Health inspection·January 18, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure one (Residents #29) of three residents sampled for Beneficiary Notice, received Beneficiary Notice when discharged from a Medicare covered Part A stay and remained in the facility. Residents Affected - Few Findings Included: Review of documentation provided by the facility's Director of Social Services related to Beneficiary notification for Resident #29 revealed a last covered Medicare Part A Day was 10/27/2023 and he remained in the facility. Documentation on the SNF Beneficiary Protection Notification Review form revealed a SNF ABN Form CMS -10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN)) form was not provided to the resident. Continued review of the form revealed a handwritten note under Other Explain which indicated Resident payor source changed on 10/28/2023 and remained in the facility. On 01/17/24 at 11:00 a.m., an interview was conducted with the Social Service Director (SSD). The SSD said she did not really know the beneficiary notices process until the new administrator started. She confirmed Resident # 29 was removed from therapy services due to his change in payor source and he was not provided with an advanced beneficiary notice. A policy related to beneficiary notification was requested; however the facility did not provider by completion of the survey. Page 1 of 28 105634 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the clinical record revealed Resident #61 was admitted on [DATE], with a primary diagnosis of a traumatic subdural hemorrhage with loss of consciousness on 10/16/2023, as well as multiple fractures. Review of a Transfer / Discharge Report showed he transferred on 10/21/2023. Review of the nursing progress showed no documentation regarding a transfer or discharge. Review of the County Emergency Medical Services Patient Care Report showed they received a call on 10/21/23 at 14:31 and the resident was transported to [name of hospital]. During an interview on 01/17/24 at 1:55 p.m. the Registered Nurse Consultant and the Director of Nursing (DON) stated the resident was discharged to the hospital due to family request. They both verified there was no documentation in the clinical record related to his transfer / discharge to the hospital. On 01/18/24 at 1:50 p.m. during an interview the DON stated no further documentation related to the resident's discharge was found. Review of the facility's policy, Transfer and Discharge, revised on 07/17/2023 showed it is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. 12. Emergency Transfers/Discharges- initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless s otherwise specified). A. obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. B. contact an ambulance service and provider hospital, or facility of resident's choice, when possible, for transportation and admission arrangements. C. for a transfer to another provider, ensue necessary information listed in #9 of this policy is provided along with, or as part of, the facility's transfer form. D. the original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record. E. provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand. F. document assessment findings and other relevant information regarding the transfer in the medical record. G. provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. H. the Social Service Director, or designee, will provide copies of notices for emergency transfer to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. I. the resident will be permitted to return to the facility upon discharge from the acute care setting. Based on interviews and record review, the facility failed to provide discharge documentation for two residents (#265, # 61) out of eight residents sampled. Findings Included 1. Review of the admission Record revealed Resident #265 was admitted [DATE] with a primary diagnosis of Type 2 Diabetes Mellitus without Complications, Difficulty in Walking, not elsewhere 105634 Page 2 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few classified, major depressive disorder, recurrent, moderate, other specified persistent mood disorders, depression, unspecified. Review of Nursing progress note dated 12/22/2023 showed Resident #265 wanted to discharge Against Medical Advice (AMA) and had been informed of the risk. It was noted that he signed all the paperwork and was escorted to the front door with all his belongings. Further clinical record review showed no evidence of Resident #265 AMA paperwork and no physician notification related to the resident leaving the facility AMA. During an interview on 01/18/2024 at 4:21 p.m., with the Director of Nursing (DON). She confirmed the facility did not have paperwork related to Resident #265's AMA discharge. Review of the facility Policy titled Transfer and Discharge (Including AMA) dated 7/17/2023. Policy: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. 13. Discharge Against Medical Advice (AMA) b. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. c. Documentation of this notification should be entered in the nurses' notes by the nursing department. The social services designee should document any discussions held with the resident/family in the social services progress notes, if present 105634 Page 3 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for one (Resident #8) of fifteen sampled residents. Residents Affected - Few Findings included: During an interview on 01/16/24 at 9:56 a.m., Resident #8 stated she was not a diabetic and did not receive insulin. Review of the admission Record showed Resident #8 was originally admitted to the facility on [DATE] with diagnoses that included but was not limited to Multiple Sclerosis, Myelodyplastic Syndrome, Paraplegia, Epilepsy and Cervicalgia. A diagnoses of Diabetes was not noted in the diagnoses information. Review of all current and discontinued physician orders showed insulin was never ordered, or administered, for Resident #8. Review of Resident #8's care plan did not identify a Focus of diabetes mellitus or insulin administration. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] Section N0350 Insulin showed Resident #8 received seven days of insulin injections. During an interview on 01/18/23 at 12:03 p.m., Staff E Registered Nurse (RN), MDS Coordinator stated she had worked in the facility for about a month. Staff E RN, MDS Coordinator reviewed Resident #8's current and discontinued orders as well as the October 2023 Medication Administration Record (MAR) and confirmed, Resident #8 had never received insulin and the MDS assessment was incorrect. 