Health inspection·October 15, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to promote care in a manner that ensured resident rights were maintained for a dignified existence related to assistance after meals for two residents (#68 and #54) out of 27 sampled residents. Findings included: During a facility tour on 10/12/20 at 11:05 AM, the first observation was made of Resident #68 in bed with wet, reddish liquid on his hospital gown. When asked what was on the gown, Resident #68 reported having spilled breakfast juice on self. Breakfast service for residents started at 7:30 am. On 10/12/20 at 11:10 AM, an interview was conducted with Staff G, Certified Nursing Assistant (CNA), who stated that she was taking care of other residents and had not gotten around to Resident #68. Breakfast service started at 7:30 a.m. An interview was conducted on 10/12/20 at 11:10 AM with Staff F, Licensed Practical Nurse (LPN), who reported that Resident #68 must have spilled juice on self during breakfast. We'll get it cleaned right now. A review of Resident #68's medical record revealed a primary diagnosis of multiple sclerosis. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate impairment. In Section G Functional Status and Section K Nutrition it was documented that Resident #68 is at risk for coughing and choking during meals and is totally dependent and extensive assistance is required for eating and hygiene. A review of Resident #68's care plan, initiated on 9/24/20 revealed a focus for assisting with meals at all times with a goal to promote independence with self feeding. The active care plan also indicated a focus as nutritional/fluid balance and required a therapuetically altered diet secondary to diabetes diagnosis and the interventions included to evaluate fluid and nutritional needs, offer fluids between meals and observe for fluid imbalance. A second observation was made on 10/13/20 at 12:36 PM of Resident #68. Resident #68 was observed in bed eating lunch, with food spilled all over the white bed sheet laid on the chest area. Resident #68 was observed wiping his mouth with a mask during the meal. An interview was conducted with the Director of Nursing (DON) on 10/13/20 at 12:46 PM. She was observed handing Resident #68 a napkin and removing the soiled mask. She reported that he was declining Page 1 of 16 105634 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and losing motor ability and that an assessment will be done to see why Resident #68 is declining so fast. She also stated, I have so many people needing assistance. During a tour on 10/12/20 at 2:37 PM, an observation was made of Resident #54. Resident 54's face, hands, clothing, mattress pad and bedside table were all soiled. The observation was completed after the lunch meal that was served at 12:30 PM. Resident #54's hands were red with spaghetti sauce. Spaghetti sauce was smeared on a tissue box and a urinal by the bed. Resident #54 attempted to clean self. Tissues were observed on the bedside table. An interview attempt was made and the resident would not respond. An interview was conducted on 10/12/20 at 2:39 PM with Staff F, LPN related to the observation of Resident #54 not being cleaned up after lunch which was served at 12:30 p.m. She walked into the room, looked at the resident and stated, That is not good. Staff F proceeded to get a CNA to assist. A review of the medical record for Resident #54 revealed a diagnosis of nondisplaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture without routine healing. A Quarterly MDS dated [DATE], Section G Functional Status revealed that Resident #54 was independent with meals and required extensive assistance with hygiene. A review of the active care plan for Resident #54 revealed he was a long term resident and his needs will be met daily and on-going. A focus for nutritional/fluid balance concern and need for a mechanically altered diet revealed one of the interventions as assist with meal setup and supervise for safety; assist as needed, initiated on 9/18/17 and revised 10/5/20. On 10/12/20 at 2:44 PM, following an observation of Resident #54, the DON stated that this was not okay, and that resident's care is their priority. A review of the facility's policy titled; Dignity, dated December 2017, revealed the following: Treat each resident with respect and dignity with regards to the following: * Personal Care * Assisting with eating and other activities of daily living. A review of the job description for Certified Nurse's Aide (CNA), Job Code 200SchCNA with an effective date of 5/30/2018, revealed the following essential duties and responsibilities: Give personal care to residents. Prepare resident for meals and assists with meal service. Treats resident with dignity. 105634 Page 2 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

