Health inspection·August 26, 2021

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the faclity failed to treat one (Resident #50) of 39 sampled residents with dignity, by serving him all of his meals on disposable tableware. The findings include: During dining observation on 8/23/21 at 12:28 PM, Resident #50 received his meal in his room on disposable tableware. There was no indication that the resident was on contact isolation. The lunch meals meal ticket, dated 8/23/21, was observed on the resident's tray indicating the use of disposable tableware. (Photographic evidence obtained) On 8/24/21 at 12:08 PM, Resident#50 received lunch in his room on disposable tableware. In an interview on 8/24/21 at 12:15 PM, Resident #50 stated he did not know why he was being served on disposable tableware. He added that most of the time his food was cold. A review of the medical record revealed that Resident #50 was admitted to the facility on [DATE] with diagnoses including major depressive disorder and malignant neoplasm of the colon. The Quarterly Minimum Data Set (MDS) assessment, dated 7/2/21, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15 points, indicating moderate cognitive impairement. No infections or behavioral issues were noted. On 8/25/21 at 2:46 PM, the Certified Dietary Manager (CDM) was asked why Resident #50 received his meals on disposable tableware. She stated she was notified by the nursing department approximately four months ago, to start serving the resident on disposable tableware due to his behavior of spitting on the plates and placing them in the trash can. In an interview on 8/26/21 at 10:18 AM , Registered Nurse (RN)/Unit Manager F stated the resident was receiving a regular meal tray and tableware on admission, but around May 2021, he started throwing the utensils in the trash. She added that he was also hoarding the silverware in his room and therefore, the interdisciplinary team (IDT) decided to provide his meals on disposable tableware. When asked where this information was documented or whether the careplan had been updated, she confirmed that there was nothing documented. . Page 1 of 16 105586 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0583 Keep residents' personal and medical records private and confidential. 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 respect the residents right to privacy, by failing to secure residents' medical records for one (Resident #66) of 39 sampled residents. Residents Affected - Few The findings include: On 08/25/21 at 4:06 PM, the medication cart on the west wing front hall was observed at the end of the hall close to the exit door located near room [ROOM NUMBER]. The medication cart was unlocked and the electronic medication administration record for Resident #66 was exposed. Residents were observed using the exit back and forth, and a compassionate caregiver visiting the resident in room [ROOM NUMBER] A used the exit to go to the kitchen and back to the resident's room while the medical record was still exposed. The nurse assigned to the cart was not administering medication and was away from the unit. (Photographic evidence obtained) On 08/25/21 at 4:08 PM, Licensed Practical Nurse (LPN) E was observed returning to the unit and went to the medication cart. In an interview on 8/25/21 at 4:09 PM, LPN E confirmed that he left the medical record exposed. He stated he had to go to the other unit to get supplies and forgot to lock the cart and shut down the the computer. In an interview on 08/25/21 at 4:41 PM, LPN H, Unit Manager, stated nurses should only have the cart open when they were preparing medication, and if they were away from the cart, the medical record should be covered or the computer should be turned off. She further stated the nurse was an Agency nurse. When asked whether orientation/training was provided to the Agency nurse on facility policies, procedures and expectations, she stated the Agency conducted the training. A review of the resident's medical record revealed that Resident #66 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis, cerebral infarction, major depressive disorder, cognitive deficit, acquired absence of other right toes, and history of alcohol abuse. The resident depended on staff for all activities of daily living (ADLs). A review of the facility's policy and procedure Confidentiality of Information and Personal Privacy (Revised October 2017), revealed: Policy statement Our facility will protect and safeguard resident confidentiality and personal privacy. Policy interpretation and implementation 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the Resident's privacy regarding his or her : a). accommodations 105586 Page 2 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0583 b). medical treatment Level of Harm - Minimal harm or potential for actual harm c). written and telephonic communication d). personal care Residents Affected - Few e). visits and f). family and resident group meeting 3. Access to resident personal and medical records will be limited to authorized staff and business associates. 