105634 Page 4 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis and / or ensure the accuracy of a PASARR Level I for 4 (#13, #17, #46, #42) of 7 sampled residents with mental health diagnoses Findings included: 1. Review of the clinical record revealed Resident #13 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to, psychosis as of 08/06/2012, recurrent major depression disorder as of 08/06/2012, cerebral vascular accident (CVA) as of 08/06/2012, anxiety as of 08/06/2012, diabetes as of 07/24/2014, vascular dementia as of 02/17/2015, mood disorder as of 08/28/2018, and dementia as of 06/12/2020. Review of the annual Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 06 (severe impairment). Section I, Active Diagnoses showed non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder (other than schizophrenia). Section M, Skin Conditions showed open lesions other than ulcers, rashes, cuts, application of nonsurgical dressings. Review of the Preadmission Screening and Resident Review (PASARR) dated 07/20/2021 showed under Section IA, depressive disorder and psychotic disorder. Section III showed to not be a provisional admission. Section IV showed a serious mental illness. A PASSAR Level II referral was not present in the clinical record. Progress Psychiatry Notes showed: On 12/15/2023 and 01/12/2024, Patient with past psychiatric history of depression and dementia. Patient denied mood swings and behavioral outbursts. No symptoms of depression or anxiety were observed. Review of the care plans showed: Resident #13 had a psychiatric diagnosis of psychosis, depression and dementia. She was on antidementia medications. She was at risk for side effects of medications initiated on 08/13/2012. Interventions included but were not limited to administering medications as ordered as of 04/08/2022; observe for effect, possible side effects as of 08/13/2012. 2. Review of the clinical record revealed Resident #17 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to paraplegia due to an injury of T7-T10 as of 03/20/2014, Stage IV pressure ulcer on sacrum as of 09/30/2019, contractures of right and left feet and ankles as of 08/18/2021, unspecified protein-calorie malnutrition as of 02/28/2023, hypertension as of 11/23/2020, and recurrent major depressive disorder as of 05/21/2020. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns 105634 Page 5 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section I, Active Diagnoses showed hypertension, diabetes, paraplegia, depression, Stage IV pressure ulcer of sacrum. Section M, Skin Conditions showed a stage IV pressure ulcer. Section N, Medications showed antianxiety, antidepressants, and opioids. Review of the Preadmission Screening and Resident Review (PASARR) dated 02/27/2015 showed under Section I was a request for admission to a nursing facility (NF). Section IIA was blank. Section III showed all no answers. Section IV showed to be not a provisional admission. Section V showed an individual may be admitted to the nursing facility (NF). A PASSAR Level II referral was not present in the clinical record. Review of the psychiatric progress notes showed: On 12/15/2023 and 01/12/2024 both showed the chief complaint was for depression, anxiety, and insomnia. Resident had past psychiatric history of depression, anxiety and insomnia. He has not been depressed and anxious. His mood was good. Resident was on Bupropion HCL ER (XL) tablet extended release 24-hour 150 milligram (mg) at bedtime for anxiety; Trazodone HCl 50 mg at bedtime related to recurrent major depressive disorder. Review of the care plans for Resident #17 revealed a psychiatric diagnosis of depression, is at risk of exacerbation of symptoms and behaviors associated with psychiatric diagnoses has potential for side effects of psychotropic drugs use related to: anti-depressant failed gradual dose reduction (GDR), restart anti-depressant hypnotic, has diagnoses of insomnia initiated on 03/20/2014. Interventions included but were not limited to medications as ordered, observe for effect, possible side effects initiated on 03/20/2014. 3. Review of the clinical record revealed Resident #46 was admitted on [DATE] and readmitted [DATE], a primary diagnosis of local infection of the skin on 12/18/2023 according to the admission face sheet. Further review of the admission face sheet revealed subsequent diagnoses that included but were not limited to bipolar disorder, current episode depressed, mild or moderate severity as of 12/18/2023, recurrent moderate major depressive disorder as of 11/04/2022 and anxiety disorder as of 10/01/2022. Review of the Minimum Data Set (MDS) dated [DATE] showed under Section I, diagnoses that included anxiety disorder, depression, bipolar disorder. Section N, Medications showed resident was taking anti-anxiety and antidepressant medications. Review of the physician's orders showed Clonazepam 0.25 mg via g-tube every 24 hours as needed for anxiety at bedtime on 01/07/2024; Sertraline HCL 50 mg via g-tube daily for depression as of 01/07/2024; trazodone HCL 50 mg via g-tube at bedtime for depression as of 01/17/2024. Review of the psychiatry subsequent note 12/01/2023 showed the chief complaint was depression, anxiety and insomnia. The Resident with a past psychiatric history of depression, anxiety and insomnia. Patient had no symptoms of depression or anxiety noted. No medication changes were done. During last visit, patient had signs of depression. Patient endorsed feeling sad due to health conditions. No anxiety symptoms noted. No mood swings or behavioral outbursts were noted. Review of the psychiatry subsequent note 12/29/2023 showed the chief complaint was depression, anxiety and insomnia. The Resident with a past psychiatric history of depression, anxiety and insomnia. 105634 Page 6 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prior to last visit, patient had symptoms related to depression but denies anxiety. No mood swings or behavior outbursts were seen. During the last visit, patient was doing well. Patient denied overt symptoms of depression and anxiety. No medication changes were done. Review of Resident #46 care plans showed he uses anti-anxiety medications related to anxiety disorder as of 12/20/2023. Interventions included but were not limited to administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift as of 12/20/2023. Resident #46 was at risk for complications related to use of psychotropic drugs. Antidepressant and anti-anxiety medication as of 10/01/2022. Interventions included but were not limited to monitor for continued need of medication as related to behavior and mood as of 10/03/2022. Review of the PASARR Level I dated 09/21/2022 revealed Section 1A was blank. All of Section II was marked no. Section III was marked not a provisional admission; Section IV was marked no diagnosis or suspicion of Serous Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required. 