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, interview and medical record review the facility failed to ensure that one resident (#5) out of 27 residents sampled had a comprehensive plan of care developed for smoking. Findings included: On 10/12/20 at 11:49 A.M. Resident#5 was observed going to the smoking patio, he reported that he has been smoking his whole life. Resident #5 was observed smoking on the smoking patio with several other residents and a staff member. When Resident #5 returned from smoking he was asked where his cigarettes were maintained; he reported in the smoking cart and added that all smoking materials are kept in the smoking cart. On 10/12/20 at 1:01 P.M. a second observation was conducted of Resident #5 smoking. The resident was greeted in the smoking patio and was observed smoking. Staff was providing hand sanitizer for the residents. A medical record review was conducted for Resident #5 on 10/12/2020, which revealed that he was admitted to the facility on [DATE] with an original date of admission of 4/20/2015. Resident #5 has multiple diagnoses but not limited to complete traumatic amputation, depression and peripheral vascular disease. Resident #5 was alert and oriented and was able to make his own decisions. He had a Brief Interview for Mental Status (BIMS) score of 13 indicating he was cognitively intact. Further medical review revealed that on 6/30/2020 a smoker screen was conducted and completed and signed by the Assistant Director of Nursing. The medical record was silent regarding a resident centered and individualized plan of care for smoking indicating goals and objectives for smoking. On 10/14/20 at 11:35 A.M. an interview was conducted with the Corporate Registered Nurse regarding Resident #5 not having a care plan for smoking. She confirmed that the care plan was not developed until yesterday (10/13/20). The resident was admitted to the facility on [DATE] and screened as being a safe smoker, however, there had not been a plan of care developed for this resident. A facility policy was provided by the Director of Nursing for the development and implementation of care plans. The facility was titled, Goals and Objectives, with an effective date of November 2019. The policy indicated that care plans shall incorporate resident-centered/trauma-informed goals and objectives that lead to the resident's goals for admission and desired outcomes. 105634 Page 3 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to review and revise the resident centered care plan related to weight loss and assistance with eating care for one (Resident #51) of twenty-seven sampled residents. Findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses of protein calorie malnutrition, Alzheimer's disease, dementia and hypokalemia. A review of the current nutritional orders for October 2020 for Resident #51 revealed the following: Ready Care 2.0 supplement three times a day 120 milliliters for malnutrition Eldertonic Liquid 15 milliliters three times a day for decreased appetite prior to meals Floor Maintenance Program (FMP) for cueing and encouragement to eat during meals Nutritional treat daily Regular diet regular texture, thin consistency Vitamin D3 400 IU (international unit) two times a day for supplement Protonix for gastro-intestinal prophylaxis Multi-vitamin with minerals two times a day for supplement A review of the admission Minimum Data Set (MDS) for Resident #51 dated 9/3/20 revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. A review of the Comprehensive Care Plan for Resident #51 revealed the following: Focus area: FMP for supervision and cues to eat at all meals (initiated 9/24/20) Goal: Maintain healthy weight (initiated 9/24/20) Interventions: (initiated 9/24/20) -set up tray and orient resident that tray is in front of her and that it is mealtime -take to dining room for meals -keep food tray in field of vision 105634 Page 4 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0657 -cue and encourage to feed self during meals Level of Harm - Minimal harm or potential for actual harm A review of the Registered Dietician (RD) notes revealed a late entry for 9/14/20 at 13:38 (1:38 p.m.) the current body weight for Resident #51 was 108 pounds and on 8/27/20 the recorded body weight was 119 pounds. The RD noted the Ideal Body Weight (IBW) was 130 pounds for Resident #51. The notes indicated the resident had lost 9% over a one-month period and the weight recorded on admission may be from the hospital 3008 form. The notes indicated the weight loss could possibly be related to poor oral intake of meals. Resident #51 was noted to be at 83% of her IBW with a Body Mass Index (BMI) of 17.5, emaciated for height and malnourished. The RD noted the resident consumes an average of 25-50% of meals with 120-240 milliliters of fluid per meal. The RD noted the resident needs cueing and supervision with meals, receives Ready Care 120 milliliters three times a day and consumes 100% and receives nutritional treat with lunch and consumes supplements 50-100% of the time. The RD recommended Elder tonic 15 milliliters three times a day prior to meals to help improve appetite. The goal listed by the RD was to stabilize weight with possible weight gain towards IBW, abnormal laboratory results to be within normal limits, and oral intake of meals to improve toward 50%. Residents Affected - Few On 10/07/20 the Registered Dietician note