Health inspection·April 9, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure fall risk care planned interventions were followed related to call light placement, for two residents (#100 and #114) of forty sampled residents. It was determined that during three of four days observed, both residents were found with call light buttons not placed within their reach, while in their rooms and in bed. Findings included: 1. On 4/6/2021 at 2:47 p.m. Resident #100 was observed in her room and lying in bed on her left side and facing the window. She was able to answer some simple questions related to her day and care at the facility. Resident #100 was also observed in bed and with her head and body turned to the left and facing the window. She was asked if she needed assistance and she said she did not know how to get staff if she needed anyone. When asked about her call light, she said she did not know what or where it was. An observation revealed the call light button was placed on the head of the bed near the edge of the top on the right side about one and a half feet and out of her reach. She confirmed she could not reach it. On 4/8/2021 at 7:41 a.m. an aide was observed waking the resident up to let her know breakfast was coming and asked if she could do her vitals. Resident #100 allowed for her to conduct the vitals. After the aide was finished with the resident and exited the room, the call light button was observed hooked to the top of her bed linen at head of bed, positioned in a way where she could not reach it. Resident #100 was asked if she could she use her call light. She looked around and indicated she did not know where it was. She confirmed she saw it before. The call light button was placed approximately one and a half feet above her head and away from her reach. On 4/9/2021 at 11:50 a.m. Resident #100 was observed lying in bed and under the covers with a nasal canula receiving oxygen via an oxygen concentrator. Resident #100 was observed without the call light button placed within her reach. The call light button and cord were on the floor on the right side of the bed between the bed and window wall. Resident #100 was asked if she was able to reach her call light, she stated that she did not know where it was. It was pointed out that it was on the floor and she said she could not reach it. (Photographic Evidence Obtained) Review of Resident #100's admission Record revealed that she was admitted to the facility on [DATE] with diagnoses to include displaced fracture to the left femur, orthopedic aftercare, bone density structure, hemiplegia, hemiparesis left dominant side, depression, joint degeneration left hip, and risk for falls. Page 1 of 7 105581 105581 04/09/2021 Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the most current Minimum Data Set (MDS), dated [DATE], revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of a 7 of 15, which indicated she had severe cognitive impact. Review of the active care plan, initiated on 3/3/21 and revised on 3/18/21, revealed a focus described as: - At risk for falls related to weakness, history of fall sustaining left femur fracture. The interventions included: Place items used in easy reach i.e., Water, telephone, call lights; Keep adaptive equipment within reach. During an interview on 4/9/2021 at 11:55 a.m. with Staff G, Certified Nursing Assistant (CNA), she indicated that call lights must be positioned on the resident's stomach area so they can reach the button easily. She was asked about Resident #100 and the call light placement and she confirmed the call light button was on the floor and it should not have been there. Staff G did not say that the resident had a history of throwing it on the floor. She confirmed that the resident does utilize the call light button. 2. On 4/8/2021 at 7:15 a.m. Resident #114 was observed lying in bed with his eyes open, sheets covering him, head of the bed at approximately 40 degrees and the ¼ rails up near the head of the bed. The room was dark, and the television was on, but with the settings turned dim. The call light button was searched for and it could not be located on or around the resident's immediate area. The call light button was observed hanging down behind the head of the bed with the button approximately seven inches above the floor and approximately two and a half feet back and away from the resident's reach. The resident was asked if he knew where his call light was located, and he looked side to side and then shook his head side to side indicating No. He was asked if he uses it, and he shook his head up and down indicating Yes. On 4/9/2021 at 7:35 a.m. Resident #114 was observed with two extra pillows on each side of his upper body and shoulder area between him and the ¼ rails. Further observation revealed the call light button was hanging off the side of the right side of the bed, between the bed and the window wall, hanging off the floor approximately six inches. The call light button was observed in a manner out from his reach. (Photographic Evidence Obtained) Review of Resident #114's admission Record revealed he was admitted to the facility on [DATE] and had diagnoses that included unspecified dementia without behavioral disturbance, pressure ulcer of sacral region, stage 4, cerebral infarction and difficulty in walking. Review of the current MDS assessment, dated 3/13/2021, revealed a BIMS score of 12 out of 15, which indicated the resident had only moderate impairment. Review of the active care plan, initiated on 3/17/21 and revised on 3/23/21, revealed a focus described as: - At risk for falls due to weakness and impaired mobility. The interventions included: Place items used in easy reach i.e., water, telephone, call lights; Keep adaptive equipment within reach. On 4/9/2021 at 3:33 p.m. an interview was