4. Review of the admission Record showed Resident #42 was admitted to the facility on [DATE] with diagnoses that included but was not limited to unspecified protein-calorie malnutrition, Atherosclerotic heart disease, peripheral vascular disease and personal history of transient ischemic attack (TIA). The admission Record showed a new diagnosis of Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety with onset date of 04/26/23. Review for Resident #42's Level II Preadmission Screening and Resident Review (PASARR) for the new diagnosis of Dementia with onset date of 04/26/23 showed no Level II referral with review results were available for review. Review of Resident #42's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #42 had a diagnosis of Non-Alzheimer's Dementia. During an interview on 01/18/24 at 2:00 p.m., the Director of Nursing (DON) stated when a Resident was diagnosed with a new mental diagnosis or intellectual disability, the facility should have referred the Resident to the state agency for a Level II review. The DON reviewed and confirmed that Resident #42 was diagnosed a new mental diagnosis after admission but a Level II review had not occurred. The DON also confirmed a PASSAR Level II was not present for residents #13, #17, and #46. Review of the facility's policy titled Resident Assessment- Coordination with PASARR Program revised date 09/18/23 showed, 9. Any Resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 105634 Page 7 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the clinical record revealed Resident #38 was admitted on [DATE], a primary diagnosis of moderate recurrent depressive disorder as of 12/15/2023 according to the admission face sheet. Further review of the admission face sheet revealed subsequent diagnoses that included but were not limited to catatonic disorder due to known physiological condition as of 11/27/2023, dementia as of 11/27/2023, brief psychotic disorder as of 12/15/2023, generalized anxiety disorder as of 12/15/2023 and mood disorder as of 12/20/2023. Residents Affected - Few Review of the admission Minimum Data Set (MDS) dated [DATE] showed under Section C, Cognitive Patterns a BIMS score of 15 (cognitively intact). Section I, diagnoses that included non-Alzheimer' s dementia, depression. Review of the Psychiatry Evaluation note dated 12/01/2023 showed chief complaint was depression and anxiety. Resident #38 with past psychiatric history of depression and anxiety. Patient was a new admit to this facility requiring evaluation for underlying psychiatric conditions and treatments. Patient feels her symptoms of depression and anxiety are controlled with medication that she was taking. Patient has depression. Patient denies having anxiety. On 12/22/2023, psychiatry subsequent note showed chief complaint was depression, anxiety and psychosis. Patient to access tolerability and effectiveness after recent medication changes. Patient with past psychiatric history of depression, anxiety and psychosis. During last visit, patient had no motivation and interest. Decreased Zyprexa 2.5 mg to twice a day for brief psychosis. Review of the care plans showed Resident #38 was at risk for adverse reactions to anti-anxiety, antidepressant and antipsychotic medications initiated on 12/04/2023. Interventions included but were not limited to administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift as of 12/04/2023. Resident had potential for psychosocial well-being problem related to depression care plan initiated on 12/11/2023. Resident was at risk for complications related to the use of psychotropic drugs care plan initiated on 12/11/2023. Interventions included but were not limited to Gradual dose reduction as ordered as of 12/11/2023, monitor for need for continued medication as related to behavior and mood as of 12/11/23. Resident uses psychotropic medications related to brief psychotic disorder, depression, anxiety care plan as of 12/18/2023, Interventions included but were not limited to administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift as of 12/18/2023. Review of the PASARR Level I dated 11/26/2023 revealed Section 1A was blank. All of Section II was marked no. Section III was marked not a provisional admission; Section IV was marked no diagnosis or suspicion of Serous Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required. Based on record review, interviews, and review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for two (Resident #38 and #47) of fifteen residents sampled for PASRR review. Findings included: 105634 Page 8 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Review of the admission Record showed Resident #47 was admitted to the facility on [DATE] with diagnoses that included but was not limited to Major Depressive Disorder, Anxiety Disorder and Schizophrenia. A review of Resident #47's PASRR assessment, dated 01/27/23 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkbox for the selection Schizophrenia was not checked. Review of Resident #47's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #42 had diagnoses of Anxiety Disorder, Depression and Schizophrenia. During an interview on 01/18/24 at 2:00 p.m., the Director of Nursing (DON) stated that when a new Resident is admitted to the facility a team of staff reviewed all PASRRs after morning meeting to ensure the PASRR was correct. The DON stated if the team of staff found a PASRR to be inaccurate the facility would request for a new a PASRR to be completed. The DON reviewed Resident #47's level I PASRR and admitting diagnoses and stated the Level I PASRR was incorrect but was never corrected. Review of the facility's policy titled Resident Assessment- Coordination with PASARR Program revised date 09/18/23 showed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs 1. All applicants to this facility will be screened for serious mental disorder or intellectual disabilities and related conditions in accordance with State's Medicaid rules for screening. 105634 Page 9 of 28 105634 01/18/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care and services related to 2 of 2 sampled residents (#13 and #49). Resident #13 lacked documentation related to a new diagnoses of melanoma, biopsy, care, and documentation of the characteristics of the wound. Resident #49 lacked follow up regarding need for antibiotics with the physician and Hospice. Residents Affected - Few Findings included: Review of the clinical record revealed Resident #13 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to, psychosis as of 08/06/2012, recurrent major depression disorder as of 08/06/2012, CVA as of 08/06/2012, anxiety as of 08/06/2012, diabetes as of 07/24/2014, vascular dementia as of 02/17/2015, mood disorder as of 08/28/2018, and dementia as of 06/12/2020. Review of the annual Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 06 (severe impairment). Section I, Active Diagnoses showed non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder (other than schizophrenia). Section M, Skin Conditions showed open lesions other than ulcers, rashes, cuts, application of nonsurgical dressings. Review of physician's orders showed as of 11/17/2023 wound care, cleanse biopsy to chest with normal saline, and cover with border foam daily and as needed. The Treatment Administration Report (TAR) showed wound care provided as per order. Review of the progress notes showed: On 11/04/23, the resident's family into see resident and noted a mole in middle of the resident's chest and wanted resident to be seen by the dermatologist. On 11/06/23, Social Services referred resident to dermatologist for a mole on her chest, awaiting a response for the next dermatology appointment date. On 11/09/23, the Dermatologist notified the social worker that he would be there on 11/13/23. The sister was called and notified of the date of dermatology appointment. On 11/13/23, Dermatology took biopsy of area on chest. Dermatologist also noted area to left breast. Left breast biopsy also taken. On 11/21/23, Social Services was notified by Dermatology that the biopsy results were in. On 12/08/23, referral faxed to Cancer Center, awaiting return call On 12/22/24, Social services spoke with resident's sister and advised that resident's appointment at Cancer Center was on 01/05/2024 at 10:30am. On 01/04/24, the resident's upcoming appointment at Cancer Center, appointment was rescheduled due to Covid + results. Sister was notified. 