indicated the current body weight for Resident #51 was 106.8 pounds and the resident has lost two more pounds. Significant weight loss of 10% over a one-month period. The RD noted the resident continued a regular diet, oral intake of meals was averaging 50%, resident was receiving supplements and recommended an increase of Ready Care to 120 milliliter three times a day to increase calories and proteins. Goal to regain IBW and continue with weekly weights. A review of the weights and vitals summary data for Resident #51 indicated the following: 8/27/20 119 pounds standing 9/8/20 108.2 pounds standing 9/14/20 108.4 pounds standing 9/21/20 110 pounds standing 9/28/20 108 pounds standing 10/5/20 106.8 pounds standing 10/12/20 106.0 pounds standing A review of the meal consumption recorded by the certified nursing assistants for Resident #51 revealed between 9/16/2020 and 10/14/2020 the resident consumed 0-25% of meals 16 times, 25-50% of meals 33 times, 51-75% of meals 13 times and 75-100% of meals one time. On 10/12/20 at 11:57 a.m. Resident #51 was observed lying in bed fully dressed. The resident was noted to be confused and unable to answer questions. The resident stated she had been at the facility for years, but did not know why she came to the facility. The resident stated she thought she had lost some weight. On 10/14/20 at 1:00 p.m. Resident #51 was observed sitting up at the side of the bed in a chair. A 105634 Page 5 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0657 Level of Harm - Minimal harm or potential for actual harm table tray was positioned in front of the resident with a lunch tray set-up on the table. The resident was holding a fork in her right hand. The resident stated she was eating and so far, she has just tasted the peas. The resident was eating slowly and appeared to be picking at the peas on the plate. There was no staff member present in the room for cueing during the meal. Less than 25% of the meal was observed to be missing from the tray. Residents Affected - Few On 10/14/20 at 1:10 p.m. the resident was observed out in the hallway in her wheelchair. The lunch tray had been removed from the resident's room. On 10/14/20 at 1:59 p.m. an interview was conducted with the RD. The RD stated the FMP stands for floor maintenance program and is for the restorative nurse to assist residents. The RD stated she did not know what the order meant that is related to cueing for food. She stated she does not put any orders in related to the nursing staff assisting residents with meals. She stated she would talk to the nurse who entered the order to verify what the order meant. The RD stated she really questioned the admission weight for the resident. The RD stated she thought it was a weight from the hospital 3008 because all the other weights since admission have been consistent. The RD stated she has been unable to get an answer from the nursing staff about the initial weight documented. The RD stated that the expectation for taking weights is to take them weekly for four weeks and then monthly if the weight is stable for the resident. She confirmed that the recorded weights for Resident #51 showed a significant weight loss of more than 10% in the last month. On 10/15/20 at 11:05 a.m. Resident #51 was observed sitting in her room. The resident stated she was hungry and waiting for lunch. The resident was asked if she could reach the water on the tray and drink from the cup. She stated yes and was able to pick up the cup and take a sip of water from the straw. She stated she did not like the water because it was too cold, and it had too much ice in it. On 10/15/20 11:15 a.m. an interview was conducted with the Director of Nursing (DON) and the Regional Director of Nursing (RDON). The DON confirmed the practice for taking weights on admission was the nurse takes a weight and if unable to do so on admission it is taken the next day. The DON confirmed Resident #51 had not had a weight taken on admission and the documented weight was from the hospital 3008. She stated that was not acceptable as an admission weight. The DON confirmed the next weight taken for Resident #51 was not for eleven days. She stated the expectation for weight was once a week for four weeks and then monthly if a resident has stable weights. A review of the resident record with the DON and ADON revealed that the resident was started on an assisted feeding program where the resident was taken to the dining room for assistance with meals. The DON and RDON confirmed that since the intervention the resident was still losing two pounds a week and no new interventions had been added to the resident care plan. The DON stated they did not have someone assisting the resident during the current week because surveyors were in the building and were in the dining room so the staff had just been cueing the resident on their way by the resident from the hallway at each meal. The DON and RDON indicated that it was the job of the restorative aide to take the weights as ordered. On 10/15/20 at 12:06 p.m. an interview was conducted with Staff A, restorative nursing aide. The aide stated