Inspection·November 17, 2022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to implement an effective infection control program, by failing to 1) Ensure staff followed infection control guidelines for hand hygiene during wound care for one (Resident #26) of two residents sampled for pressure ulcers, 2) Prevent cross contamination during catheter care for one (Resident #17) of one resident sampled for catheter care, 3) Ensure that the infection control committee was fully involved in the infection control program by offering feedback on infection control concerns during monthly meetings, and 4) Investigate an increase in urinary tract infections for one of two months available for review (October 2022). Residents Affected - Few The findings include: 1. On 11/16/22 at 11:28 AM, an observation was made of Licensed Practical Nurse (LPN) A performing wound care for Resident #26. LPN A performed hand hygiene, applied clean gloves, removed the soiled dressing, removed her gloves, washed her hands, applied clean gloves, and then cleaned the wound. LPN A then applied the clean dressing without changing gloves or washing hands. LPN A proceeded to apply barrier cream to the peri-area without changing gloves or washing hands. On 11/16/22 at 11:50 AM, an interview was conducted with LPN A. When asked if LPN A changed her gloves and washed her hands between cleaning the wound and applying the clean dressing, she stated, No, I did not. When asked if LPN A changed her gloves and washed her hands after applying the dressing and applying barrier cream to the peri-area, she replied, No, I did not. LPN A confirmed that this could be an infection control issue. On 11/16/22 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated her expectation of the nurses was that they should wash their hands, apply gloves and remove the soiled dressing, then wash their hands and apply gloves, clean the wound from the inside out, wash their hands, apply gloves, and apply a dressing as per the facility's policy. On 11/16/22, a review was conducted of the facility's policy titled Clean Dressing Change, last revised on 11/28/2017, which revealed under Purpose: To ensure the licensed nurse or therapist completes dressing change in accordance with State and Federal Regulations, and National Guidelines. Under Procedure: 23. Cleanse wound as ordered with single outward strokes and using separate gauze for each cleansing wipe. 24. Use dry gauze or other ordered supply to pat the wound dry, as needed. 25. Discard any used gauze for cleaning/drying in resident's trash, as needed. 26. Remove gloves. 27. Hand hygiene. 28. [NAME] gloves. 29. Apply clean dressing as ordered and ensure dressing is dated. 30. Remove gloves. 31. Hand hygiene. 32. Hand hygiene. etc. 2. On 11/16/22 at 4:00 PM, an observation was made of Certified Nursing Assistant (CNA) D providing catheter care to Resident #17 with the assistance of CNA E. At the start of the observation, Resident #17's brief was loosened and tucked under his left side. CNAs D and E assisted the resident onto his right side. The brief was noted to be slightly soiled with a dark brown substance. CNA D instructed CNA E to get a new brief for the resident. Upon returning to the bed, CNA E proceeded to place the new brief on top of the soiled brief without attempting to remove the old brief. CNA E then informed CNA D to remove the old brief. The old brief was removed, however the new brief was left under the resident. At this time, the resident was rolled onto his back and CNA D left to gather supplies, leaving the resident uncovered with his genitals exposed. CNA D returned to the bedside with a basin of soapy water, two wash cloths and a package of disposable wipes. He then dampened the first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105548 If continuation sheet Page 2 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moultrie Creek Nursing and Rehab Center 200 Mariner Health Way Saint Augustine, FL 32086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few washcloth in the basin and began to clean the catheter tubing in a back-and-forth motion from the tip of the penis down the tubing then back up the tubing toward the penis. CNA D discarded the cloth, changed his gloves, dampened the second wash cloth in the basin and washed the resident's genital area starting at the pubic bone, down between his right thigh and the right testicle, across the pubic bone, down between the left thigh and the left testicle, and then down the penis shaft and over the head of this penis. CNA D then wiped down the catheter tubing away from the penis. At no point did CNA D change the cloth or use a different area of the cloth. On 11/16/22 at 4:20 PM, an interview was conducted with CNA D. He stated during catheter care, you wash the head of the penis and the shaft, and then down the tubing starting with the cleanest field possible. He further stated that you start at the top and work your way down the penis. He then verified that the new brief was placed on top of the soiled brief and should have been changed out. On 11/17/22 at 9:00 AM, an interview was conducted with the Director of Nursing (DON), who stated that it was her expectation that during catheter care the staff member would clean down the tubing away from the