Health inspection·February 24, 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 observations, interview and record review the facility failed to maintain resident rooms in a safe and clean manner for 2 of 39 (#62, #91) sampled residents. Residents Affected - Few Findings included: 1. Observations on 2/21/21 at 10:26 AM of Resident #62's room/bathroom during the initial tour of the facility revealed the following: -Call light string in Resident #62's bathroom was wrapped around the grab bar located next to the toilet. -1 of 2 portable oxygen tanks was noted to be freely standing in the corner of the resident's room unsecured. -2 pieces of stainless steel cutlery and 3 pieces of disposable cutlery were stored in the toothbrush holder and on the soap dispenser. -A regular ceramic plate covered by another plate was stored on the side of the bathtub, next to the garbage. -A soiled washcloth was hanging on the grab bar located in the resident's bathroom next to the toilet. -Ceramic floor around the toilet located in Resident #62's bathroom was soiled with a brown substance. 2. Observations on 2/21/21 at 10:46 AM of Resident #91's room revealed that there was an oxygen tank sitting in a tank holder. The holder wheel was not securely in place and did not provide secured placement for the oxygen tank. 3. Interview on 2/24/21 at 8:53 AM with the NHA revealed that the oxygen tanks should not be stored in resident rooms and was made aware of them during the life safety inspection. He reported that the resident rooms should be maintained by housekeeping. He reported that he will get housekeeping to Resident #62's room to be cleaned, and that staff will be in-serviced. Interview on 2/24/21 at 10:51 AM with the Director of Nursing (DON) revealed that the residents' oxygen tanks should always be secured. Page 1 of 11 105553 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0584 Photographic evidence was obtained. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105553 Page 2 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

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 provide respiratory care in accordance with standards of practice and the comprehensive plan of care for two (#62 and #91) sampled residents out of 17 facility residents receiving respiratory treatment. Residents Affected - Few Findings included: 1. Observation of Resident #62's 2/21/21 at 10:26 AM revealed that his oxygen tubing was lying on the floor. The resident was noted to be able to sit at his room door and go into his bathroom while the oxygen tubing was still attached to both him and the tank. The tubing was noted to drag across the floor and wheeled over by the resident's wheelchair as he maneuvered around his room. (Photographic evidence obtained). Observations of Resident #62's room on 2/23/21 at 12:50 PM revealed the resident sitting in his wheelchair in the doorway of his room. The residents oxygen concentrator was on the far side of the room close to the window and the oxygen tubing was noted to be stretched across the room . At this time the resident was observed to back up into his room running over the oxygen tubing that was on the floor and maneuvered around his room with the oxygen tubing noted to be dragging across the floor. At this time, this surveyor pointed to the oxygen tubing on the floor and asked why it was on the floor, the resident responded it's fine. It's always like that. Everything is fine. Observations on 2/24/21 at 8:24 AM of Resident #62 revealed that the resident was noted in his bathroom with his oxygen tubing stretched from his bed, under the bathroom door and resting on the floor of the bathroom. Review of the resident's current physician orders revealed that he has orders that include, Oxygen at 2 LPM [liters per minute] via NC [nasal cannula] continuously for SOB [shortness of breath]; Change Oxygen tubing & set up weekly; Clean oxygen filter weekly Review of Resident #62's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that this resident had a Brief Interview of Mental Status (BIMS) score of 11 (indicating moderate cognitive impairment). He had diagnoses of asthma (Chronic Obstructive Pulmonary Disease/COPD) or chronic lung disease, bronchiectasis with acute lower respiratory infection, and acute and chronic respiratory failure with hypoxia. Review of the resident's care plans revealed a care plan to address Oxygen related to risk of SOB with oxygen therapy dated 11/21/19 with interventions that included Keep exterior of respiratory equipment clean dated 11/21/19. Interview on 2/24/21 at 8:53 AM with the Nursing Home Administrator (NHA) revealed that he will need to get nursing involved to see if the resident will allow any type of alternative to receiving oxygen when he is out of bed. Interview on 2/24/21 at 10:51 AM with the Director of Nursing (DON) revealed that the resident's oxygen tubing should not be on the floor. 