they are required to take the actual height and weight on admission for each resident. The aide stated on the off shifts any aide can do it but if it is not done then it must be completed the next morning when the restorative aide comes in. The aide stated he never uses a weight from the 3008 because it may not be accurate. The aide confirmed weights are done weekly for the first month 105634 Page 6 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0657 and then monthly if the weight is stable. The aide stated the weights are reported to nursing and the RD. Level of Harm - Minimal harm or potential for actual harm A review of the policy entitled, Weighting and Weight at-risk Protocol. Nutritional Services March 2020 indicated the following: Residents Affected - Few Weights: -Restorative to complete all weights with re-weights on the following parameters: 0-175 pounds variances of 4 pounds loss or gain 175 pound and above variances of 7 pounds loss or gain Over 250 pounds variances of 10 pounds loss or gain -Ensure same time of day, same clothing, same scale, and same chair are used every time -Monthly weights are recommended to be taken on the same day of the week -Weights should be entered into PCC upon completion into the electronic health record admission: Weights-weigh daily for 3 days enter all three weights into the electronic health record Scale: 2 Ensure all restorative staff knows how to work scale and alert management if scale inaccurate or not working 3 Ensure residents are placed appropriately on scale Identification: When all weights are completed Dietary Department to review weights for significant weight loss and at risk weight loss and determining variances with re-weights as noted above Dietary Department to notify nursing staff of significand and at risk residents next day during morning meeting Investigation: Dietary Department and nursing staff begin investigating weight loss some questions to investigate are: 1 Is the resident assisted with eating? Is staff assisting with eating appropriately? Giving enough time? 105634 Page 7 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0657 5 Does the resident need appetite stimulant? Level of Harm - Minimal harm or potential for actual harm 7 Does the resident like food? Have food preferences? Family involved in bringing food. 8 Does the resident need small, frequent meals? Alternative eating schedule? Residents Affected - Few Intervention: 1 Notify dietician of newly identified significant weight loss 3 Frequent meals or snacks 5 Review intakes at minimum weekly Documentation: 1 Dietary to document within 72 hours of investigation 2 Dietary to document monthly until resolved 3 Narrative documentation should include areas identified and measures put in place to show intervention 4 Care plans should be reviewed, if no existing care plan on weight loss/gain, care plan should be initiated 5 Nursing may also document intake and any monitoring being done for acute problems identified 6 Review weekly with nursing and dietary until weight loss resolved. Keep minutes of meeting, residents reviewed, and interventions initiated on all residents with significant weight loss and at risk. 105634 Page 8 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, and policy review the facility failed to provide necessary care and services related to: 1. constipation was not identified and treated for one resident (#27), and 2. the facility did not ensure the physician's order was entered correctly in the electronic medical record, and implemented for one resident (#11) of 27 sampled residents. Residents Affected - Few Findings included: 1. On 10/12/20 at 11:06 a.m. an interview was conducted with Resident #27. She said she hadn't had a BM (bowel movement) in a week. Resident #27 was admitted to the facility with a relevant diagnosis of fecal impaction, according to the face sheet in the admission record. Review of the Minimum Data Set (MDS) assessment, Section H, Bladder and Bowel, dated 8/23/20, reflected Resident #27 was always incontinent of bowel. A review of the physician orders for October 2020 in the medical record reflected an order dated 8/25/20 for Milk of Magnesia (MOM) Suspension 1200 mg/15 ml (milligram/milliliter) give 30 ml by mouth every 24 hours as needed for constipation. A review the BM record for the last 30 days reflected Resident #27 did not have a BM from 10/3/20 to 10/6/20, four days. Resident #27 also did not have a BM from 9/26/20-9/29/20, four days. A review of the October 2020 Medication Administration Record (MAR) revealed the MOM order was not administered. Review of the September 2020 MAR revealed the MOM order had not been given. On 10/14/20 at 1:36 p.