penis and use a new cloth or another area of the washcloth to clean the genitals. She stated it was never okay to start at the top and work your way down the penis. The DON provided a copy of an in-service dated 9/2/22 titled Peri Care/E-Coli/UTI Prevention. CNA D signed as having attended. Attached to the sign-in sheet was a copy of the Perineal and Catheter Care training offered in the facility's online education program. Under the section titled Catheter Care it stated, Start by cleansing around the urethral meatus, which is the catheter's point of insertion, using a downward motion. Repeat this process to clean the entire perineum as described above. Remember to use a clean part of the washcloth with each stroke. Using a clean washcloth, cleanse the catheter itself starting at the urethral meatus working your way down the catheter about four inches or further if visibly soiled. Under the section titled Cleansing the Genital Area for males it stated, Grasp the penis and clean the tip using a circular motion starting at the urethral opening and working outward. Repeat until the area is clean moving down the shaft of the penis to the scrotum and inner thighs. Remember to use a clean part of the washcloth for each stroke to prevent contamination. A review of the policy SHCRC20007.06, Indwelling Catheter Care, last revised on 3/26/2019, stated on page 2, item #11, Clean by wiping away from the urinary meatus and not towards the urinary meatus. 3. On 11/17/22 at 9:00 AM, an interview was conducted with the DON, during which she stated that the infection preventionist had been out for several weeks due to an injury, and that she had been working in the role until his return a few weeks ago. She stated she had identified an increase in urinary tract infections (UTI) for the Month of October and felt this was due to the Medical Director ordering Urinalysis (UA) on any resident noted to have confusion. She stated she spoke with him a few nights ago about the need to have more than confusion to order a UA. She was asked if she had done any staff education as a result of the increase or if the infection control committee had made other recommendations. She stated the infection control committee met monthly at the beginning of each month and was made up of the department heads and a nurse and a CNA she pulled off the floor. She stated she only reported the infection rates for the previous month, and that she did all the talking and they just listen to me. She stated she had conducted an in-service in September for UTI Prevention and felt that the increase in UTIs for October was skewed, because everyone would test positive for a UTI if they were to have a UA every time they got confused. She stated the issue was systemic and not the fault of staff or care concerns. She stated she had not conducted audits of staff performing catheter or perineal care. She also stated that she was behind in the documentation related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105548 If continuation sheet Page 3 of 4 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105548 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moultrie Creek Nursing and Rehab Center 200 Mariner Health Way Saint Augustine, FL 32086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tracking and trending of infections in the facility and that the data was available but was not always mapped out. She handed the surveyor two maps of the facility for what she stated were September and November. The maps identified each resident room and any room with an identified infection was highlighted using a color system on a key in the bottom left-hand corner of the documents. UTIs were highlighted in pink. Neither document had a month written on it to identify what month was being mapped out. When asked how she could tell what month the maps represented, she stated she would compare the map to the Monthly Infection Prevention & Control Summary Report. It was then when she realized the map she reported for September was actually for October, and she then wrote the month on the bottom of the map. She reported that she did not have a map for September but could make one quickly if needed. At this time, the DON provided a copy of the Monthly Infection Prevention & Control Summary Report for October 2022, which stated that the UTI (Urinary Tract Infection) rate for the facility was 14.2% in October, up from 2.1% in September, 2.8% for August and 2% in July. A review of the facility floor map dated for October for Healthcare Acquired Infections (HAI) revealed that of the 9 UTIs identified in October, 7 were on the south hall where the observation of catheter care had been conducted the previous afternoon in which concerns had been identified. When shown the map that identified increased concerns on the south hall, she stated, I did not catch that and I take full responsibility for that. A review of the policy Infection Prevention and Control Program, last revised in October 2018, revealed it read that the Infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Under item 11. Prevention of Infection (3) educating staff and ensuring that they adhere to proper techniques and procedures. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105548 If continuation sheet Page 4 of 4