, Cook, came over to the tray line and replaced Employee H. He began plating the food. At 12:10 PM he changed gloves without washing his hands. He then continued to plate food. During an interview with the CDM on 12/20/2023 at 12:15 PM. She stated she emptied out the two reach in freezers that were leaking water inside and the ice had built up. She stated that she thinks the drip pans from the condensers were clogged and that was what was causing them to freeze up inside. She was informed of the observation of the ice beginning to form on the inside of the reach in freezer in the back hallway of the kitchen. She indicated she was unaware of the new ice formation. She was informed of the staff changing gloves without washing their hands. She stated that they should have washed their hands after taking the soiled gloves off and donning new gloves. They both have been trained to wash their hands between glove changes. She confirmed that the kitchen only has one hand washing sink and it is not near the tray line. She stated that it is hard for the cook to stop what they are doing and go wash their hands. The sink is not conveniently located. During a tour of the kitchen on 12/21/2023 the walls and floors of the kitchen, the walk-in cooler and freezer had not been cleaned. The shelves of the walk-in cooler had not been cleaned. The gaskets on the coolers had not been cleaned. The buildup of grease and debris under the fryer and the stove had not been cleaned. Food products were stored on the floor of the freezer (Photographic evidence obtained). Review of the facility dietary cleaning schedules provided revealed the last week deep cleaning had been initialed as being done was 11/12/2023 through 11/18/2023 (Copy obtained). During an interview with the CDM on 12/21/2023 at 2:40 PM she stated that she was on leave for a while and things just did not get done. and her morning cook was out for a while and she had to cook the breakfast and lunch meals herself. Review of the staff in-services for hand hygiene revealed Employee H received training on 12/12/2022. Employee E received training on 09/27/2023 (Copy obtained). Review of the facility policy and procedure titled Hand Hygiene revealed it read: Handwashing/hand hygiene shall be regarded by this Center as a means of preventing the spread of infections. 1. All personnel shall follow tour established handwashing procedures to prevent the spread of invention and disease to other personnel, patients and visitors. 2. Associates must perform appropriate handwashing procedures under the following conditions: j. after removing gloves. 3. The use of gloves does not replace handwashing (Copy obtained). References: Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Reference: United States Food and Drug Administration Food Code 2022. Sections 3-305.11 Food Storage 105547 Page 7 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

F 0812 https://www.fda.gov/food/fda-food-code/food-code-2022 Level of Harm - Minimal harm or potential for actual harm FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. Residents Affected - Many Reference: United States Food and Drug Administration Food Code 2022, Sections 2-301.13 Special Handwash Procedures. 2-301.14 When to Wash. (A-I). Page 79. U.S. Department of Health and Human Services Public Health Service, Food and Drug Administration. https://www.fda.gov/food/fda-food-code/food-code-2022 . 105547 Page 8 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on kitchen food service observations, staff interviews, and facility document review, the facility failed to ensure that all mechanical equipment in the kitchen was maintained in a safe operating condition. This failure had the potential to impact any resident receiving food from the facility's kitchen. Residents Affected - Many The findings include: During the first tour of the facility kitchen on 12/18/2023 at 10:12 AM the Certified Dietary Manager (CDM) participated in the tour. Dietary Aide F was observed operating the dish machine. The wash cycle temperature was 110 degrees Fahrenheit ('F). Three loads were observed and the temperature did not change. The chlorine bleach sanitizer level was tested and resulted in 100 parts per million (ppm). Employee F did not know the wash cycle temperature was only 110'F. She stated that it was 130'F when she started washing dishes this morning. She stated that it was supposed to be 120'F or higher. Review of the dish machine temperature log revealed the wash cycle had been recorded to be 130'F and the wash cycle was recorded to be 130'F. During a tour of the kitchen on 12/19/2023 at 9:15 AM the dish machine was being operated by Employee G. The wash cycle temperature was 118'F and the rinse cycle temperature was 120'F on the first load