Health inspection·April 3, 2024

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #7 Residents Affected - Few On 4/2/24 a record review was conducted for resident #7 who had diagnoses of Diabetes Type II (non-insulin dependent), Anxiety disorder, atrial fibrillation (heart dysrhythmia), depression, altered mental status, and hypertension (high blood pressure). Resident #7 was prescribed the following medications: Eliquis (a medication used to thin blood and prevent blood clots), Prozac (a drug used for depression), Trazadone (a drug used for depression and trouble sleeping), Ozempic (a drug used to lower blood sugar), Glipizide (a drug used to lower blood sugar), Tresiba (a drug used to lower blood sugar), Lasix (a drug used to excrete excess fluid), and Ativan (a drug used for anxiety). A review of resident #7's care plan dated 4/2/24 revealed the resident did not have care plans addressing medication monitoring and side effects. On 4/2/24 at approximately 1:09 PM, an interview was conducted with the Director of Nursing (DON) regarding care plans for resident #7. The DON indicated they have had recent issues with the care plans not being adequate and the facility is working on the problem. The DON indicated the facility has hired a new coordinator for the development of care plans. Base on staff interview and record reviews, the facility failed to develop care plans for 2 of 5 residents sampled for unnecessary medications, Resident #7 and 41. The findings include: Resident # 41 Electronic Medical record review reveals resident #41 was re-admitted to the facility on [DATE] with a previous admission in October 2023. Medical diagnosis and history include Cerebral infarction (stroke), type 2 diabetes and chronic Atrial Fibrillation (AFIB-an irregular heartbeat). admission orders revealed resident receiving Insulin Glargine and Insulin Lispro (injectable medications used to lower blood glucose levels) for type 2 diabetes. Resident is also receiving Eliquis (a blood thinner used to prevent blood clots). A review of the initial care plan, dated 1/25/2024 for resident #41 did not include a care plan for Diabetes or use of an Anticoagulant. On 04/03/24 at approximately 12:35 PM an interview with the care plan coordinator, registered nurse, who indicated that the resident should have a care plan for anticoagulants, if taking one, and a diabetic care plan if the resident is diabetic. The care plan coordinator confirmed resident #41 care plan did not include being diabetic or use of an anticoagulant. The care plan coordinator further stated, she would add these care plans. Page 1 of 7 105552 105552 04/03/2024 Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570

F 0656 Level of Harm - Minimal harm or potential for actual harm On 04/03/2024 at approximately 2:49 PM in an interview was conducted with the director of nursing (DON) and the regional nursing director. The surveyor asked, is a care plan for Diabetes and anticoagulant use expected when a resident is receiving medications for diabetes and an anticoagulant? DON indicated, yes, a care plan is expected for both. The DON confirmed care plans for anticoagulant use and diabetes were not present for resident #41. Residents Affected - Few 105552 Page 2 of 7 105552 04/03/2024 Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility failed to develop and implement a process regarding turning and repositioning to prevent the development of pressure ulcers for 1 of 3 residents sampled for facility acquired pressure ulcers, resident #49. Residents Affected - Few The findings include: On 4/1/2024 at 2:02 PM an interview was conducted with resident #49. Resident #49 indicated he had a bed sore on his bottom for which he was receiving wound care every day. The resident indicated he was dependent upon staff for mobility, and was unable to turn or reposition himself when he arrived at the facility back in February. The resident indicated he does not recall any staff turning or repositioning him in bed or a chair during the time he was unable to reposition or turn himself. The resident indicated the facility ordered an air mattress for him after he developed a pressure ulcer. On 4/3/2024 at 9:45 AM a wound care observation was made of resident #49 with Registered Nurse A (RN A, Wound Care Nurse). The wound was observed to be an oval size stage 2 (an open wound affecting both the top and bottom layers of the skin) pressure ulcer of the coccyx (tailbone) area with a small amount of granulated tissue in the center of the wound. The wound appeared to be the circumference of a half dollar. On 4/3/2024 at 9:58 AM an interview was conducted with RN A immediately following the wound care observation. RN A was asked if she thought the residents are being turned and repositioned often enough to prevent and heal pressure ulcers. RN A indicated the Certified