7. Release of resident information, including video, audio, or computer stored information, will be handled in accordance with residents and privacy policies. . 105586 Page 3 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, family interview, clinical record review, and staff interview, the facility failed to ensure a clean living environment for four (Residents #26, #30, #53 and #97) of 11 residents receiving enteral feedings. Enteral food product was observed on various surfaces in the residents' rooms throughout the survey. Failure to maintain a clean living environment may create the potential for infection and affect the resident's ability to attain or maintain his/her highest practicable physical, mental, and social well-being. The findings include: 1. An observation was made of Resident #30 on 08/23/21 at 12:51 PM and an interview was conducted with his father at that time. The resident's room had what appeared to be enteral food product splattered on the intravenous (IV) pole, feeding pump, bed frame, wall, and the floor under the pole (Photographic evidence obtained). The resident's father confirmed that the food product had been on the various surfaces for the last several days since he had been visiting his son from out of state. During an observation of Resident #30's room on 08/25/2021 at 1:41 PM, the enteral food product had not been cleaned up. The room looked the same as it had on 08/23/2021 at 12:51 PM. (Photographic evidence obtained) During an observation of Resident #30's room on 08/26/2021 at 9:30 AM, the enteral food product had still not been cleaned up. The room looked the same as it had on 08/23/2021 at 12:51 PM and 08/25/2021 at 1:41 PM. (Photographic evidence obtained). 2. During an observation of Resident #26's room on 08/26/2021 at 12:10 PM, the resident's room had what appeared to be enteral food product splattered on the intravenous (IV) pole, feeding pump, bed frame, wall and the floor under the pole. (Photographic evidence obtained) 3. During an observation of Resident #53's room on 08/26/2021 at 11:51 AM, the resident's room had what appeared to be enteral food product splattered on the intravenous (IV) pole, feeding pump, bed frame, wall and the floor under the pole. (Photographic evidence obtained) 4. During an observation of Resident #97's room on 08/26/2021 at 11:55 AM, the resident's room had what appeared to be enteral food product splattered on the intravenous (IV) pole, feeding pump, bed frame, wall and the floor under the pole. (Photographic evidence obtained) A review of the physician's orders for Resident #30 revealed an order dated 09/09/2020 which read: Enteral Feeding: Formula: DiabetiSource AC. Strength: 1.2 continuously. Flow rate 80 cc/ml. Every shift; 7-3, 3-11, 11-7. A review of the physician's orders for Resident #26 revealed an order dated 12/05/2020 which read: Enteral Feeding: Formula Iso Source Strength: HN. Flow Rate: 65 ml/hr. x 20 hours off at 10 am on at 2 pm. Twice a day. A review of the physician's orders for Resident #53 revealed an order dated 03/04/2021 which read: Enteral Feeding: Formula: DiabetiSource. Strength: 1.2 off at 12 am on at 2 am for Synthroid dosing. Flow rate: 82 ml/hr. x 22 hours only. Twice a day. 105586 Page 4 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the physician's orders for Resident #97 revealed an order dated 03/04/2021 which read: Fiber source HN at 65 ml/hr. continuously which will provide 1872 calories. Every shift. 7-3, 3-11p, 11p-7. During an interview with Licensed Practical Nurse (LPN) C on 08/26/2021 at 2:35 PM, he was shown the enteral food product on the poles, pumps, walls, and floor. He was asked who was responsible for cleaning up the food splatter from the enteral feedings in the residents' rooms. He stated housekeeping was responsible for the walls, beds, and floor. The nursing staff was responsible for cleaning the IV poles and pumps. . 