105634 Page 10 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 Weekly Skin Evaluations showed: Level of Harm - Minimal harm or potential for actual harm On 11/07/2023, mole in the middle of the chest On 11/14/2023, middle of chest already noted Residents Affected - Few On 11/21/2023, middle of chest already noted On 11/28/2023, chest blister On 12/05/2023, middle of chest On 12/12/2023, chest On 12/19/2023, skin intact On 12/26/2023, chest, already being treated On 01/02/2024, pre-existing open area to chest On 01/11/2024, middle of chest Review of the pathology report dated 11/13/2023 showed melanoma in situ of mid chest and compound melanocytic nevus of left breast. Review of the care plans showed: Resident #13 had potential for impaired skin integrity related to decreased mobility, bowel and bladder incontinence and diabetes initiated 03/09/2014. Interventions included but were not limited to observe skin daily with care, preventive skin care as of 03/09/2014. Inspect and chart skin integrity weekly and as needed as of 03/09/2014; weekly skin checks, observe and document as of 03/09/2014. No documentation noted regarding melanoma, melanoma biopsy or wound care. During an interview on 01/17/2024 at 5:20 p.m. the Registered Nurse Consultant verified there was no description of the wound / biopsy in the progress notes, there were no measurements documented in the chart. The Care Plan was not updated to reflect the diagnoses of melanoma, biopsy, or wound care. She verified the biopsy was performed on 11/13/23 and wound care was put into place. During the same interview, Staff G Registered Nurse, the wound care nurse, confirmed there were no descriptions, measurements, etc. in the chart. Staff G stated, she did not know to do that until recently. They both verified the skin sheets/documentation did not address the wound. Review of the facility's policy, Wound Treatment Management, revised on 11/23/2022 showed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy and Explanation and Compliance guidelines: 5. b. characteristics of the wound: i. pressure injury stage. 105634 Page 11 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 ii. size- including shape, depth, and presence of tunneling and / or undermining Level of Harm - Minimal harm or potential for actual harm iii. volume and characteristics of exudate. iv. presence of pain Residents Affected - Few v. presence of infection or need to address bacterial bioburden. vi. conditions of eh tissue in the wound bed vii. condition of the peri-wound skin 5. c. Location of the wound 5. d. Goals and preferences of the resident/ representative. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. lack of progression towards healing. b. Changes in the characteristics of the wound c. Change in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. An observation on 01/16/24 at 9:47 a.m., showed Resident #49 was on Contact Precautions. (photographic evidence obtained) Review of the admission record showed Resident #49 was originally admitted to the facility on [DATE] with diagnoses included but not limited to Adult failure to thrive, hyperlipidemia, paroxysmal atrial fibrillation and Dementia. A review of a current order dated 01/13/23 showed contact isolation related to Clostridioides Difficile (C-Diff). There were no other current physician orders related to C-Diff. Review of the Resident #49's stool testing results with reported date 01/10/24 showed Resident #49 was positive for C. Difficile/EPI Ceph. Review of Resident #49's care plan revised on 01/14/24 showed Focus: [Resident #49] has active infection: C-Diff. Goal: [Resident #49] will be kept comfortable through medical interventions as evidenced by s/s of effective pain management through the review date. Interventions/Tasks Administer medications as ordered Monitor for pain and administer medications for pain as ordered. 105634 Page 12 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 Observe facility policies for infection control Level of Harm - Minimal harm or potential for actual harm Review of progress note Orders - Administration Note dated 01/11/24 showed, Vancocin Oral Capsule 125 MG. Give 1 capsule by mouth every 6 hours for C-diff for 14 Days awaiting delivery. May administer upon delivery. PCP [primary care physician] aware. Residents Affected - Few During an interview on 01/18/24 at 11:20 a.m., Staff B, Licensed Practical Nurse (LPN) stated, Resident # 49 was on contact precautions for C-diff. Staff B, LPN stated there were no orders for an antibiotic for C-diff and she did not administer Resident #49 any antibiotics for C-Diff on 01/13/24 and 01/18/24. During an interview on 01/18/24 at 11:25 p.m., Staff A Licensed Practical Nurse (LPN), Unit Manager (UM) stated Resident #49 did have C-Diff. Staff A LPN, UM stated Resident #49 was recently admitted to Hospice care and was now considered to be on comfort measures only. Staff A LPN, UM stated Hospice may have taken Resident # 49 off all medications and to put him on comfort measures. During an interview on 01/18/24 at 12:30 p.m., Staff C, Regional Nurse Consultant (RNC) stated just because a resident was placed on Hospice should be no reason to not treat an active C-diff infection with antibiotics. During an interview on 01/18/24 at 11:37 a.m., the Director of Nursing (DON) stated maybe hospice discontinued all meds and put him on comfort measures only, but I would check on that. Review of Resident #49's physical medical record showed a Hospice progress note dated 01/16/24. The progress note stated medications: 1. D/C [discontinue] current Ativan and Morphine. 2. Start Morphine 100 mg[milligrams]/5 ML[milliliters] (20 MG/ML) give 0.25 ML's Po Q 8 Routine for pain/ sob. 3. Start Lorazepam 2 mg/ml give 0.5 ml's Po Q 8 routine for anxiety. 