2. Observations of Resident #91's room on 2/21/21 at 10:46 AM revealed that the resident's oxygen 105553 Page 3 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tubing was noted to be lying on the floor. Closer inspection of Resident #91's room revealed that the resident had an over bed table, which contained an oxygen mask that was un-bagged and unlabeled. Observation of the resident's room on 2/23/21 at 1:10 PM revealed that the oxygen tubing was appropriately placed and labeled and the oxygen mask was noted on the over bed table in a clear bag dated 2/23/21. Interview with the resident's family member who was present in the room at the time revealed that the oxygen tubing had been on the floor and the oxygen mask was on the table with no bag, but she reported this to the facility and they changed everything. Review of the resident's current physician orders revealed orders to include: -Mode: AVAP-AE Tidal volume: 450ml Max pressure 30 cmH2O EPAP min/Max: 4/15 cm H2O PS min/Max 6/26CM H2O (Bi-Pap) breath rate auto- every night shift for chronic hypercapric respiratory failure. Patient needs assistance applying mask, turning machine on/off and removing mask everyday. Wear as tolerated nightly and as needed for chronic hypercapric respiratory failure -auto pap: oxygen to bleed into machine @ 2 L [liters] as resident tolerates -Clean oxygen filter weekly every evening shift every Sunday -Change tubing every week every evening shift every Sunday label with date -Change oxygen tubing and set-up weekly every evening shift every Sunday label with date -Oxygen at 2 LPM via nasal cannula continuously for COPD Review of the admission MDS dated [DATE] revealed that the resident had diagnoses of Asthma (COPD) or chronic lung disease and acute respiratory failure unspecified with hypoxia or hypercapnia. The MDS indicated that the resident received oxygen while in the facility prior to admission and after admission. Review of the resident's care plan dated 2/4/21, with a revision date of 2/9/21, related to oxygen therapy. Interventions included 2/4/21 Keep exterior of respiratory equipment clean. On 02/24/21 at 10:51 AM, the DON revealed that the resident's oxygen mask should be in a bag labeled with a date and time. She reported that the oxygen tubing should not be on the floor. 105553 Page 4 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

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 did not maintain the kitchen in a safe and sanitary manner related to kitchen staff failing to use beard guards, failed to ensure that the range hood was free from dust and cobwebs, failed to ensure that the dish machine was free of white build-up, and failed to ensure that the walls were free from black bio-growth. Findings included: Observations during the initial tour of the kitchen on 2/21/21 at 9:34 AM revealed that the kitchen housed a range hood which was located over the stove and steam oven. Closer observation of the range hood revealed that the light cages were covered in dust particles. In addition, cobwebs were noted on the piping attached to the range hood. Continued observations at this time revealed that there were 2 large baking trays which contained dinner rolls stored on top of the steam oven and under the range hood. The trays of dinner rolls were not covered to protect the food items from the dust noted on the light cages of the range hood. Interview at the time of observation with Staff I, Cook, revealed that she was unsure as to when the range hood was last cleaned. Observations of the dish machine area during the initial tour on 2/21/21 at 9:47 AM revealed that the wall behind the clean side of the dish machine and wall behind the dirty side of the dish machine was noted with black bio-growth. Interview with Staff H and Staff G, Dietary Aides, at the time of the observation revealed they were unsure as to what the black substance on the wall was. Continued observation of the dish machine area revealed that the dish machine has blue curtains on both the clean side and the dirty side of the machine where dirty dishes enter the unit and clean dishes exit the unit after they have been washed. Closer observation of the curtains revealed that both curtains were covered in a white substance. At this time, Staff H and Staff G reported that they were unsure as to why the curtains were covered with the white substance. Upon arrival for the comprehensive tour of the kitchen on 2/23/21 at 9:36 AM, Staff E, Dietary Aide was noted to be in the dish room on the soiled side of the dish machine loading dirty dishes. He was wearing a surgical mask under the N95 mask with his beard exposed up the side of his face. Inspection of the kitchen during the comprehensive tour with the Certified Dietary Manager (CDM) revealed that the cage lights under the range hood were still noted to be covered in dust with cobwebs noted on the range hood piping. Continued inspection of the kitchen on 2/23/21 at 10:12 AM revealed that Staff F, Dietary Aide was wearing a face mask. The face mask only covered his face and nose area, leaving facial hair exposed on the cheeks of his face. At this time, Staff F reported that he was aware that he needed to cover his facial hair. He reported that, I have one on now, so what's the big deal? Interview at this time with the CDM revealed that beard guards were available for use for all staff. It was noted that they were stored in a hanging file pocket in the kitchen. The container had an ample supply of beard guards present in the file pocket. Interview with the CDM at this time revealed that all staff with facial hair should wear a beard guard and that hair should not be exposed. 