conducted with Staff H, Licensed Practical Nurse (LPN). She indicated that the expectation for placement of call lights was that they are to be attached to the patient or the bed, so that the resident can call for assistance. She was asked what does it mean 105581 Page 2 of 7 105581 04/09/2021 Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the care plan when it says have call bell within reach? She revealed that it must be in the reach of the resident, so they know where it is, and they can touch/reach it. Staff H was further asked how she monitors residents on the unit for the placement of call bells. She revealed, when a resident is in their room, we make sure they have it and check. On 4/9/2021 at 3:40 p.m. an interview was conducted with the Director of Nursing (DON). She revealed, call lights should be placed within the resident's reach, and most of the time staff will clip it to the bed linens, and some residents request how they would want it placed. The DON revealed, the nurses should check that the call bells (lights) are in reach during medication administration and CNAs when they do their rounds throughout the shift, which is 2 hours or more frequently. The DON confirmed that Residents #100 and #114 should always have their call light placed within their reach, while in their room and in bed. 105581 Page 3 of 7 105581 04/09/2021 Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that documentation in the medical record for one resident (#119) out of 40 sampled residents was accurate related to the application of a neck collar for positioning. Findings included: Resident #119 was observed on 04/06/21 at 11:00 a.m. and at 12:30 p.m. At 11:00 a.m. the resident was observed in bed without a neck collar in place, at 12:30 p.m. the resident was observed in bed without a neck collar in place. Multiple observations were made of Resident #119 on 04/08/21: at 7:32 a.m. the resident was observed in bed without a neck collar in place; at 12:03 p.m. the resident was observed in bed without the neck collar in place; at 12:23 p.m. the resident was observed in bed without the neck collar in place; at 4:12 p.m. the resident was observed in bed without the neck collar in place. At each observation there was a plastic hamper observed against the wall in the resident's room and placed on top of it was a neck collar. (Photographic Evidence obtained) Review of the medical record for Resident #119 revealed that she originally had been admitted to the facility on [DATE]. Diagnoses included stroke, hemiplegia (paralysis of one side of the body), Alzheimer's disease, abnormal posture, and rheumatoid arthritis. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which meant that the resident had severe cognitive impairment. The MDS revealed that the resident required extensive to total assistance of two persons for bed mobility, positioning, and transfers. Review of the active April 2021 physician orders for the resident revealed the following order with a start date of 09/10/19: Put neck collar when resident is sitting in the chair. every shift. Review of the Treatment Administration Record (TAR) for April 2021 revealed that the neck collar was documented with a check mark and nursing staff initials for every shift for dates 04/01/21- 04/06/21, nothing was documented for the day shift on 04/07/21, a check mark and nursing staff initials was documented for the evening and night shift of 04/07/21, and nothing was documented for the day shift of 04/08/21. An interview was conducted on 04/09/21 at 11:00 a.m. with Staff I, Registered Nurse (RN) and Staff J, Licensed Practical Nurse (LPN) Unit Manager (UM). Staff I made a confirmatory observation during the interview that Resident #119 was in bed without a neck collar on, and that the neck collar was on top of the hamper against the wall. Staff I was asked to reveal documentation on the TAR and confirmed that it reflected that the neck collar had been provided to the resident every shift 04/01/21-4/06/21, and the evening and night shift 04/07/21. Staff I could not confirm having seen the resident out of bed during the week and did not have an explanation for why the neck collar would have been documented as provided. Staff J confirmed that the documentation on the TAR reflected that the nurse had provided the neck collar to the resident. She confirmed that a check mark meant that a treatment had been administered. She said, If not done [the nurse] should put another code like 9 which I think means see nurse's note .should not be putting a check mark (if not administered) unless they don't understand the order, but the order seems very clear to me. On 04/09/21 at 11:56 a.m. the Director of Nursing (DON) was interviewed. She confirmed that the documentation on the TAR reflected that the neck collar had been applied. She confirmed that the 105581 Page 4 of 7 105581 04/09/2021 Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761