4. Start Hyoscyamine 0.125 mg Q 6 PRN [as needed] for secretions. During an interview on 01/18/24 at 11:57 a.m., Resident #49's Primary Care Physician (PCP) stated that no one from the facility informed him Resident #49 had a C-Diff infection. Resident #49's PCP stated if Resident #49 had diarrhea and had active symptoms of C-Diff then Resident #49 should have been treated for the infection. Review of Resident #49's Bowel and Bladder Elimination documentation showed the following: 01/11/24- Bowel movement was Loose/Diarrhea 01/12/24- Bowel movement was Loose/Diarrhea 01/13/24- Bowel movement was Loose/Diarrhea 01/14/24- Bowel movement was Loose/Diarrhea 01/15/24- Bowel movement was formed/normal 01/16/24- No Bowel Movement 01/17/24- No Bowel Movement 105634 Page 13 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 01/18/24-No Bowel Movement Level of Harm - Minimal harm or potential for actual harm During an interview on 11/18/24 at 12:10 p.m., the DON stated there were discontinued physician orders that showed Vancocin Oral Capsule was ordered on 01/11/24 for C-diff and a progress note to show that Resident #49's Nurse Practitioner (NP) discontinued the antibiotic. Residents Affected - Few Review of Resident #49's discontinued orders dated 01/11/24 showed three Vancocin Oral Capsule orders. The orders were as follows: -Vancocin Oral Capsule 125 MG [milligrams] (Vancomycin HCI) Give 1 capsule by mouth every 12 hours for C-Diff for 7 days -Vancocin Oral Capsule 125 MG [milligrams] (Vancomycin HCI) Give 1 capsule by mouth every 6 hours for C-Diff for 14 days -Vancocin Oral Capsule 125 MG [milligrams] (Vancomycin HCI) Give 1 capsule by mouth one time a day for C-Diff for 7 days Review of a progress note dated 01/11/24 showed, Resident continues to decline. Daughter expresses that she does not want the resident to go to the hospital and wants a Hospice consult. Notified NP [name of NP] regarding resident status and the wishes of the daughter/resident. New orders for CMO, discontinue all medications, and Hospice Consult, and Morphine and Ativan for comfort. Notified daughter and she is agreeance of the plan of care. During an interview on 01/18/24 at 12:18 p.m., Staff D, Nurse Practitioner (NP) stated, I was the one who discontinued Resident #49's medications including the antibiotic. The NP stated Resident #49 was very lethargic and felt allowing Resident #49 to take pills since he was having difficulty swallowing was a safety concern. Staff D NP stated she knew Resident #49 had tested positive for C-Diff but the risks out weighted the benefits at that time. Staff D NP stated she knew Resident #49 was being referred to Hospice so all medications were discontinued and was going to let Hospice take over.Staff D NP stated, usually the facility will call and update her on the Hospice recommendations for coordination of care but the facility did not. Staff D NP stated, I do not even know if Hospice has even been in to see him yet. Staff D NP stated there should have been follow up between the facility and physician services. 105634 Page 14 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate care related to pressure ulcer care for 1 of 3 sampled residents (#17). The facility failed to document the characteristics of the pressure ulcer in the medical record. Residents Affected - Few Findings included: Review of the clinical record revealed Resident #17 was admitted on [DATE] and readmitted on [DATE]. Further review of the admission face sheet revealed diagnoses that included but were not limited to paraplegia due to an injury of T7-T10 as of 03/20/2014, Stage IV pressure ulcer on sacrum as of 09/30/2019, contractures of right and left feet and ankles as of 08/18/2021, unspecified protein-calorie malnutrition as of 02/28/2023, hypertension as of 11/23/2020, and recurrent major depressive disorder as of 05/21/2020. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed in Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section I, Active Diagnoses showed hypertension, diabetes, paraplegia, depression, Stage IV pressure ulcer of sacrum. Section M, Skin Conditions showed a stage IV pressure ulcer. Section N, Medications showed antianxiety, antidepressants, and opioids. Review of the physician's orders showed cleanse the sacral wound bed with wound cleanser then pat dry, place protective barrier cream around the wound, place Aquacel, place wound dressing over Aquacel into wound, cover with sacral foam border dressing daily and as needed, low air loss mattress. Review of nursing progress notes showed no documentation regarding the stage IV pressure ulcer on sacrum. Review of the care plans for Resident #17 revealed he had a wound on the sacrum was unavoidable related to impaired mobility, chronic voiding dysfunction and diagnosis of paraplegic, initiated on 08/05/2019. Interventions included but were not limited to observe and report signs and symptoms of infection and poor healing as of 03/25/2021. Review of the outside wound care clinic documentation revealed location of wound, orders related to wound, but no documentation of wound characteristics. During an interview on 01/17/24 at 1:55 p.m. with the Registered Nurse Consultant (RNC) she stated she had advised the Director of Nursing (DON) to do weekly wound notes even though the resident goes out to the wound care clinic. She stated they (the facility) are responsible to do weekly notes related to the wound. She verified there was only one note in the chart related to the wound. She verified the wound notes from the outside wound care clinic, that was scanned into the chart. did not include the wound sizes, etc. During an interview on 01/17/2024 at 2:13 p.m. Staff G, Registered Nurse (RN) wound care nurse, stated she had just started documenting the wound sizes around 01/04/2024 due to the RNC informing her the wound documentation needed to be in the chart. She stated prior to that she had not been documenting the information into the chart, only updating the physician orders. 105634 Page 15 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/17/2024 at 2:00 p.m. the Director of Nursing (DON) stated she had called the wound care clinic for wound measurements, etc. The DON stated the wound care nurse provides the wound care to the resident Monday through Friday and on Saturday and Sunday the floor nurses provide the care. The DON stated the resident goes to an outside wound care clinic weekly. Review of the facility's policy, Wound Treatment Management, revised on 11/23/2022 showed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy and Explanation and Compliance guidelines: 5. b. characteristics of the wound: i. pressure injury stage. ii. size- including shape, depth, and presence of tunneling and / or undermining iii. volume and characteristics of exudate. iv. presence of pain v. presence of infection or need to address bacterial bioburden. vi. conditions of eh tissue in the wound bed vii. condition of the peri-wound skin 5. c. Location of the wound 5. d. Goals and preferences of the resident/ representative. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. lack of progression towards healing. b. Changes in the characteristics of the wound c. Change in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 105634 Page 16 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one resident (# 4) was assessed to conduct self- catheterization out of four residents sampled. Finding included: On 01/16/24 at 12:16 p.m., Resident # 4 observed laying down in bed with his call light within his reach and bedside table next to him. Resident was observed with his catheter bag stored in a trash can with two urinals placed on the side of the trash can. The room was observed little cluttered, proper lightening and home like environment. On 01/17/2024 at 3:00 p.m., Resident # 4 observed laying down in bed with his call light within his reach. 