Health inspection·July 15, 2021

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 observation, interview, and record review the facility failed to accurately assess Activities of Daily Living (ADL) assistance with eating for 1 of 2 residents reviewed for tube feedings of a total sample of 38 residents, (#37). Residents Affected - Few Findings: Resident #37 was admitted to the facility 4/24/18 and readmitted on [DATE]. His diagnoses included Parkinson's disease, dysphagia, diabetes type II, dementia, and gastrostomy. The quarterly Minimum Data Set (MDS) assessment with assessment reference date 5/12/21, revealed the resident's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of 4/15. The resident required extensive assistance for bed mobility, transfers, toilet use, and had total dependence for dressing, and personal hygiene. Eating was assessed as activity did not occur. Observations on 7/12/21 at 10:04 AM, 7/13/21 at 10:05 AM, and 5:13 PM showed resident #37 with gastrostomy tube (GT) feed Glucerna 1.2 Cal infusing at 65 milliliter/hour (ml/hr.). On 7/14/21 at 11:37 AM, Registered Nurse (RN) E stated resident #37 was on GT feed Glucerna 1.2 Cal at 65 ml/hr. with physician order for feeds to be on at 2 PM, and off at 10 AM. On 7/14/21 at 2:53 PM, the MDS Coordinator stated assessments were completed by doing a seven day look back of the resident's medical records, interviews with staff involved in the resident's care, and observations of the resident. A review of the resident's quarterly MDS was conducted with the MDS coordinator. He acknowledged the assessment was not correct, and stated the ADL assistance required for eating should have been assessed as total dependence, since the resident received nourishment via gastrostomy tube. The policy Comprehensive Assessments and the Care Delivery Process Revised December 2016 read, Comprehensive assessments will be conducted to assist in developing person-centered care plans. Page 1 of 7 105643 105643 07/15/2021 Island Lake Center 155 Landover Place Longwood, FL 32750

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #29 was admitted to the facility on [DATE] with diagnoses of compression fractures, altered mental status, muscle weakness, and lack of coordination. Residents Affected - Few The resident's admission MDS assessment dated [DATE] showed he required two person extensive physical assistance for personal hygiene needs such as grooming and nail care. He required total dependence of two persons physical assist for bathing. He required total dependence of one person physical assist for toileting needs. The resident's Brief Interview for Mental Status (BIMS) score was 8 which indicated his cognition was moderately impaired. On 7/12/21 at 1:34 PM, the resident was resting in bed. He spoke in short one and two word sentences. His fingernails on both hands were long and uneven, about 1/4 over the tips of his fingers. His fingernails had black, dark brown residue underneath them. On 7/13/21 at 11:50 AM and 7/14/21 at 1:45 PM, the resident's fingernails remained long with black, dark brown, debris underneath the nails. On 7/14/21 at 1:50 PM, the resident's assigned caregiver, CNA A stated she did not take care of him often and that her assignment had been shifted. CNA A said she was not familiar with the specifics of the resident's care and added that his regularly assigned CNA would know better. The resident's Kardex and Shower Schedule were reviewed. It revealed that resident #29's regularly scheduled bathing and shower days were on Mondays and Fridays during the 7 AM - 3 PM shift. On 7/14/21 at 2:15 PM, the Unit Manager said that residents' nails were expected to be cleaned and clipped by the CNA during personal hygiene care and bathing. The UM observed the resident's nails and acknowledged his nails were long with brown residue underneath them. She said his fingernails needed to be cleaned and trimmed. Review of resident #29's care plan for ADLs initially dated 5/2/21 indicated he required assistance with personal hygiene needs. It included, Ensure clean neat appearance daily. Policy and procedure on ADLs revised on March 2018 indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, oral care) . Based on observation, interview and record review, the facility failed to provide nail care for 2 of 5 dependent residents reviewed for activities of daily living (ADL) out of a total sample of 38 residents, (#8, #29). Findings: 1. Resident #8 was admitted on [DATE] with diagnoses of Parkinson's Disease, Diabetes Mellitus Type 2, Hemiplegia and Hemiparesis affecting left non-dominant side and muscle contracture. The quarterly Minimum Data Set (MDS) assessment with reference date 07/04/21 revealed resident #8 105643 Page 2 of 7 105643 07/15/2021 Island Lake Center 155 Landover Place Longwood, FL 32750