105586 Page 5 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to identify a geri-chair as a physical restraint for one (Resident #13) of one resident reviewed for restraints from a total of 39 residents sampled. Residents Affected - Few The findings include: The medical record for Resident #13 was reviewed. He was admitted to the facility on [DATE]. Medical diagnoses included intracerebral hemorrhage, cerebral infarction, and schizophreniform disorder. A comprehensive Minimum Data Set (MDS) assessment, dated 5/27/2021, indicated a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The resident required limited assistance with bed mobility and transfers. No restraints or alarms were identified in the assessment as being used for this resident. On 8/23/2021 at 1:00 p.m., Resident #13 was observed in a geri-chair which was located in an alcove across from the nurse's station. The chair was fully reclined. Resident #13 was attempting to rise independently out of the chair but was repeatedly unsuccessful. On 8/24/2021 at approximately 11:45 a.m., Resident #13 was observed in the geri-chair, which was fully reclined. The chair was positioned near the nurse's station. He was observed throwing his left leg over the side of the chair repeatedly while yelling nurse!. No staff members responded. On 8/25/21 at 10:22 a.m., Resident #13 was observed in the geri-chair. He was restless and attempting to scoot out of the chair. Registered Nurse (RN) N was standing at the medication cart, which was positioned adjacent to the resident and in her line of sight. She was notified the resident was attempting to get out of the chair. She stated, Oh yeah, we're used to it. The nurse then told the resident to Stop doing that. You're scaring the surveyor. On 8/25/21 at 11:38 a.m., Resident #13 was observed reclined back in a geri-chair in an alcove across from the nurse's station. The chair was reclined fully. Resident #13 was repeatedly throwing his left leg over the left side of the chair and scooting toward the bottom of the chair. He stated, Young man, can you help me out of here? When an interview was attempted with the resident, he closed his eyes and would not answer any questions. On 8/25/21 at 11:40 a.m., Certified Nursing Assistant (CNA) K approached the resident and rolled him to his room. She explained that she was taking the resident to his room for lunch. She was asked why the resident had been placed in a geri- chair. She stated, I'm not sure. You might want to ask the nurse, but he is in it all the time. On 8/25/21 at 11:47 a.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She confirmed that she was assigned to care for Resident #13. She was asked why Resident #13 was using a geri-chair. She explained that she had been told in report a while ago that the resident was leaning forward in his regular wheelchair and had fallen out of it. The facility then placed the resident in the geri-chair as a result of the fall. The nurse further explained that the resident had been independently ambulatory prior to his admission and explained that his ambulation had declined since readmission. She confirmed that the resident was unable to independently rise from the geri-chair in it's reclined position. 105586 Page 6 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/25/21 at 11:51 a.m., Resident #13 was observed in the geri-chair in his room. The geri-chair was fully reclined. His left leg was lying over the left armrest of the chair. On 8/25/21 at 1:41 p.m., an interview was conducted with Physical Therapist (PT) L. He explained that therapy had not recommended the geri-chair and he stated, I can ask the nursing staff how they came up with that. I think they do their own screenings. He further explained that the resident was able to ambulate with two-person contact-guard assistance. The therapist was then asked whether the resident was able to propel himself in a wheelchair. He stated, I haven't seen that during this episode of therapy. He then confirmed that a regular wheelchair had not been trialed prior to the resident being placed in the geri-chair. When asked if a regular wheelchair would be less restrictive, he explained that the resident's safety concerns would need to be considered. When asked to expand, he referenced the resident's trunk control could be a concern, but then stated he hadn't seen any trunk control safety concerns during the episodes of therapy. A review of the resident's fall history was conducted. The resident sustained a fall on 5/30/2021 where he was observed ambulating on the 300 hall. He attempted to sit in a chair located in the hallway. The resident was able to catch himself into a seated position on the floor. The resident sustained a fall on 6/30/2021 in which he was observed lying on his back on the floor in his room. No assistive devices were in use. The resident sustained a fall on 8/2/2021 in which he was observed lying on the mat bedside his bed. The resident was assisted into a geri-chair and placed by the nurse's station. Continued review of the resident's fall history revealed no falls from his wheelchair. A review of the resident's nursing progress notes revealed no documentation of the resident sustaining a fall from his wheelchair due to leaning forward or poor trunk control. A review of