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C said Resident #27 has never complained about anything. Sometimes she is constipated. She uses the brief. She is incontinent. On 10/14/20 at 2:25 p.m. in an interview with Staff E, Licensed Practical Nurse (LPN); she said Resident #27 has never complained of constipation. She (Resident #27) reported an upset stomach since last night. The doctor was here, and I told him. The CNA would report diarrhea or constipation. There is a flag on the MAR also. These residents are alert and oriented for the most part and can tell you. On 10/15/20 at 9:28 a.m. in a follow up interview with Staff E, LPN she said The residents down here are pretty oriented. They tell me if they are constipated or want MOM. The girls (cnas) come and tell us too. I did see a drop down I think that alerts us if someone hasn't had a BM. The Director of Nursing (DON) who was present during the interview said, Yes, there is a dashboard. The nurses can see the dashboard, they monitor it. And the double check is the clinical meeting Monday through Friday. I have a follow up form for the ADON (assistant director of nursing). Then the ADON comes out and follows up with the nurses. 105634 Page 9 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff E, LPN said the dashboard says, No BM in 48 hours. The DON said we start with the CNA going in and asking if they had a BM; if they are alert and oriented. We start with MOM or Dulcolax if they haven't, if there's an order. If not, we get an order. The DON said Resident #27 has loose stools. The DON said that they have been working on that (documentation). Some of them were charting in the progress notes. The CNAs weren't always charting in the computer program, but they are now. Staff E, LPN said usually [Resident #27] tells me. I go in there and talk to the residents. She has not told me anything about constipation. 2. On 10/13/20 at 9:36 a.m. an interview was conducted with Resident #11. He said he has an ongoing yeast infection and only gets antifungal cream once a day. A catheter was observed hanging on Resident #11's right side of the bed off the floor in a privacy bag. Resident #11 was admitted to the facility with diagnoses including neuropathic bladder and urinary retention, according to the face sheet in the admission record. A review of the October 2020 physician orders in the medical record reflected an order dated 8/24/20 for Phytoplex Z- guard paste (petrolatum-zinc oxide) apply to penis topically every day and evening shift for fungal cleanse area with warm soapy water, pat dry, apply paste. A review of the 7/16/20 MDS assessment, Section H, Bladder and Bowel, in the medical record reflected an indwelling catheter. Further review of the MDS reflected a BIMS score of 15, indicating Resident #11 was cognitively intact. A review of the written physician order dated 8/21/20 revealed house antifungal cream to penis bid (twice a day)-indefinite. Review of the Treatment Administration Record (TAR) for August, September, and October 2020 revealed the Phytoplex Z-guard paste was entered and being used, rather than antifungal cream. On 10/15/20 at 11:23 a.m. an interview was conducted with the ADON. She said, Yes, that is a zinc. It's a zinc paste. It (the order) says it's for fungal. He is an [Insurance Company] patient so his ARNP (Advanced Registered Nurse Practitioner) is probably the one who ordered that. House skin anti fungal to penis twice a day. The ARNP ordered it. We use Miconazole. The surveyor asked why wasn't Resident #11 getting the Miconazole The ADON said, That's a good question. I agree with you. On 10/15/20 at 1:53 p.m. a telephone interview was conducted with the resident's PA (physician's assistant). She said she hasn't looked at it lately. He has diabetes and has had a fungal infection in the past. He has complained of it and is at risk for fungal; so I have no problem having him on a house antifungal. It could be an irritation, or it could be moisture. I did not order the zinc paste. Review of the facility policy titled, Physician's orders, dated November 2017, revealed the following: Policy Resident medications, treatments, and services must be ordered by a licensed physician or licensed practitioner. 105634 Page 10 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 Policy Interpretation and Implementation Level of Harm - Minimal harm or potential for actual harm 2. All medications administered to the resident must be ordered by the resident's attending physician or licensed. Residents Affected - Few 5. Medications may not be administered to the resident without the written approval from the attending physician. 105634 Page 11 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews and policy review, the facility failed to discard expired food in accordance with professional standards for food service. Residents Affected - Few Findings included: An initial tour of the kitchen was conducted on 10/12/20 at 10:00 A.M. with the Registered Dietician (RD). The following was observed: A case of goldfish crackers was observed with an expiration date of 09/13/20, and 3 cans of [Brand Name] Pulled Pork with an expiration date of 12/18/18 . (Photographic Evidence Obtained) An additional tour of the kitchen was conducted on 10/12/20 at 11:46 AM, a plastic bag containing cookies was observed and had a date of 9/22/20. The cookies were in a snack bin that was to be delivered to the units for evening snacks for the residents. (Photographic Evidence Obtained) The RD threw them away. Following this observation, an interview was conducted with the RD, who confirmed that the residents should not consume expired food, and that all expired items would be removed. She added that the food policy indicated employees are to throw out the outdated food items every 3 days. Upon further inquiry, the RD explained that the policy to throw out food that is past manufacturer's dates and storage is very clear. A review of the facility's policy titled, Food Storage, dated November 2017 revealed that food expiration and dating protocols were not addressed. 