observed. The wash cycle temperature was 110'F and the rinse cycle temperature was 128'F on the second load. The chlorine bleach sanitizer was tested and the result was 100 ppm. Review of the manufacturer's specifications revealed the wash cycle temperature is to be 120'F at a minimum. The chlorine bleach sanitizer should be 50 ppm at a minimum. Detergent Control. Water temperature is an important factor in ensuring the machine functions properly, and the machine's data plate details what the minimum temperatures must be for the incoming water supply, the wash tank, and the rinse tank. If minimum requirements are not met, ware might not be clean or sanitized. Preventative Maintenance: 1. Ensure that the water temperatures match those listed on the machine data plate. Water temperature could be too low for a variety of reasons (Copy obtained). During an interview on 12/20/2023 08:38 AM with the Administrator. He stated that he was made aware of the dish machine not working properly. He was informed of the failure of the machine to reach 120'F during the wash cycle. He stated he did not know that the wash cycle was not reaching the minimum temperature. He stated that the facility does not have control of the settings on the dish machine. He stated that he would make sure the contracted provider of maintenance would be called to come and fix the machine. During the lunch meal service at 11:55 AM the contracted provider of maintenance for the dish machine was observed in the dish room working on the dish machine. During a tour of the kitchen on 12/21/2023 at 9:05 AM Employee G was observed loading the dish machine. The dish machine wash cycle at 110'F, the rinse cycle was 112'F. The CDM opened the machine and looked inside. She stated that there was no water in the machine. She looked down in the well and pulled out a plastic sippy cup lid and put in in the dish rack to be re-washed. She stated that the lid had been blocking the water flow inside the machine. She shut the doors and let the machine run again. She ran the machine through 4 cycles. Each time the wash temperature only reached 110'F and the rinse cycle only reached 112'F. She confirmed the temperatures. She stated that the contracted maintenance provider was called to fix the machine yesterday, 12/20/2023 and they came and conducted 105547 Page 9 of 10 105547 12/21/2023 Flagler Health and Rehabilitation Center 300 Dr Carter Boulevard Bunnell, FL 32110

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many maintenance on the machine. She observed the machine while they were at the facility and again after they left and the wash cycle and rinse cycle were above 120'F. She stated she does not know why the temperatures are so low again today. During an interview with the Maintenance Director on 11/21/2023 at 9:20 AM. He stated he raised the temperature on the water heater for the kitchen yesterday, 12/20/2023, by 5'F making the water temperature 150'F. He checked the machine again after that and the wash and rinse cycles were both above 120'F. He stated he does not understand why the temperature is so low. He suggested using a thermometer to test the temperature of the water in the machine. The CDM went and retrieved a digital thermometer and tested the water twice. The first reading was 105'F and the second one was 108'F (Photographic evidence obtained). The Maintenance Director gave the Administrator an infrared thermometer to test the water. He tested the water in the machine and the reading was 105'F. Review of the facility water temperature log dated 12/20//2023 revealed a handwritten note at the bottom that read: Turned hot water heater up 5 degrees on 12/20/2023 (kitchen). Review of the contracted provider for dish machine maintenance receipt for service dated 12/21/2023 revealed it read: Issue (s) Called in for Dishmachine sanitizer to high, testing at 1:00 PM. Work Performed: Rep adjusted dish machine sanitizer to 75 ppm (range is 50pm-100pm) Sanitizer is with in range. Checked Dishmachine temperature, wash and rinse are both at 120 (minimum temp is 120) temperatures with in range. Recommendations/Comments: 1. Test both sanitizers daily. 2. To insure proper washing and rinsing temperatures are with in range please run the water until the Dishmachine water reaches 120. Reference: The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. When chemical sanitizers are used, specific minimum temperatures must be met because the effectiveness of chemical sanitizers is directly affected by the temperature of the solution. FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines Annex 3 - C. Section 4-204.115 Warewashing Machines, Temperature Measuring Devices. pages 165, 170-171. https://www.fda.gov/food/fda-food-code/food-code-2022 . 105547 Page 10 of 10