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had a Brief Interview for Mental Status (BIMS) Score of 15 indicating her cognition was intact. The assessment noted the resident was totally dependent on 1 staff person for personal hygiene and bathing. On 07/12/21 at 11:13 AM, resident #8 was in bed, alert and watching television. Both of her hands were noted to have tremors while at rest. Her finger nails were observed to be 3/4 to 1 centimeter (cm) long, some jagged, with hardened, reddish-brown debris underneath. She stated she would like her nails cut as she looked at them. She was unable to recall the last time her nails were trimmed. On 07/13/21 at 10:22 AM, and on 07/14/21 at 11:40 AM, the resident's nails remained the same. She stated nobody had asked if she wanted them trimmed. On 07/14/21 at 2:24 PM, Certified Nursing Assistant (CNA) H said the resident was totally dependent on 1 staff for personal hygiene and bathing. She added the resident had never refused ADL care. CNA H explained CNAs were expected to trim the finger nails of their assigned residents when needed. On 07/15/21 at 9:38 AM, the Unit Manager (UM) observed resident #8's finger nails and acknowledged her nails were long and needed to be trimmed. Resident #8 told the UM she preferred to have her finger nails trimmed so she didn't scratch herself. The UM said either CNAs or nurses could file or trim fingernails. On 07/15/21 at 1:15 PM, the Director of Nursing (DON) stated the facility did not have specific policy for nail care because it was part of grooming. She said when CNAs provided showers, they were expected to clean and trim the residents' finger nails. If the resident refused, the CNA would inform the nurse so the refusal could be documented. A review of the resident's Care Plan dated 04/01/21 showed the resident required assistance with ADLs due to Parkinson's disease and right sided weakness. Interventions included to ensure that resident was clean and had neat appearance daily. 105643 Page 3 of 7 105643 07/15/2021 Island Lake Center 155 Landover Place Longwood, FL 32750

F 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED 8/05/21 Residents Affected - Few Based on observation, interview and record review, the facility failed to provide hand splints and foot orthotic device treatments for 2 of 3 sampled residents reviewed for limited range of motion of a total sample of 38 residents, (#71, #16). Findings: 1. Resident #71 was admitted to the facility on [DATE] after a fall resulting in right upper arm humerus fracture. His diagnoses included repair of right humerus fracture, right hand flexion contractures, diabetes, and dementia. On 7/14/21 at 1:15 PM, resident #71 was observed in bed. His right hand was noted to be contracted and the resident was not wearing a splinting device. Review of the resident's Treatment Administration Record (TAR) and Certified Nursing Assistant (CNA) Kardex care plan, both dated July 2021, did not include splinting management for his hand contractures. Review of resident #71's medical record showed a written physician's order for hand splint. The order dated 3/30/21 read, Right progressive hand splint with air bladder for contracture management 6-8 hours/day as tolerated, may be removed during activities of daily living (ADL) care. Review of the current physician orders in the electronic medical record revealed the physician order for the right hand splint had not been entered in the electronic medical record. On 7/14/21 at 2:25 PM, the resident's assigned Certified Nursing Assistant (CNA) D said the resident did not have a splint for his hand. On 7/14/21 at 2:25 PM, the Unit Manager (UM) said she did not recall if the resident had a hand splint. On 7/14/21 at 3:40 PM, the Therapy Director said resident #71 had a right hand splint for flexion contractures. She explained that since last year, the CNAs on the floor had assumed restorative duties for splinting and contracture management. She said they were educated by the therapy staff regarding each resident's splint. She added that the nurse's station had a notebook of residents who required splints with a photo of the correct placement of each splint. The Therapy Director then entered resident #71's room along with the UM and pulled the right hand splint from the bedside table drawer. She then placed the right hand splint onto the resident's hand without any resistance from the resident. Review of the Customer Photo-Educational Tool notebook at the nurse's station with the Therapy Director and UM revealed resident #71 had a right hand contracture. It included a photo and instructions for resident #71's right hand splint to be applied every shift. CNA D had initialed that she had received the inservice education regarding resident #71's hand splint on 4/15/21. The Therapy Director said the residents' assigned CNAs were supposed to follow the directions in the notebook. The UM acknowledged the splint treatment was not on the CNA Kardex and the physican order for the splint was 105643 Page 4 of 7 105643 07/15/2021 Island Lake Center 155 Landover Place Longwood, FL 32750