12-inch catheter products were observed on the resident nightstand. He said he took his indwelling catheter out yesterday and inserted the 12-inch catheter. His 12 inch catheter products came in that he normally uses, which is easier for him to insert himself. He wishes the facility keeps the 12-inch catheter in stock because they are easier from him to insert instead of the indwelling catheter. He said no one observes and assesses him to conduct his self-catheter. Review of the admission Record dated 01/18/2024, showed Resident # 4 was admitted originally on 11/10/2021 and readmitted on [DATE] with diagnoses to included but not limited to Neuromuscular Dysfunction of Bladder, Unspecified, Pain Unspecified, Need for assistance with Personal Care, Pressure Ulcer of Sacral Region Stage 3 Review of Annual Minimum Data Target date 11/2/2023 showed Section C, Cognitive Patterns, Brief Interview for Mental Status showed no score recorded. Review of Order Summary Report dated 01/18/2023 showed active order revealing resident may straight Catheterize Self (Self Cath) every 4 hours (Q4hrs) while awake. For bladder retention. Active order date 11/11/2021. Review of Care plan dated 11/27/2023 showed Resident #4 is at risk for infection and voiding difficulty. Resident straight catheterizes self-due to neurogenic bladder. Further review of the care plan intervention showed to ensure resident uses good infection control techniques, provided needed equipment, and supplies to do so. During an Interview on 01/17/2024 at 1:45 p.m., the Director of Nurses said Resident # 4 has an order to conduct Self-Catheterization but was not assessed to ensure he can safely Self-Catheterize himself. Her expectation is that if a resident has an order to Self-Cath that the nursing staff conducted an assessment to ensure that the resident is capable to do it safely. She confirmed the facility did not have a policy to provide for self-catheterization. Review of facility policy titled, Catheter Care Revision date 1/6/2023 showed Policy: It is the policy of this facility to ensure that resident with indwelling catheters received appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 105634 Page 17 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0690 Policy Explanation: Level of Harm - Minimal harm or potential for actual harm 1. Catheter care will be performed every shift and as needed by nursing staff. Residents Affected - Few 105634 Page 18 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the medication error rate was below 5% for three (#10, #31, #35) of 6 sampled residents who were administered medications. This resulted in 3 errors of 30 medication administration opportunities for a medication error rate of 10%. Residents Affected - Few Findings included: On 01/16/2024 at 9:45 a.m. Staff I, Registered Nurse (RN) was observed performing medication administration for Resident #10. She administered -Oscal 500/200, D-3 milligrams (mg)-unit daily for supplement; -Vitamin B 12 extended release 1000 micrograms (mcg) daily for supplement; -Refresh solution 1.4-0.6%, instill 1 drop in both eyes four times a day for dry eyes Review of the Medication Administration Record (MAR) showed: Lysine 500 mg in the morning for a supplement was documented as given by Staff I. During an interview on 01/18/2023 at 1:45 p.m., Staff I stated that was an error, she did not have any Lysine in the medication cart or facility to give the resident. She did not receive her Lysine that day. The Director of Nursing (DON) verified the documentation. On 01/16/2024 at 9:55 a.m. Staff I, RN was observed performing medication administration for Resident #31. She administered Advair diskus aerosol powder breath activated 250 / 50 mcg / dose every 12 hours for SOB [shortness of breath], rinse mouth and spit after each use and Ventolin 1 puff every 4 hours as needed for SOB was administered, including rinse and spitting. Review of the MAR revealed Ventolin 1 puff every four hours as needed had not been documented as given, instead Albuterol sulfate HFA 108 (90 base) MCG/ACT aerosol, 1 puff inhale orally every 6 hours for SOB/Wheezing was documented as administered. During an interview on 01/18/2023 at 1:45 p.m., Staff I stated that she had given the resident his Albuterol not Ventolin. The DON verified Staff I had documented she had given the Albuterol not the Ventolin. On 01/16/2024 at 11:45 a.m. Staff H, Licensed Practical Nurse (LPN) was observed performing a blood glucose monitoring procedure and insulin injection for Resident #35. The glucose monitoring results were 224. The order was for Humalog 4 units with the use of an insulin pen. Staff H, LPN removed the insulin pen and turned the knob to 4 units. She took the insulin pen and the needle in a container into the resident's room. She placed the needle on the insulin pen and donned gloves. She gave the insulin in the abdomen. Staff H removed her gloves, exited the room, placed the insulin pen back into the medication cart and then hand sanitized. During an interview with Staff H, LPN following the administration, she stated she has never primed an insulin pen before. She just looks to see there was no air in the needle. She looked up the insulin pen directions on her phone. It showed to remove the air from the needle by priming the pen first with 2 units of insulin and make sure the insulin came out the needle. She stated without priming the needle, she guessed the resident was not getting the full dose of ordered insulin. Review of Resident #35's physician orders showed the following: HumaLOG KwikPen 100 UNIT/ML (units 105634 Page 19 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few per milliliter) Solution pen-injector, Inject as per sliding scale: if 151 - 200 = 2 units NOTIFY MD IF BS BELOW 70; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units CALL MD (physician) IF BS OVER 400, subcutaneously before meals and at bedtime related to TYPE 2 During an interview on 01/16/2023 at 12:00 noon, the Director of Nursing (DON) stated she would have to look at the facility policy regarding priming of insulin pens. She stated she did know the insulin pens needed to be primed. Review of the facility's policy, Insulin Pen, revised on 05/03/2022 showed it is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. Policy Explanation and Compliance Guidelines: 1. Insulin pens contain doses of insulin but are used for a single resident only. 4. A new needle will be used for each injection. 5. Monitor blood sugar as ordered by physician. 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. 11. Procedure: A. gather supplies needed B. perform hand hygiene. C. [NAME] gloves. D. verify resident identification. E. check the expiration date on the pen. F. examine the appearance of the insulin. G. attach pen needle. H. prime the insulin pen: i. dial 2 units of insulin by turning the dose selector clockwise. Ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. I. set the insulin dose. 105634 Page 20 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0759 J. inject the insulin. Level of Harm - Minimal harm or potential for actual harm K. remove gloves and perform hand hygiene. L. document the dosage, site, and time in the medication record along with nurse signature. Residents Affected - Few Review of the facility's policy, Medication Administration, revised 10/2023 showed medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy and Explanation Compliance Guidance: 3. Identify resident by photo in the MAR 4. Wash hands prior to administering medication per facility protocol and product 8. Obtain and record vital signs, when applicable or per physician orders 10. Review MAR to identify medication to be administered 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route and time. A. refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 13. Remove medication from source, taking care not to touch medication with bare hand 14. Administer medication as ordered in accordance with manufacturer specifications 16 Wash hands using facility protocol and product 17. Sign MAR after administered. For those medications requiring vital signs, record the vital sign onto the MAR. 105634 Page 21 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of the facility's policy titled Food: Quality and Palatability the facility failed to serve food at an appetizing temperature for one Resident (#48) out of 15 sampled residents reviewed for food services. Residents Affected - Few Findings included: During an interview on 01/16/24 at 10:43 a.m., Resident #48 stated hot food was being served cold. Resident #48 stated dinner on 01/14/24 was cold. The State Surveying Agency (SSA) requested a test tray be placed on the last tray cart leaving the kitchen for 01/17/24 lunch meal. An observation on 01/17/24 at 12:25 p.m., showed the test tray remained on the tray cart until the last resident tray was delivered. The test tray was then removed by Staff F, Food Service Director (FSD) for food temperatures. During an interview on 01/17/24 at 12:25 p.m., Staff F, FSD stated the thermometer had been calibrated and was ready to take food temperatures. Staff F, FSD stated he expected all cold food to be under 41 degrees Fahrenheit (F) and would expect all hot foods to be above 135 degrees Fahrenheit for appetizing temperatures. The test tray food temperatures were completed and results were as follows: -Milk- 40.8 degrees F -Juice-46 degrees F -Ice cream- 20.3 degrees F -[NAME]- 124.2 degrees F -Broccoli- 117.3 degrees F -Noodles- 114.2 degrees F -Biscuit- 100.2 degrees F An observation on 01/17/24 at 12:25 p.m., showed no steam from the plate of hot food when the plate cover was removed. The State Surveyor felt the [NAME] on the plate with finger and the fish and other food items were not hot. During an interview on 01/17/24 at 12:30 p.m., Staff F, FSD stated the test tray did not meet appetizing temperature levels. Staff F, DFS stated the food items did not meet appetizing temperatures because the hot food items were not at 135 degrees or higher and the juice was too warm because it was above 41 degrees. A review of the facility's policy titled, Food: Quality and Palatabilitydated October 2019 showed, It is the center policy that, food is prepared by methods that conserve nutritive value, flavor and 105634 Page 22 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0804 appearance. Food is palatable, attractive, and served at a safe and appetizing temperature. Proper temperature means both appetizing to the resident and minimizing the risk for burns. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105634 Page 23 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews and review of the facility's policy titled Use and Storage of Food brought in by Family of Visitors, the facility failed to ensure food items were stored in accordance with professional standards for food service safety for one refrigerator (dining area) out of three refrigerators reviewed in the facility. Findings included: An observation on 01/16/24 at 12:12 p.m., revealed a refrigerator designated for residents located in the dining area. The resident refrigerator had a sign on it that stated, Resident Refrigerator Only This refrigerator will be checked every Tuesday any items expired or not dated will be thrown in the trash. On the inside of the resident refrigerator revealed an expired egg nog with an expiration date of 12/23/23, a container of a red substance not labeled or dated and a bag of food items that were not labeled or dated. On the outside of the resident refrigerator showed an empty sleeve with no temperature log available. (photographic evidence obtained) During an interview on 01/16/24 at 12:13 pm., Staff F, Director of Food Services (DFS) stated, To be honest, I didn't even know this was here. Staff F, DFS looked inside the resident refrigerator and saw the egg nog dated 12/23/23 and stated that is old. Staff F, DFS stated the container of unknown red substance was not labeled or dated and the bag of food items was not labeled or dated both needed to be discarded immediately. Staff F, DFS stated there should be a temperature log available in the empty sleeve to the outside of the refrigerator but stated that would be the Certified Nursing Assistance (CNA) responsibility for that. During an interview on 01/16/24 at 12:30 p.m., Staff A Licensed Practical Nurse (LPN) and Unit Manager (UM) stated the refrigerator in the dining room was designated as a resident refrigerator and used by all residents. Staff A, LPN, UM stated any staff can store resident food in the resident refrigerator. Staff A LPN, UN confirmed there should have been a temperature log in the plastic sleeve on the outside of the resident refrigerator and that both the dietary department and nursing department was responsible for the resident refrigerator. Staff A LPN, UM stated she would expect that all items in the resident refrigerator be labeled and dated and no expired food items should have been in there. Review of the facility's policy titled Use and Storage of Food brought in by Family of Visitors revised date 03/20/23 showed, 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. 2a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. 2b. The prepared food must be consumed by the resident within 3 days. 2c. If not consumed within 3 days, food will be thrown away by the facility staff. 105634 Page 24 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure staff followed acceptable standards of practice related to infection control including hand hygiene, disinfecting of the glucose monitoring machines, and water testing. Residents Affected - Few Findings included: On 01/16/2024 at 9:55 a.m. Staff H, Licensed Practical Nurse (LPN) was observed performing medication administration for Resident #34. During the medication administration hand sanitizing was not performed. On 01/16/2024 at 10:00 a.m. Staff H, LPN was observed performing medication administration for Resident #50. No hand sanitizing was performed prior to gathering medications, before entering room and none post medication administration. On 01/16/2024 at 11:45 a.m. Staff H, Licensed Practical Nurse (LPN) was observed performing a blood glucose monitoring procedure and insulin injection for Resident #35. Staff H, LPN removed blood glucose monitoring machine and placed it, the container of strips and lancet on top of the medication cart. Staff H applied gloves without hand sanitizing and removed a wipe from the purple top cleaning wipes container. She wiped the blood glucose monitoring machine and replaced it on top of the medication