F 0842 Level of Harm - Minimal harm or potential for actual harm documentation expectation if something was not administered would be to enter a 9 and a note explaining why it was not administered. She confirmed that a check mark meant administered. The DON confirmed that it was important for documentation in the medical record to be accurate and said, .is a record for what was done and not done. She stated that nursing staff should not be documenting a treatment as administered when it hadn't and said, That's an education moment. Residents Affected - Few Review of facility policy titled Nursing - Charting and Documentation, dated October 2014 revealed the following within the section titled purpose: The purpose of this procedure is to provide: 1. A complete account of the resident's care treatment, response to the care, signs, symptoms, etc. as well as the progress of the resident's care .3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. 4. Nursing services personnel with a record of the physical and mental status of the resident .6. The elements of quality medical nursing care. 7. A legal record that protects the resident, physician, nurse, and the facility. The policy revealed the following within section rules for charting and documentation: .3. Document only the facts. Use only approved abbreviations and symbols. 105581 Page 5 of 7 105581 04/09/2021 Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and facility record review, the facility failed to ensure, 1. two (A wing and B wing) of three self-making ice machines and the internal ice-storage chests were clean and free from bio growth/debris and a gelatinous substance and 2. sanitary maintenance of a shower chair in a shared resident bathroom (#315) on one nursing unit (South) of two nursing units for two of two days observed. Findings included: 1. A review of the policy titled, Infection Prevention and Control Manual Ice Chests and Machines, dated 12/2020 revealed, Ice may become contaminated from the use of impure water, contamination of ice making machines, or from improper storage of handling of ice. Ice machines that dispense ice directly into portable containers at a touch of a control provide a more sanitary method to store and obtain ice than the use of ice chests. The policy procedure under #12, revealed, Clean ice storage compartments on a preset schedule. The policy continued with, #2. Employees cleaning ice machines/ice chest must be competent in cleaning procedure. #4. Clean the ice machine on a regular schedule, at least quarterly. #5. Follow the manufacturer's guidelines for cleaning. #6. Use an EPA-registered disinfectant suitable for use on the ice machine, chest, and dispensers. On 4/9/21 at 9:25 a.m. a tour of the nourishment rooms was conducted with the Certified Dietary Manager (CDM) and revealed the following: * At 9:25 a.m. the B wing unit nourishment room was entered. There was an ice maker with an internal ice storage chest that held the ice. Upon opening the lid to the machine, it was approximately ¾ full of ice cubes. A further observation revealed the condenser, which makes the ice, and the ice rack and cover, where the ice forms and falls, was observed with a heavy black bio growth covering the entire area. (Photographic Evidence Obtained). An interview, at this time, with the CDM revealed that the ice was used for residents and the ice machine maintenance and cleaning was the responsibility of the maintenance department. He revealed that the maintenance man just cleaned the machine. * At 9:50 a.m. the A wing unit nourishment room was entered. There was an ice maker with an internal ice storage chest that held the ice that was used for residents. Upon opening the lid to the machine, it was approximately ¾ full of ice cubes. A further observation revealed the condenser, and the ice rack and cover had a yellow and clear color gelatinous substance stuck and along the entire area of the rack and the part where the ice falls out. (Photographic Evidence Obtained) On 4/9/21 at 10:30 a.m. an interview with Staff F, Maintenance revealed that he followed an electronic maintenance schedule, and he cleans the ice machines monthly. He indicated that when he cleans the ice machines; he cleans the outside of the machine, changes or cleans the internal filter and 105581 Page 6 of 7 105581 04/09/2021 Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then some parts of the internal ice holding chest area if need be. He was unaware that he needed to clean and maintain the condenser area and the area where ice was made. Staff F confirmed there was black bio growth and yellow and clear gelatinous areas observed on the ice making components. He said he never saw that growth before and did not know to look for it. 2. On 4/07/21 at 10:10 a.m. an observation was conducted in resident room [ROOM NUMBER]. There was a shower chair in the shared bathroom with brown matter observed on and underneath the front of the seat. Upon return to the shared bathroom for resident room [ROOM NUMBER] on 4/09/21 at 1:41 p.m., another observation was conducted. [NAME] matter was observed on the shower chair seat. (Photographic Evidence Obtained) An interview was conducted at 1:52 p.m. on 4/09/21 with Staff B, Certified Nursing Assistant (CNA). Staff B, CNA confirmed there was brown matter on the shower chair. Staff B, CNA said staff clean the shower chairs after the shower with bleach wipes. She doesn't know when the last time the shower chair was used. Staff B, CNA said both residents in room [ROOM NUMBER] use the shower chair. On 4/09/21 at 4:22 p.m. an interview was conducted with the Director of Nursing (DON). She said the expectation is that the equipment is cleaned between uses. Review of the policy, from the Infection Prevention and Control Manual titled, Resident Care Equipment, dated December 2020, reflected the following: Resident Care Equipment and Articles for Handling, Processing, and Transport Purpose Reusable equipment is to be cleaned between resident use and reprocessed appropriately. Single use items are to be properly discarded. The facility must protect indirect transmission through decontamination (i.e., cleaning, sanitizing, or disinfecting) of an object to render it safe fro handling. Policy 2. The employee will disinfect reusable equipment between resident uses or before transport using a hospital grade disinfectant. Procedure 2. Remove body fluids and debris with damp cloth or towel. 3. Apply appropriate EPA registered disinfectant solution identified per manufacturer's recommendations with cloth and wipe surface thoroughly, in accordance with the label use on hospital grade disinfectant. 105581 Page 7 of 7