105553 Page 5 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0812 Level of Harm - Minimal harm or potential for actual harm Review of the training documents provided by the facility on 2/24/21 revealed that staff were to Wear approved hair restraints (hair net, or cap) to prevent hair from falling into and contaminating the food. Review of the facility policy titled Personal Hygiene, with an effective date of January 2021 revealed the following: Residents Affected - Some 3. Wear a hair restraint while in the kitchen -Hairnets and scrub caps are acceptable -Beard restraints are required for male employees with facial hair -Cover all of hair -Failure to wear hair restraint will result in disciplinary action Photographic evidence was obtained. 105553 Page 6 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

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** 3. Observations of the 600 hall on 2/21/21 at 1:03 PM, revealed that Staff A, Agency CNA, and Staff B, Agency Registered Nurse (RN) both entered Resident #86's room to provide care and did not don any PPE until after they had entered the room. This surveyor observed Staff C, Unit Manager enter the room to ask a question of Staff B and then exit the room with no hand hygiene noted. Close observation of Resident #86's room door revealed an isolation kit mounted on the door. There was no signage noted on or around the door that would direct anyone entering the room as to what type of PPE was needed in the room, or what type of isolation the room was under. Residents Affected - Few Review of Resident #86's medical record revealed that this resident was admitted to the facility on [DATE]. Review of the resident's physician order summary revealed that the resident had a physician order for contact isolation for VRE in the urine which began on 2/21/21. Further review of Resident #86's record revealed results from a urine culture with a collection date of 2/15/21 which revealed VRE Isolated as positive in the urine. Review of the list of resident on isolation provided by the facility on 2/21/21 revealed that this resident was on contact precautions. Based on observation, interview and record review the facility failed to maintain an infection prevention program to prevent the transmission of infections as evidenced by: 1) failing to ensure four staff members (Staff N, O, A, and B) donned Personal Protective Equipment (PPE) needed when entering isolation precaution rooms and practiced proper hand hygiene for three (#13, #66, and #86) out of six residents in isolation rooms outside of the Persons Under Investigation (PUI) unit, and 2) failing to ensure one staff member (Staff P) practiced proper infection control during medication administration and use of shared medical equipment for one (#150) of four residents observed during medication administration. Findings Included: 1. During a tour of the 400 hall on 2/21/21 at 9:15 a.m. two isolation caddies were observed in the hallway to be used for Resident #13 and #66. No isolation precaution signs were observed on the doors. On 2/21/21 at 10:10 a.m., Staff O, Certified Nursing Assistant (CNA) confirmed she had the residents on isolation precautions and knew that Resident #13 was on droplet precautions as her roommate had tested positive for COVID-19 recently. Staff O was unaware of the isolation precautions in place for Resident #66. Staff O stated that regardless of the type of precautions she should wear full Personal Protective Equipment (PPE) in both rooms to consist of a gown, gloves, mask and face shield or goggles. Review of Resident #13's physician orders revealed the resident was on droplet precautions dated 2/16/21 due to roommate exposure and a Clostridium-difficile culture was sent to the lab on 2/19/21. Observation of lunch service on 2/21/21 at 12:20 p.m. revealed Staff N, CNA walking into Resident #13's room, which had an isolation caddy on the door without a sign. Staff N, CNA was wearing a N95 mask and eye glasses. She did not don a gown, gloves, face shield or goggles when going into Resident #13's room to place the tray on the bedside table. She exited the resident's room and went to the clean linen cart without performing hand hygiene and retrieved a towel. Staff N, CNA returned to Resident #13 and applied the towel to the resident's chest, touched her shoulder, and picked up the call 105553 Page 7 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few light and placed it on the resident's chest. Staff N then adjusted the resident's tray table, opened the juice lid, fruit cup, butter, and milk. Staff N, then removed the lid from the hot plate and left the room without performing hand hygiene. Upon exiting the room, Staff N was asked why Resident #13 was on isolation. Staff N stated the room was not on isolation precautions, her roommate was. Staff N then turned to look at the door and saw the isolation caddy. Staff N said, Sorry, I did not know and then started heading towards the meal cart. Staff N was asked to perform hand hygiene. Staff N went back into Resident #13's room and washed her hands. Review of Resident #66's physician orders revealed the resident was on contact isolation precautions for Clostridium-difficile (C-DIFF) dated 2/8/21. On 2/21/21 at 