Nursing Assistants (CNAs) have gotten better about repositioning the residents, but there needs to be a system in place to remind the CNAs to turn and reposition the residents to promote healing of pressure ulcers and prevent pressure ulcers. RN A confirmed the pressure ulcer was facility acquired (developed after admission to the facility) On 4/3/2024 at 1:26 PM a telephone interview was conducted with Advanced Practice Registered Nurse (APRN) C regarding facility acquired pressure wounds and Resident #49. APRN C indicated she was routinely treating and assessing resident #49's wound. APRN C indicated she educates the staff and residents regarding offloading pressure wounds, changing positions, pressure relief and wound care in general. APRN C indicated she was not aware if the facility has a policy for turning and repositioning immobile dependent residents. On 4/3/2024 a medical record review was conducted for resident #49. The record review revealed resident #49 was admitted to the facility on [DATE] with diagnoses to include MRSA (Methicillin-resistant Staphylococcus aureus), Sepsis (blood poisoning), acute respiratory failure, exacerbation of Chronic obstructive pulmonary disease (COPD), malnutrition, Discitis of thoracic region (a rare but serious infection of the discs that cushion the spine's vertebrae), and limited mobility. The resident's admission history, initial comprehensive assessment and Minimum Data Set Assessment section M dated 2/20/24 were reviewed and revealed the resident did not have a coccyx pressure ulcer upon admission to the facility on 2/16/2024. A review of resident #49's progress notes indicate the coccyx wound was discovered on 2/25/2024, 9 days after admission to the facility on 2/16/2024. A review of resident #49's physician orders indicated resident #49 had current wound care ordered for the coccyx pressure ulcer. The Baseline Plan of Care dated 2/16/24 indicated resident #49 was at risk for skin breakdown. Interventions marked with a check mark included inspecting the skin daily and food and fluid to 105552 Page 3 of 7 105552 04/03/2024 Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few promote nutrition. The section stating encourage, remind, assist in position change regularly and frequently was not checked, and nothing was circled to indicate level of assistance needed. The Activities of Daily living indicated that Resident #49 required extensive assistance with bathing, dressing, grooming and toileting. The Braden Scale (pressure ulcer risk assessment) dated 2/16/24 indicated Resident #49 was scored at 16 indicating At Risk for skin breakdown. The form indicated that resident #49 has probably inadequate nutrition, had very limited mobility, was chairfast and had a potential problem with friction and shear. 105552 Page 4 of 7 105552 04/03/2024 Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on staff interviews, record review and policy review, the facility failed to ensure resident's are free from unnecessary psychotropic (medications that affect behaviors) medications for 1 of 5 residents sampled for unnecessary medications. (Resident # 28). The findings include: A review was conducted of the Electronic Medical Record for resident #28, which revealed an order for Lorazepam Oral tablet (a medication used to treat anxiety) 1 milligram (MG) tablet twice a day as needed for anxiety dated 3/20/24. Further review of the medication order revealed no stop date for the medication. On 4/3/24 at approximately 1:37 PM, an interview was conducted with the Director of Nursing (DON) who confirmed that the order for Lorazepam for resident #28 had no stop date. The DON indicated that it is her expectation for all 'as needed' psychotropic medications to have a 14 day stop date at which time the physician should review the medication for continuation or discontinue and document the reasoning for the decision. Review of facility policy titled Pharmacy services: Psychoactive meds revealed: In accordance with State and Federal Guidelines, revised regulation §483.45(e) Psychotropic Drugs which states that based on a comprehensive assessment of a resident, the facility must ensure that: -Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. -Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated. -Residents do not receive PRN psychotropic drugs unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. -PRN (as needed) orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then he or she should document the rationale in the resident's medical record and indicate the duration for the PRN order. 