105634 Page 12 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to implement an appropriate plan of action to correct an identified deficiency, F812, as evidenced by not ensuring food storage practices were implemented in accordance with professional standards; and not training the Certified Dietary Manager to implement the facility plan of correction for appropriate food storage. In addition, the facility had conflicting documentation of QA (Quality Assurance) meetings and attendance. Findings include: During the recertification survey conducted on 10/12/20 to 10/15/20, the facility was cited F812, the facility failed to discard expired food in accordance with professional standards for food service. For the plan of correction, the facility included the following corrective actions: An initial audit of food shelves and refrigerators were completed on 10/12/20 and no additional issues were identified. Current dietary staff were educated on ensuring that no expired foods are on shelves, refrigerator, etc. on 10/12/20. The Dietary Manager, or designee shall spot check refrigerators and shelves for compliance, and document accordingly. The Dietary manager or designee will randomly audit shelves and refrigerators via observation for compliance weekly x 4 weeks and monthly thereafter until substantial On 01/06/21 a Revisit survey was conducted to the facility. At 10:40 a.m., a tour of the kitchen with Staff A, [NAME] and a review of the dry goods area was conducted. Staff A stated that the Certified Dietary Manager (CDM) was in charge of the emergency supply. She stated that that was where the expired food products were found during the recertification survey. She stated that the CDM had to cook this evening and she would be in later. Observations conducted at approximately 10:52 a.m. with Staff A of the emergency supply and a shelving unit across from the emergency supply that held dry goods: 1. An open box with a bag of single serve pie shells, the date on the bag was 10/10. Staff A was asked what the item was for. She stated that it was for when they made pies. She confirmed that she did not know how long they were good for. Approximately 24 single serve pie shells in the bag in aluminum pie pans, some broken and crumbling. (photo) 2. In the open box, under the pie shell bag was an unsealed blue bag. Staff A identified the contents as panko breadcrumbs. She confirmed that there was no label on the bag. 3. 105634 Page 13 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0867 Level of Harm - Minimal harm or potential for actual harm A second opened box with an unsealed blue bag was observed on the shelving unit. Staff A identified the contents as panko breadcrumbs. She was asked if the food product was stored correctly. She stated no, that it should be in a sealed, labeled container. The box had a written date, opened 11/24/20. 4. Residents Affected - Few In an open box for oatmeal cookies was a gallon bag of miscellaneous breakfast bars, oatmeal cookies, nutrition bars. No labeling on the bag was observed. When the bars were reviewed, no expiration date was observed. Staff A was not able to state when the expiration date was of the bars. 5. Observed on the shelving unit with the spices were 15 boxes of [NAME] Choice Iodized salt, 40 ounces each. The fronts of the boxes had visual compromise, pealing paper and bumps. When the boxes were picked up, the product in the box felt rock hard as if the product had been wet and solidified. An interview was conducted on 01/06/21 at 11:45 a.m. with the CDM. She stated that she had not been at the facility during the recertification survey, she had been off for 3 months and that she had returned on 12/12/20. The CDM was asked, who was in charge while you were gone? She stated, we had a couple of dieticians due to the ownership change, believe that it was the corporate dieticians that came in. When you came back, did the facility share with you the deficient practice that was identified in the kitchen/food products? The CDM stated, I thought that it was taken care of by the former dieticians. It was not something that I focused on. I did not participate in the correction. Are you in charge of the kitchen? Yes. At 12:07 p.m., the dry storage area was reviewed with the CDM. The bag of bars was observed to be removed from the box of oatmeal cookies box. The CDM stated that she was unaware of what had been in the box. In addition, the 2 unsealed bags of panko breadcrumbs in the unsealed boxes had been removed. The CDM stated that the boxes, they got rid of those, they had old