12:30 p.m., Staff O, CNA was observed taking a lunch tray to Resident #66's room. Staff O stopped and asked if she needed to wear PPE to take the tray in the room, then called over Staff N, CNA and asked her to hold the tray while Staff O, who was wearing an N95 mask, donned an isolation gown (without gloves) and took the tray to Resident #66. Staff O placed the tray on the table and the lid to the hot plate on the left side at the end of the bed. Staff O, CNA adjusted the height of the bed with the remote and the tray table. Staff O removed the coffee cup from Resident #66's tray table, went to the bathroom with the cup, and placed the cup back on the tray table prior to exiting the room. Staff O, CNA doffed the blue gown and left the room without handwashing. Staff O, CNA was observed using hand sanitizer, and did not wash her hands with soap and water, prior to taking the next meal tray to a resident. 2. On 2/23/21 at 8:43 a.m., Staff P, LPN was observed during the medication administration for Resident #150. Staff P, LPN drew up insulin in a syringe and placed it inside an alcohol pad box from the medication cart along with a glucometer, alcohol wipes, a bottle of glucometer strips, and lancets. Staff P, LPN placed the alcohol box with the contents onto the resident's bed side table without placing a barrier. Staff P, LPN then donned gloves without performing hand hygiene and placed the glucometer on the resident's upper left chest of his t-shirt. Staff P, LPN pulled a thermometer out of her right pant pocket and checked the resident's temperature. She then placed the thermometer back in her right leg pant pocket. Staff P, LPN then pulled a wrist blood pressure (BP) monitor out of her left pant pocket and applied it to Resident #150's left wrist. Staff P, LPN used the same gloves and gave the resident his insulin in the left upper arm after wiping with an alcohol pad. Staff P then took the syringe to the medication cart and placed it in the biohazard bin, doffed gloves and wiped her hands with an alcohol wipe from the top of the medication cart. Staff P, LPN then took the alcohol box with the supplies inside it from the resident's bedside table and the glucometer that was on the resident's t-shirt and brought the contents back to the medication cart. Staff P, LPN was asked what she would normally do with the glucometer and supplies after removing them from a resident's room. She stated that she would disinfect the glucometer with a sani wipe. Staff P, LPN then used her bare hands to remove the used glucometer from the alcohol pad box that was sitting in the medication cart and placed it on top of the medication cart. She then took another glucometer and placed it in the alcohol pad box which was used in Resident #150's room. Staff P, LPN then went through the bottom of the medication cart to remove another blood pressure monitor to re-check the resident's blood pressure without performing hand hygiene. Staff P, LPN donned gloves and cleaned the glucometer with a sani wipe and left it on the medication cart. She removed the wrist blood pressure monitor from her left pant pocket and placed it on the medication cart without disinfecting it. Staff P, LPN confirmed she did not hand sanitize or disinfect the reusable equipment prior to placing it back in the medication cart. The Risk Manager was present at 9:02 a.m. and confirmed that Staff P should not have used the equipment and placed it back in the medication cart without disinfecting first or placing it in her pockets. The Risk Manager 105553 Page 8 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed that the alcohol pad box should never have been in the resident's room and then placed back in the medication cart. The Risk Manager stated she would remove everything from the medication cart and disinfect it immediately. During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON & IP) on 2/23/21 at 9:45 a.m. he stated that his expectation would be for the nurse to clean the BP cuff and the thermometer and not put it in pant pockets. The ADON also stated that he would not want the nurse placing the glucometer on the resident and then not disinfecting it before placing it back in the medication cart. The ADON stated that he would expect the nurse to hand sanitize prior to donning and doffing gloves. The ADON stated he would expect the aides and nurses to know who was on isolation precautions and what type of isolation they were on. The ADON would expect the aides to go in the isolation room in full PPE and in a C-DIFF room, he would expect the staff to wash their hands and not use hand sanitizer. Review of the facility policy for isolation precautions dated 2/21, 4 pages reflected: In addition to standard precautions, implement contact precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Contact Precautions: c. gloves and handwashing, 2) remove gloves before leaving the room and wash hands with an antimicrobial agent or a waterless antiseptic agent. d. gown 1) in addition to wearing a gown as outlined under standard precautions, wear a gown for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Review of the facility policy for hand hygiene effective 2/21, 2 pages reflected: the facility considers hand hygiene the primary means to prevent the spread of infections. 