105552 Page 5 of 7 105552 04/03/2024 Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and policy review, the facility failed to demonstrate a water management plan had been implemented for the prevention and surveillance of legionella (a water born virus). The facility failed to follow infection control practices for 2 of 55 residents observed during initial tour for nebulizer equipment (machine that provides breathing treatments for respiratory compromised residents), Resident #202 and #252. Residents Affected - Few The findings include: On 4/3/24 at approximately 3:45 PM, an interview was conducted with the Maintenance Director concerning the water management plan. The Maintenance Director indicated that he did not have a book for monitoring for legionella, or any water temperature monitoring completed weekly for this year per facility plan. The Maintenance Director went on to state that he has gotten behind due to being the only maintenance worker for the building. On 4/3/24 at approximately 4:00 PM, an interview was conducted with the Administrator, who indicated that the monitoring for legionella in his experience has always been completed by the Maintenance director and kept with the emergency preparedness plan for testing annually. Stated he was not sure when the last time the facility was tested but would see what he could find. On 4/3/24 at approximately 4:30 PM a follow up interview was conducted with the Administrator, who indicated he was unable to find the last test for legionella for the facility and had attempted to contact his predecessor to see if it was located somewhere he was not aware of and has not received a reply at this time. Review of the facility policy titled: Administrators-Water Management Plan revealed: A water management plan will be implemented to identify and manage conditions that support the growth and spread of legionella. The plan includes a facility risk assessment along with control measures and monitoring. Legionella is found naturally in [NAME] environments, like lakes and streams but generally the low amounts in [NAME] do not lead to disease. Legionella can become a health problem in building water systems. To pose a health risk, legionella first has to grow and has to be aerosolized so that people breathe in small, contaminated water droplets. Procedure: A. A team will be formed to coordinate activities for the water management effort. B. The team will describe the facility water system. C. The team will conduct facility risk assessments. 105552 Page 6 of 7 105552 04/03/2024 Sandy Ridge Center for Rehabilitation and Healing 5360 Glover Lane Milton, FL 32570

F 0880 D. Level of Harm - Minimal harm or potential for actual harm Control measures will be implemented and monitored Resident #202 Residents Affected - Few On 4/1/2024 at 1:20 PM during the initial pool process an observation was made of resident #202's room. A nebulizer mask was observed on the resident's bedside table. On 4/2/2024 at 9:38 AM an observation was made of resident #202's room. A nebulizer mask was observed on the resident's bedside table with tubing connected to the nebulizer machine. On 4/2/2024 at 12:44 PM an interview was conducted with resident #202 who is alert and oriented regarding the nebulizer mask. The resident indicated when his nebulizer treatment is complete, he places the mask on the bedside table. The resident indicated he has not seen the staff place the nebulizer mask in a bag. The resident indicated the nebulizer mask always stays out on his bedside table. On 4/3/2024 at 11:35 AM an interview was conducted with Infection Preventionist regarding the storage of nebulizer masks when not in use. The Infection Preventionist indicated the nebulizer mask should be placed in a plastic bag after each use and stored in the plastic bag until the next use. Resident #252 On 04/01/24 at 03:04 PM an observation of Resident #252 room was conducted. The nebulizer machine and mask are observed sitting on the nightstand, mask is not inside a plastic bag. On 04/02/24 at 10:01 AM The nebulizer machine and mask are seen sitting on nightstand in the room of resident #252, they are not covered with plastic bag. On 04/02/24 at 02:35 PM an observation of the room of resident #252 was conducted. The nebulizer machine and mask are seen on the nightstand, not in plastic bag. On 04/03/24 at 09:04 AM Resident #252 is observed lying in bed, nebulizer machine and mask are seen on the nightstand, not in plastic bag. (Photographic evidence obtained). On 04/03/24 at approximately 11:01 AM an interview conducted with Staff (G), a Registered nurse (RN), indicated that the nebulizer mask should be covered in a plastic bag when not in use. The RN acknowledged that this nebulizer mask has not been in a plastic bag. On 04/03/2024 at approximately 2:49 PM an interview was conducted with the Director of Nursing (DON) and regional nursing director. The surveyor asked, what is the policy for storage of respiratory equipment such as nebulizer masks while not in use? The DON indicated, this equipment should be stored in a bag while not in use. 105552 Page 7 of 7