cart. She removed her gloves. She did not hand sanitize and picked up the supplies including a pair of gloves and entered the resident's room. She placed the supplies on the over bed table without a barrier. She then applied her gloves and removed a strip from the bottle and placed it in the blood glucose monitoring machine. She then cleaned the left pointer finger of Resident #35 with alcohol. She used the lancet and stuck his finger. She placed a drop of blood on the blood glucose monitoring machine strip and the results were 224. She removed her gloves and exited the room carrying the blood glucose monitoring machine, used lancet and strip. She placed the lancet and strip in the biohazard box on the side of the medication cart. She sat the blood glucose monitoring machine and strip bottle on the medication cart. Without hand sanitizing or donning gloves, she removed a wipe from the purple topped container and wiped down the blood glucose monitoring machine. She sat both the blood glucose monitoring machine and bottle of strips into the top drawer of the medication cart. She then touched the computer, hand sanitized and inputted data into the computer. The order was for Humalog 4 units with the use of an insulin pen. Staff H, LPN removed the insulin pen and turned the knob to 4 units. She took the insulin pen and the needle in a container into the resident's room. She placed the needle on the insulin pen and donned gloves. She gave the insulin in the abdomen. Staff H removed her gloves, exited the room, placed the insulin pen back into the medication cart and then hand sanitized. On interview Staff H, LPN stated the blood glucose monitoring machine was to be cleaned between residents. She stated she wipes it down and places it in the medication cart, it will be cleaned again before she uses it for another resident. When asked long it took for the disinfectant to clean the blood glucose monitoring machine, she stated she did not know, but she would be cleaning it again before the next resident. Reviewed the purple top disinfectant container which directed for the machine to need to be wet for 2 minutes to disinfect. She stated she had never timed how long she was wiping the blood glucose monitoring machine. She thought it just could not be used for 2 minutes between cleanings. During an interview on 01/16/2023 at 12:00 noon, the Director of Nursing (DON) stated she would have to look at the policy before she could accurately say how long the blood glucose monitoring machine needed to be wet to disinfect it. 105634 Page 25 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 01/18/2024 at 9:57 a.m. the Registered Nurse Consultant stated she would expect the nurses to perform hand sanitizing during medication pass and before and after gloves. During an interview on 01/18/2024 at 11:15 a.m. the Infection Control Preventionist (ICP) stated that hand sanitizing was supposed to be done prior and after contact with the medications, with the residents, after taking off your gloves. She stated hand sanitizing was supposed to be performed before and after gloves changes. The ICP stated the staff was to clean the blood glucose monitoring machine with the wipes in the purple top container. The machine was supposed to be left wet for 2 minutes. They are supposed to have to blood glucose monitoring machines so one was ready to use at all times. They are supposed to disinfectant between residents. The machine and supplies should be laid on a barrier to keep them clean and not place on a dirty surface. The staff was to wear gloves during the cleaning process of the blood glucose monitoring machine, it is toxic. The staff was to hand sanitize between all processes. During interview on 01/18/2024 at 4:22 p.m. the Director of Nursing (DON) stated they were unable to find any education documentation that infection control practices was provided to the staff including hand sanitizing, Personal Protective Equipment (PPE), etc. Review of the Legionnaires Precaution Plan showed Center Specific Plan: -Water features on property: No water features on property. -Other areas that could potentially spread water droplets: none. -The purpose of the procedure is to provide guidelines for changing, maintaining, and disinfecting devices that potentially create aerosolization of water and / or prevention of water stagnation to minimize exposure to potential legionnaires. -The Legionnaires Precaution Plan nor the Legionella Water management Plan address the water feature / pond in the outdoor, common area. During an interview on 01/18/2024 at 11:17 a.m. the Maintenance Director stated they had a pond water feature on the patio. They had a Legionnaires Precaution Plan. He stated they had sent water samples to a company about 6 months ago. They did not receive the results back because the bill had not been paid. He stated they regularly check the temperatures in the kitchen, resident rooms, showers and sinks. They run water through any bathrooms of resident rooms not occupied. During an interview on 11/18/2024 in the afternoon, the Regional Administrator stated he had spoken with the water testing company and they had thrown away the results. They were going to send water samples again and have the water retested. Review of the facility's policy, Glucometer Disinfection, revised 08/15/2022 showed the purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Definitions: Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 3. The 105634 Page 26 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 Level of Harm - Minimal harm or potential for actual harm glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C, and Hepatitis B virus. 5. Procedure: A. obtain needed equip and supplies: gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes Residents Affected - Few b. wash hands c. explain the procedure to the resident d. provide privacy e. put on gloves f. obtain capillary blood glucose sampling according to facility policy g. remove and discard gloves, perform hand hygiene prior to exiting room h. reapply gloves i. retrieve 2 disinfectant wipes from container j. using first wipe, clean first to remove heavy soil, blood and / or other contaminates left on the surface of the glucometer k. after cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, follow the manufacturer's instructions. Allow the glucometer to air dry. l. discard disinfectant wipes in waste receptacle. m. perform hand hygiene. Review of the facility's policy, Hand Hygiene, revised 05/21/2022 showed staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. the use of gloves does not replace hand hygiene. If your tasks requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table: Between resident contacts After handling contaminated objects Before performing invasive procedures 105634 Page 27 of 28 105634 01/18/2024 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 Before applying and after removing personal protective equipment (PPE) including gloves Level of Harm - Minimal harm or potential for actual harm Before preparing or handling medications Before performing resident care procedures Residents Affected - Few When in doubt 105634 Page 28 of 28