the comprehensive care plans revealed a focus area for activities of daily living (ADLs). The interventions included extensive assistance with bed mobility, extensive assistance with transfers, and directed staff to provide adaptive equipment: wheel chair. On 8/25/21 at 2:52 p.m., an interview was conducted with Occupational Therapist (OT) M. She was asked about the rationale for Resident #13 using a geri-chair. She explained that, when the resident was assessed after readmission, the resident was sleepy and lethargic, and that the recommendation was made at that time for a geri-chair. She was asked whether the resident was reassessed after that determination was made. She stated, No. We haven't seen him since he was released from therapy in July. She stated the resident would be reassessed immediately. On 8/26/21 at 11:20 p.m., an observation of Resident #13 was conducted. He was in the therapy gym sitting in a Broda chair. His feet were on the floor. The chair was slightly reclined. His eyes were closed and his hands were in his lap. The facility's restraint policy was reviewed. The policy was titled, Use of Restraints with a revision date of April 2017. The policy indicated that restraints shall only be used for the safety and well-being of the residents only after other alternatives had been tried unsuccesfully. The policy indicatd that restraints should only be used to treat medical symptoms and never for discipline, staff convenience, or for the prevention of falls. The policy directed staff to conduct ongoing re-evaluation for the need for restraints and that the evaluations would be documented. The policy indicated that the definition of a restraint was based on the functional status of the resident and not the device. It also provided examples of devices that were or could be considered 105586 Page 7 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0604 physical restraints such geri-chairs. (Photographic Evidence Obtained) Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Few 105586 Page 8 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, resident and staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure that the care plans for one (Resident #42) of 39 sampled residents, were revised to reflect wound care for arterial wounds to the feet. Failure to update the care plan puts the resident at risk of not receiving appropriate care and services. The findings include: 1. During the initial tour of the facility on 08/23/2021 at 11:40 AM, Resident #42's feet were observed to be bandaged around the toes and down to the middle of the foot, covering the arch of the foot. His heels were bare and presented with no wounds or injuries. A dark reddish brown biological substance was draining and bubbling out from under the bandage on the left foot. The bandages were not dated. (Photographic evidence obtained). The resident stated he thought he last had wound care on 08/20/2021 and that it was to be done once a week. During an interview with Licensed Practical Nurse (LPN) A on 08/24/2021 at 8:30 AM, she stated Resident #42 had a Health Care Surrogate (HCS). She thought it was the resident's niece or his sister, she was not sure. She knew that the HCS only wanted palliative care to the resident's feet and a vascular consult had not been done. She stated she asked for dermatological and wound care consults. On 08/24/2021 at 10:10 AM, an observation was made of the resident's wounds. Both of the resident's legs presented with atrophy (wasting) of the calf muscles, loss of extremity hair, and thickened toenails on the right foot. Toes 1-5 on the left foot had been amputated, indicating vascular insufficiency. Both feet were wrapped with conforming gauze. The dark reddish-brown biological substance was no longer visible, and the bandages were clean. LPN A/Wound Care Nurse removed the dressing to the left foot revealing multiple wounds affecting the dorsal (top) and plantar (bottom) aspects of the distal half (away from the center of the body) of the foot. Approximately 60% of the affected area was open and actively draining. There were small islands of intact skin between the wounds. The wounds were deep red to purple in appearance and the edges were macerated ( broken down by moisture). The surrounding skin was shiny and taught. The nurse sprayed wound cleanser on gauze pads and began to clean the areas. The resident reacted by frowning, covering his head with a blanket, and moving his foot away from her. The resident was asked whether the wound cleansing was painful. He nodded his head Yes. The wound care nurse finished the dressing change and removed the dressing to the right foot. The resident's great toe and second toe were dark brown to black in color with loosely-attached, stringy necrotic (dead) tissue hanging from them. The skin on the right foot was shiny and taught with no hair growth observed. As the nurse was applying iodine-soaked gauze to the toes, the resident again covered his head with a blanket and moved his foot away from the nurse. When asked how long his left foot looked like this the resident stated, It's been awhile. He stated the last nurse told him she saw puss coming out of it. LPN A stated this was the first time she had seen the wound this way. She identified the wounds as new and worsening, and confirmed that no vascular studies or workup had been done. On 08/26/2021 at 2:14 PM, a telephone interview was conducted with the contracted wound care physician for Resident #42. He stated, It would be great if [Resident #42] had a vascular consult! He stated he had discussed it with the resident. This is an old conversation. He agreed that vascular surgery would increase the blood flow to his feet and that would aid in the healing process. In fact, he did not think the resident's feet would heal without increasing the blood flow. 105586 Page 9 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/26/21 at 5:20 PM with the MDS Coordinator, she reviewed the care plan that she had provided for review. She confirmed that the care plan had not been updated to include a focus area for the care of the arterial wounds on Resident #42's feet. A review of the facility's policy and procedure entitled Care Plan, Comprehensive Person-Centered, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial ad functional needs is developed and implemented for each resident. 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. b. The resident's physician (or primary healthcare provider) is integral to this process. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. . 105586 Page 10 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to provide respiratory care as ordered for one (Resident #41) of 39 sampled residents. Residents Affected - Few The findings include: A review of Resident #41's medical record revealed an admission date of 5/1/2018 with diagnoses including heart failure, sequelae of nontraumatic intracerebral hemorrhage, cerebral infraction, arteriosclerotic heart disease without angina pectoris and hypertension. A review of the resident's physician's orders included the following: Administer oxygen at 2 liters per minute via nasal cannula (started on 6/9/21), change tubing every week on Tuesday, check lung sounds for normal or abnormal and record, check oxygen saturation and record. A review of the resident's care plans revealed no care plan for oxygen or respiratory care. A review of the August 2021 Medication Administration Record (MAR) revealed oxygen tubing had been changed on 8/3/21 and 8/10/21, but had not been changed on 8/17/21. An interview with Resident #41 was conducted on 08/23/21 at 11:00 AM. She reported that her oxygen tubing was not changed as it should be, and the staff did not add water to the oxygen concentrator, so her nasal passages were dry. At the time of the interview, the oxygen concentrator's flow rate was set at three liters per minute. An interview was conducted with Registered Nurse (RN) R on 08/26/21 at 11:24 AM. RN R stated, [Resident #41] is on oxygen and has been for the last 3 to 4 months. RN R stated the resident's physician's orders were that she have oxygen as needed. RN R was asked what oxygen flow rate was to be set at for Resident #41. She stated two liters. RN R was asked if the resident should be care planned for oxygen therapy and she stated yes. She was asked about care of the oxygen concentrator and oxygen tubing, and she stated the nursing staff changed the tubing weekly. RN R checked the physician's orders and verified that oxygen was ordered as needed at 2.0 liters per minute. RN R stated the resident's oxygen would only be set at a higher flow rate if the resident had shortness of breath. In that case, the resident's physician would be called. An observation of the resident's oxygen concentrator was made on 08/26/21 at 11:30 AM with RN R. RN R verified the oxygen flow rate was set at 3.0 liters per minute. The resident was asked why the flow rate was set at 3 liters, and she replied that she didn't know. The resident was asked if she had shortness of breath and she stated no. No humidifier was attached to the concentrator. A canister was sitting on the resident's side table, but the RN stated that did not go with the concentrator and she didn't know why it was there. Resident #41 told the nurse she wanted a concentrator with a water attachment, and the nurse said she would exchange the device. The nurse also set the flow rate to 2.0 liters. The facility policy titled Oxygen Administration, revised in October 2010 read, Verify there is a physican's order for this procedure and review the physicians's orders or faciilty protocol for oxygen adminstration. . 