F 0688 not entered in the resident's electronic medical record. Level of Harm - Minimal harm or potential for actual harm On 7/14/21 at 3:55 PM, in a follow up interview, CNA D recalled the resident had a hand splint in the past but she was not aware he still required one. She acknowledged she signed the therapy Photo Educational Tool training but noted she had not been applying the right hand splint for resident #71. Residents Affected - Few Review of the Occupational Therapist's (OT) Discharge summary dated [DATE] for the certification period of 4/12/21-5/11/21 included, Patient will be provided right hand splint for 6-8 hours as tolerated to increase joint alignment, mobility and decrease further contracture. The discharge recommendation dated 5/13/21 read: Patient is now able to tolerate right hand splint provided 2-4 hours as tolerated to increase joint alignment, mobility, and decrease further contracture On 7/14/21 at 5 PM, the Director of Nursing and UM acknowledged that therapy had provided education, photos, and description of splinting care to the CNAs and the CNA should have provided restorative splinting services for resident #71. The DON also acknowledged that orders for splinting needed to be placed in the electronic medical record for the nurses and CNAs to follow. 2. Resident #16 was admitted to the facility on [DATE]. Her diagnoses included vascular dementia with behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alzheimer's disease, contractures to right hand and right ankle. The resident's physician orders dated 5/18/21 noted right Ankle Foot Orthosis (AFO) for 4-6 hours as tolerated, and right-hand splint 4-6 hours or as tolerated. The quarterly Minimum Data Set (MDS) assessment, with assessment reference date 4/12/21, revealed the resident was rarely/never understood, and required extensive assistance for bed mobility, transfers, and had total dependence for dressing, eating, toilet use, and personal hygiene. The assessment revealed the resident had limitation in Range of Motion (ROM) with impairment on one side for her upper and lower extremities. Observations on 7/12/21 at 9:51 AM, and 2:00 PM, 7/13/21 at 9:35 AM, and 5:09 PM, and on 7/14/21 at 11:28 AM, and 12:56 PM, showed resident #16 in her room. Her right hand was contracted, and she was not wearing a splint. She was also not wearing a right AFO. On 07/14/21 at 11:30 AM, Registered Nurse (RN) E stated the resident's right hand was contracted, and she provided ROM, when she administered medications to the resident. The resident's room was entered with RN E and she acknowledged the resident's contracted right hand and right ankle without splint or AFO. The resident's physician orders were reviewed with RN E, and she verbalized the orders for the right-hand splint and right foot AFO. On 07/14/21 at 11:46 AM the UM stated resident #16 had contractures and was supposed to have splints. The UM explained the resident was previously on the Restorative Nurse Program (RNP), and the splint and AFO were now being applied by the restorative CNAs. She said the RNP was discontinued approximately one month ago, and since then, the floor CNAs were applying the splints. The UM stated she was aware the resident's splint and AFO were not being applied as ordered. She said, placement of the splint, and AFO was up and down, due to the discontinuation of the RNP. The resident's physician's orders were reviewed with the UM, and she acknowledged the orders for the resident's right hand 105643 Page 5 of 7 105643 07/15/2021 Island Lake Center 155 Landover Place Longwood, FL 32750