5) employees must wash their hands for twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after performing an invasive procedure (finger stick blood sampling). Before and after entering an isolation precautions settings. After contact with a resident with infectious diarrhea, including but not limited to infections caused by C. Difficile (hand washing with soap and water). After removing gloves or aprons. The alternate method of hand hygiene is with an alcohol based hand rub. If hands are not visibly soiled or the resident does not have or suspected to have C. difficile infection. Review of the facility policy for equipment-cleaning/disinfecting, effective 2/21, 2 pages reflected: The facility will take action to prevent resident care equipment and supplies from becoming sources of infection. Used equipment and supplies are considered contaminated with potentially infections material and will be cleaned and disinfected as applicable before use with another resident. Resident care equipment has three categories. Semi-critical items - thermometers, glucometers requires intermediate-level disinfection. 105553 Page 9 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review and interview the facility failed to maintain kitchen equipment in a safe operating condition, related to a 6 burner stove and a dish machine. Residents Affected - Some Findings included: Observations during the initial tour of the kitchen on 2/21/21 at 9:34 AM revealed that the kitchen housed a 6 burner stove which was located in the center of the kitchen. Inspection of the stove with Staff I, Cook, revealed that the left back burner and the center back burner did not light when the knob was placed to the on position. The cook was noted to light a piece of paper towel from a lit burner and light both the left back burner and the center back burner with the lit paper towel. Observations of the dish machine during the initial tour on 2/21/21 at 9:47 AM revealed that the dish machine was in use. Interview at this time with Staff H, Dietary Aide, revealed that the dish machine was a low temperature machine. When asked by this surveyor to test the sanitizer levels in the machine she utilized the test strips for the 3 compartment sink. Staff H was noted to put the test strips in the dish machine and run it thru the cycle 2 times. Both times it was noted that the test strip did not come out the other end of the dish machine. Staff H reported that she did not know why the test strips kept disappearing, but that was how the sanitizer was tested on the dish machine. Observation of the spec label and notice attached to the dish machine revealed that the dish machine was running at a Hot water sanitizing Mode and that the final rinse temperature was 180 degrees F Min [minimum]. Observations during the comprehensive tour of the kitchen on 2/23/21 at 9:36 AM with the Certified Dietary Manager (CDM) revealed that Staff E, Dietary Aide, and Staff H, Dietary Aide, were present in the dish machine area. Staff E was loading the dish machine and Staff H was unloading the dish machine. Staff H reported that the dish machine was a low temperature machine with a sanitizer. This surveyor asked both Staff E and Staff H to test the sanitizer in the dish machine. At this time, Staff E tested the water in the dish machine using the test strip from the 3 compartment sink and noted on the strip as 0-150 and Staff H confirmed that this was correct. At this time, the CDM reported that the dish machine was a high temperature machine and does not need the sanitizer and that the final rinse should be 180. He provided the dish machine log for the month of February 2021. Review of the dish machine log revealed that there was 67 entries from 2/1/21 8:15 to 2/23/21 9:00 with one entry that was documented at 183 degrees, all others entries were noted to be under 170 degrees with the lowest rinse at 168. The CDM reported all of the entries noted in the rinse column were in the wrong place and should be in the final rinse column. Observation of the 6 burner stove during the comprehensive tour revealed that the left rear burner and center rear burner still would not ignite when the knob was turned to the on position. Interview on 2/23/21 at 10:30 AM with the CDM revealed that he was not aware of the final rinse temperatures being recorded below 180. He reported that he did not know if the kitchen staff had received training on the use of the dish machine. Interview on 2/23/21 at 11:25 AM with the CDM and the Nursing Home Administrator (NHA) revealed that there was a breakdown in the system and staff will be trained in reporting inadequate rinse 105553 Page 10 of 11 105553 02/24/2021 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperatures to the supervisor to allow for a call to the vendor for repairs. The NHA reported that a call had been placed to the vendor and they will be in the facility today and until that happens the facility will be using paper goods. The NHA reported that the kitchen staff will be in-serviced on reporting concerns in the kitchen to the supervisor right away. A policy was requested of the facility related to maintaining kitchen equipment, but the policy was not provided. Photographic evidence was obtained. 105553 Page 11 of 11