105586 Page 11 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to 1) Monitor blood pressure when using an antihypertensive medication and administer medication when blood pressure was within the specified parameters to do so for one resident (Resident #81), and 2) Monitor behaviors for one (Resident #103) of five residents reviewed for unnecessary medications, from a total of 39 residents sampled. Residents Affected - Few The findings include: 1. The medical record for Resident #13 was reviewed. He was admitted to the facility on [DATE]. Medical diagnoses included intracerebral hemorrhage, cerebral infarction, and schizophreniform disorder. A comprehensive Minimum Data Set (MDS) assessment, dated 5/27/2021, indicated a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The resident required limited assistance with bed mobility and transfers. During a review of the resident's physician's orders, an order dated 7/26/2021 read, Clonidine 0.1mg (milligrams), give one tablet by mouth every 8 hours as needed for systolic blood pressure greater than 160. A review of the resident's vital signs revealed the resident's blood pressures were not being monitored every eight hours as required by the Clonidine order. (Photographic Evidence Obtained) Continued review of the vital signs revealed that on three occasions, the resident's systolic blood pressure was higher than the parameter specified by the physician, and Clonidine should have been administered. 7/30/2021 04:22 PM 163/95 8/7/2021 07:37 PM 183/110 8/12/2021 5:15 PM 199/100 A review of the resident's medication administration records (MARs) for August 2021 revealed no documented administration of the Clonidine on 7/30/2021, 8/7/2021, or 8/12/2021. A review of the resident's progress notes on 7/30/2021, 8/7/2021, and 8/12/2021 revealed no documented communication to the resident's physician regarding the resident's elevated blood pressures. On 8/25/21 at 1:00 p.m., an interview was conducted with Licensed Practical Nurse (LPN) I. She was asked to review the blood pressures from 7/30/2021, 8/7/2021, and 8/12/2021 in addition to the resident's order for Clonidine. The nurse reviewed the record and confirmed that the Clonidine should have been administered in those instances. The nurse also confirmed that the resident's blood pressures were not being taken as required by the order for Clonidine. 2. A record review for Resident #103 revealed an admission date of 5/7/21 with diagnoses including chronic respiratory failure with hypoxia, dysphagia following cerebral infarction, congestive heart failure, hypertension, adult failure to thrive, cardiomyopathy, anxiety disorder, spinal stenosis, chronic pain, arteriosclerotic heart disease, and depression. 105586 Page 12 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Quarterly Minimum Data Set (MDS) assessment, dated 8/13/21, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition, and a score of 11 for moderate depression. Resident #103 received antianxiety, antidepressant, and anticoagulant medication on 7 of 7 days duirng the MDS lookback period. The resident's care plan, dated 5/7/21, noted the resident was at risk for adverse consequences related to receiving antidepressant and antianxiety medications. Interventions included the administration of medications as ordered and a psychiatric consult as needed. The resident's current physician's orders included Xanax for anxiety three times a day, Remeron at bedtime for major depressive disorder, Buspirone three times a day for anxiety disorder, and Trazodone once daily for anxiety disorder. No orders for behavior monitoring were found. During an interview with Employee R on 8/26/21 at 11:42 AM, she was asked about Resident #103, and she reported the resident was on medications requiring behavior monitoring. Employee R was asked if the resident was currently being monitored for behaviors, and she replied, I don't see behavior monitoring for her. The facility's policy titled Behavior Assessment , Intervention and Monitoring, revised in March 2019, was reviewed. The policy read, The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. . 