F 0688 splint, and right foot AFO. Level of Harm - Minimal harm or potential for actual harm On 7/14/21 at 12:02 PM, CNA D acknowledged the resident had contracture of her right hand and verbalized that she had the resident in her assignment and had not applied her splint or AFO. Residents Affected - Few On 7/14/21 at 12:55 PM, the Rehab Director said resident #16 had orders for a right-hand splint and right foot AFO. The Rehab Director said that due to the pandemic, the RNP was merged with nursing, so CNAs on the floor could apply splints. She verbalized that when resident #16 was on Occupational Therapy (OT) caseload, therapy ensured the resident wore the splint for up to 3 hours. The Rehab Director explained the splint was to prevent the risk for further contractures. If the splints were not placed, the contractures could become worse. She stated she had no report from nursing regarding difficulty with placing the resident's splint, and no report of the resident refusing the splint. The Rehab Director said the splint should be placed after activities of daily living (ADL) care, and ROM. On 7/14/21 at 1:06 PM, the DON said the facility had a formal RNP, and the Restorative CNAs would place splints. She explained that splinting and other RNP tasks were assigned to the CNAs on the floor and added to the resident's Kardex. The DON stated the facility did an audit of all splints, reviewed care plans, and Kardexes, and did in service with the CNAs, to inform them that splint application was included in their assignment. The DON acknowledged that resident #16's splint and AFO should have been applied as ordered. Review of the resident's OT Discharge Summary with dates of service: 11/8/2019-12/11/2019, revealed the following documentation, Establish a RNP to maintain functional movement of the B UE (bilateral upper extremities) and decrease risk of further contractures . 12/11/19 RNP established for splinting and PROM (passive range of motion) ex (exercise) for R hand.' Pt made the following progress in OT since SOC (start of care): tolerated R hand splint x 3 hrs. with no adverse reaction noted; maintained ROM on shoulders and elbows. RNP was established for PROM ex for R UE and for R hand splint to maintain ROM and prevent risk of further contractures. The Rehab/Restorative Nursing training Agreement dated 11/26/2019 noted right upper extremity splint, donning/doffing for 3 hours to maintain skin integrity/ and reduce the risk of progressing contracture. Staff in-service date was documented as 11/20/2019. Tasks documented on the Kardex, the CNAs care plan included: Right hand splint-apply x 4-6 hours or as tolerated. Dressing/Splint Care: Right AFO for 4-6 hours as tolerated .for prevention of further ankle contracture. The resident's care plan Self-care performance deficit related to cognitive deficit, cardiovascular accident with right side paralysis and contracture right arm, created on 7/02/19 with revision on 10/07/20 included interventions dated 6/22/20 for, makes use of a right-hand splint. The policy Resident Mobility and Range of Motion revised July 2017 read, Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. 105643 Page 6 of 7 105643 07/15/2021 Island Lake Center 155 Landover Place Longwood, FL 32750

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, interview, and record review, the facility failed to provide proper storage and sanitation practices for the clean storage of nested pans and cooking sheets, failed to provide appropriate and scheduled cleaning of kitchen equipment, and failed to provide proper training for the washing and storage of pots and pans to prevent potential food contamination. Findings: On 07/12/21 at 9:57 AM, during the initial kitchen observation, the cook and dietary aides prepared food that would be placed onto the steam table for the lunch meal and prepped the steam table with metal warming pan inserts. An open rack of washed and nested metal pots and pans was observed on the wall by the walk-in freezer. There were five steam table pan inserts that were 6 inches deep noted to be wet and nested on top of each other. Drops of water were observed on the pans when removed from on top of each other. There were 2 metal baking sheets that were also wet on the same rack nested on top of each other. At this time, the Dietary Manager (DM) acknowledged the warming inserts and baking sheets were not dry. She stated that for food safety purposes, washed pots and pans needed to be air dried before being stored. She explained the evening shift dietary Cook/Aide B was new to the facility and had stacked the pots and pans after washing them the night before. On 07/12/21 at 10:00 AM, a portable fan in the dish washing room was observed mounted in the corner of two adjoining walls. The fan was observed to have stringy gray lint residue on the outer metal wire cover. There was dark residue located in the inner grooves of the fan paddles. The fan was on high speed, blowing air onto clean drinking cups and plate covers that were drying on racks. The inside of the cups and plate covers were exposed to the blowing air. The DM said, the room gets really steamy and hot. The fan helps to cool it off. She revealed the fan had not been cleaned in three weeks, since the first day she started in her role as DM. Review of the equipment cleaning log with the DM showed the dish washing room fan was not included in the cleaning schedule. She acknowledged the fan was not included in the cleaning schedule. On 7/14/21 at 11:20 AM, the evening Cook/Dietary Aide B said he started work at the facility October 2020. He acknowledged he had stacked the wet pans onto the rack. He said he did not realize they were wet when he stacked them. Review of his orientation paperwork did not reveal any specific education about the importance of air drying pots and pans to prevent potential food contamination. Review of the facility's Policies and Procedures for Washing Pots and Pans and for Sanitation/Infection Control included the sanitary practices of air drying pots and pans after being washed to reduce the possibility of food contamination. It included the Dietary Manager and Consultant Dietician were responsible to develop a cleaning schedule and responsible for supervising and training all personnel in proper sanitation procedures for storing, preparing, and servicing foods. 105643 Page 7 of 7