Health inspection·February 11, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview and record review the facility failed to provide housekeeping and maintenance services to maintain a sanitary and homelike environment related to not ensuring a mattress was in good repair for one resident (#9) of a sample of nine residents for two days (2/10/24 and 2/11/24) of a two day survey. Findings included: An observation on 2/10/24 at 10:01 a.m. revealed the bare mattress for Resident #9 had a large worn area in the shape of a circle in the middle to upper area of the mattress. The first layer of the dark blue material was worn through and exposed the next layer of a lighter blue material. Towards the top of the worn circle was a yellow stained area. (Photographic Evidence Obtained) An interview on 2/10/24 at approximately 11:50 a.m. with Staff A, Certified Nursing Assistant (CNA) revealed Resident #9 was at dialysis. She confirmed if something was wrong with a mattress a work order would be completed. An interview on 2/10/24 at 12:00 p.m. with Staff B, Registered Nurse/Unit Manager (RN/UM) was conducted. Staff B stated if a repair was an emergency it would be put into the system (work order) and reported to maintenance. The repair was usually completed within the same day. She confirmed if a family member reported it and it was going to create a problem for the resident a grievance and work order would always be completed. The repair to the mattress would be handled within a day. During an interview on 2/10/24 at 1:51 p.m. Staff C, Licensed Practical Nurse (LPN) stated the CNA reports it (mattress or equipment breakdown) to the LPN and the LPN puts it (work order) into the work order system for maintenance to handle. They (maintenance) get paged if an emergency such as an air mattress not working. For other mattresses it would be considered urgent if it was irritating the skin of the resident. The work order for the mattress would usually be taken care of within the next business day. An observation on 2/10/24 at 1:59 p.m. revealed Resident #9 was not in his room and the bed was made with clean linen. During an interview on 2/10/24 at 2:31 p.m. the Director of Plant Operations stated a work order would be entered for something wrong with a mattress. Anyone can put in a work order and he would try to fix or replace it that day or by the next day. He stated the facility completes walking rounds and completes a monthly review of all mattresses to ensure they are in good condition and when the CNAs are changing the beds or if observed by housekeeping a work order should be completed if they Page 1 of 2 105566 105566 02/11/2024 Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884

F 0584 Level of Harm - Minimal harm or potential for actual harm notice something is wrong with the mattress. If noticed on the weekend the Manager on Duty can take care of it and there are mattresses in the storage unit. There are four in the storage unit right now. During an additional interview with the Director of Plant Operations on 2/10/24 at 2:50 p.m. he stated a monthly audit for mattress checks are not on the work order system. Residents Affected - Few Review of the completed work orders from 1/28/24 - 2/11/24 did not reveal a work order for Resident #9's mattress. An observation on 2/11/24 at 9:49 a.m. revealed the bare mattress for Resident #9 had a large worn area in the shape of a circle in the middle to upper area of the mattress. The first layer of the dark blue material was worn through in the middle of the mattress and exposed the next layer of a lighter blue material. Towards the top of the worn circle was a yellow stained area. (Photographic Evidence Obtained) During an observation and interview on 2/11/24 at 9:55 a.m. Staff B, RN/UM confirmed Resident #9's mattress had wear and tear and stated it should not be in that condition. Staff B confirmed they would put a work order in to change out the mattress. Staff B said, If this bad, they should of let us know. (Photographic Evidence Obtained) During an observation and interview on 2/11/24 at 9:57 a.m. the Director of Plant Operations confirmed the wear and tear of Resident #9's mattress and the CNA should have created a work order for the mattress. In an interview on 2/11/24 at 10:47 a.m. the Nursing Home Administrator stated the facility does not have a particular policy for doing audits for mattresses, but they do have the deep cleaning checklist. Review of the procedure titled, Deep Clean Once A Month, undated, documented the procedure as: Deep clean is the process of wiping down of all furniture, pulling furniture beds, dressers, night stands, chairs, and wardrobes if there is one 4. Spray bed down, also let stand for 10 minutes . Review of the policy titled, Infection Prevention and Control Manual - Environmental Services/Housekeeping/Laundry, effective December 2020, documented: It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. Purpose: It is the purpose is [sic] to provide standard operating procedures for a clean, safe, and sanitary environment for the residents. 105566 Page 2 of 2