105586 Page 13 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls for three og three medication carts inspected for medication storage from a total of four medication carts in the facility. The findings include: On 08/25/21 at 4:06 PM, the medication cart for the west wing front hall was observed at the end of the hall close to the exit door located near room [ROOM NUMBER]. The medication cart was unlocked and the nurse assigned to the cart was not administering medication and was away from the unit. (Photographic evidence obtained) On 08/25/21 at 4:08 PM, Licensed Practical Nurse (LPN) E was observed returning to the unit and went to the medication cart. In an interview on 08/25/21 at 4:09 PM, LPN E confirmed that he went to the other unit to get supplies and forgot to lock the cart. In an interview on 08/25/21 at 4:41 PM, LPN H/Unit Manager, stated nurses should only have the cart open when they were preparing medication, and if they were away, the cart should be locked. She stated the nurse was an Agency nurse. When asked whether orientation/training was provided to the Agency employee on facility policy, procedures and expectations, she stated the Agency conducted this training. On 08/26/21 at 9:51 AM, the following unopened insulin pens were found in the west wing back cart: Four pens for insulin aspart 100 units/ml (milliliter) and one pen for insulin Novolog 100 units/ml. The pharmacy label indicated, Refrigerate until opened'. (Photographic evidence obtained) In an interview on 08/26/21 at 9:55 AM, LPN J confirmed that the pens were not opened and should have been in the refrigerator. On 08/26/21 at 10:13 AM, two unopened insulin pens (Lantus 100 units/ml ) were found in the east wing back hall medication cart. Both insulin pens had pharmacy labels indicating to refrigerate until opened. (Photographic evidence obatined) In an interview on 08/26/21 at 10:15 AM, LPN I confirmed the insulin pens were unopened. She added that she was not aware that they needed to be refrigerated. A review of the facility's policy and procedure: Storage of Medication (Revised April 2007) revealed: Policy statement: The facility shall store all drugs and biological in a safe, secure and orderly manner. 105586 Page 14 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0761 Policy interpretation and implementation: Level of Harm - Minimal harm or potential for actual harm 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biological's shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Residents Affected - Some 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location . Medications must be stored separately from food and must be labeled accordingly. . 105586 Page 15 of 16 105586 08/26/2021 Oak View Health and Rehabilitation Center 833 Kingsley Ave Orange Park, FL 32073

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility did not ensure appropriate sanitation and Food Code Standard procedures were maintained to prevent the potential for the spread of foodborne illness. The nourishment room refrigerators, microwave, ice machine, sink and contact surfaces were not clean. Cross contamination can occur when harmful substances, such as chemical or disease-causing microorganisms are transferred to food by unsanitary food contact surfaces. Any resident receiving anything from either the east or west wing nourishment room was at risk. The findings include: During a tour of the east wing nourishment room on 08/26/2021 at 9:18 AM, the ice machine was observed to have black biological grown on the inside. (Photographic evidence obtained) The inside of the refrigerator had dried on food debris. (Photographic evidence obtained) The sink was clogged with a tan-colored liquid substance. (Photographic evidence obtained) During an interview with Certified Nursing Assistant (CNA) P on 08/26/2021 at 9:21 AM, she stated they got the ice for the residents from the kitchen ice machine, but if they ran out, they could get ice from the machine in the east wing nourishment room. She was not sure who was responsible for the cleaning of the nourishment rooms or the ice machine. During a tour of the west wing nourishment room on 08/26/2021 at 9:38 AM, the inside of the refrigerator had dried on food debris and yellow liquid on the shelves. Next to the refrigerator there were paper products on the floor between the unit and the wall. The inside of the microwave had dried on food stuck to the entire interior of the oven. (Photographic evidence obtained) During an interview with the Assistant Dietary Manager on 08/26/2021 at 10:45 AM, she stated the dietary department was not responsible for the cleaning of the nourishment rooms. It was a nursing duty. The dietary department only stocked the snacks. During an interview with the Director of Nursing on 08/26/2021 at 6:15 PM, she indicated she was unaware that the rooms had not been cleaned. She stated the nursing staff (CNAs) were responsible for cleaning the nourishment rooms. It was to be done on Fridays on the 11 PM - 7 AM shift. They were to clean everything. She stated, I heard about the condition of the nourishment rooms. I went and looked and saw it was a mess. I will talk to the CNA (Certified Nursing Assistant) that was assigned to the task. . 105586 Page 16 of 16