outdated contents. I do not know what was in them. The CDM reviewed the 15 boxes of salt on the shelf, she stated those are a little hard. She confirmed that she would not use any of them. She stated that they were delivered in 07/20. On 01/06/21 at 1:05 p.m., an interview was conducted with the Nursing Home Administrator (NHA), the surveyor requested a copy of the sign in sheets for the QA (Quality Assurance) meetings that were conducted since the recertification survey, 10/15/20. She stated that they had only one meeting; that they had combined one of the months. At 1:25 p.m., the NHA provided a copy of the Risk Management and QAA committee meeting signature page dated 11/20/20. She stated that there was not a meeting held in December 2020. The January meeting has not been held yet. We have had just the one meeting since the recertification survey. At 1:30 p.m., the Director of Nursing (DON) provided a signature list, dated 11/20/20 for the Risk Management and QAA Committee Meeting Signature page. She identified one of the signatures as the CDM's. She was asked if she was sure that was the CDM's signature because, the CDM had stated that she did not return to the facility until 12/15/20. The DON stated, oh, that may have been one of the contracted dieticians. 105634 Page 14 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 1:35 p.m., the DON returned with a different sign in sheet that was dated 12/29/20. She stated that the QA meeting was really held on 12/29/20 and that the CDM did attend this meeting. The DON stated no meeting was held on 11/20/20. At 1:38 p.m. the NHA was re-interviewed. She stated, that the 11/2020 meeting was held. She said herself, the DON, Social Services, the Activities director, and the Medical director, but the (CDM) was not there for the whole meeting. The NHA stated, for 11/2020, the CDM was not here; she signed the form by accident in the 12/2020 meeting. The CDM was on family medical leave in 11/2020. An interview conducted on 01/06/21 at 4:34 p.m. with the Nursing Home Administrator (NHA). She stated that the in-service sheet, dated 10/12/20, was provided by a Regional Dietician. The NHA stated that no other training had been provided to the dietary staff that she was aware of. In addition, the NHA confirmed that no training had been conducted after the 10/12/20 training that included the CDM. Also, during the interview, the NHA stated that she conducted the audits. That she had completed them weekly from 11/06/20 thru 12/11/20; and that they would be conducted monthly thereafter. At 5:05 p.m., the NHA provided an audit tool, Emergency Food Audit, that listed audits conducted on 11/06/20, 11/13/20, 11/20/20, 11/27/20, 12/11/20. The NHA stated that she only checked the Emergency Food Supply because that is what the facility was cited on. A review of the CDM's Job Description, dated 12/12/20, documented essential duties & responsibilities which included: Develop plan of correction following State, Federal and QA surveys, as needed. 105634 Page 15 of 16 105634 10/15/2020 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interview and photographic evidence, the facility failed to ensure that one of one walk-in freezers was maintained in a safe operating condition to ensure appropriate food storage. Residents Affected - Some Findings included: On 01/06/21 at 11:08 a.m. a tour of the kitchen with Staff A, [NAME] was conducted. An observation of the facility walk-in refrigerator revealed a door to the walk-in freezer with approximately 10 inches of 1-inch thick ice buildup on the floor of the door of the freezer on the outside. When the freezer door was opened, the door seal area had an approximate 1.5-2 inches of ice buildup on the right side down the length of the door, the top of the door and the left of the door had approximately 1 inch of build up along the seal. The top of the freezer was observed to have frozen droplets of ice throughout. (Photographic Evidence Obtained). An interview was conducted on 01/06/21 at 11:45 a.m. with the Certified Dietary Manager (CDM). The CDM reviewed the freezer and stated, That must have happened last night. It was not like that yesterday. An interview was conducted on 01/06/21 at 3:44 p.m. with the Maintenance Director. He was asked if he had been aware of the ice buildup in the walk-in freezer. He confirmed that he was not aware of the freezer malfunctioning until the CDM had called him that morning. He stated, sometimes if they do not shut the door all the way, it will condensate on the inside or the heat strip that goes on the inside of the door-jam will malfunction. He stated, I chipped away all the ice and spoke to the dietary staff. He stated that he was going to see how the freezer did over night to determine whether he needed a new strip or that staff were not closing the door right. He further stated that since the changeover in ownership, the Computerized Name Brand system was not up and running. Normally, staff will put into the Computerized Name Brand system a maintenance request, and that is how he would find out if something needed to be fixed. 105634 Page 16 of 16