Health inspection·May 19, 2022

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to complete a significant change minimum data set assessment for 1 of 5 residents, Resident #136, when enrolled in a hospice care program. Residents Affected - Few Findings include: Review of Resident #136's medical record documented Resident #136 was enrolled in a hospice care program on 10/21/2021. Review of Resident #136's Minimum Data Sets (MDS) completed over the period of 10/21/2021 through 4/22/2022 did not contain documentation of a MDS being completed when the resident suffered a significant change and was admitted into a hospice care program on 10/21/2021. During an interview on 5/18/2022, the Director of Nursing verified Resident #136 began receiving hospice services on 10/21/2021. She verified the facility had not completed a significant change minimum data set when Resident #136 enrolled in the hospice care program. Page 1 of 4 105652 105652 05/19/2022 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

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 observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to decrease the risk of urinary tract infections for 1 of 4 residents with an indwelling catheter, Resident #104. Findings include: Review of Resident #104's medical record documented the resident was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, stage 3 chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified dementia without behavioral disturbance, and adult failure to thrive. During an observation on 5/17/2022 at approximately 2:40 PM, Resident #104's catheter drainage bag was resting on the floor with urine leaking from the corner of the bag onto the floor (Photographic evidence obtained). During an observation with the Director of Nursing (DON) on 5/17/2022 at approximately 3:15 PM, Resident #104's catheter drainage bag was resting on the floor with urine leaking from the corner of the bag onto the floor. During an interview on 5/17/2022 at approximately 3:15 PM, the DON verified the catheter drainage bag was leaking onto the floor and stated, It obviously needs to be changed right away. I would expect the nurses to change a Foley bag that looked like this. Review of the facility policy and procedure titled, Catheter Care, including Drainage Bag Care/Maintenance reviewed on 1/25/22, reads, Purpose: To provide safe and proper care of the resident with an indwelling urinary catheter; To minimize the risk of bladder infection . Procedure: 12. Empty the catheter drainage bag at least every eight hours or as necessary. The level of urine should not be allowed to reach the antireflux valve at the top of the drainage bag. 13. If an obstruction of the system is suspected, if the system has been contaminated or if sediment is accumulating in the lumen of the tubing, report this to the resident's nurse. 105652 Page 2 of 4 105652 05/19/2022 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 2 of 4 residents, reviewed for respiratory care, Residents #15 and #94. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #94 documented the resident was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease, heart disease, anemia, and dependence on supplemental oxygen. During an observation on 5/16/2022 at 10:10 AM, Resident #94 was resting in bed with his eyes open. The resident was being administered oxygen at 3.5 liters per minute via nasal cannula. Review of Resident #94's physician order dated 4/15/2022 reads, Oxygen at 3 liters/minute via nasal cannula every shift. During an observation on 5/17/2022 at 9:00 AM, Resident #94 was resting in bed with his eyes closed. Oxygen was being administered at 3.5 liters per minute via nasal cannula. During an observation on 5/17/2022 at 8:51 AM, Resident #94 was resting in bed with his eyes closed. Oxygen was being administered at 3.5 liters per minute via nasal cannula. During an interview on 5/18/2022 at 10:00 AM, Staff B, Licensed Practical Nurse (LPN), confirmed Resident #94's physician's order was to administer oxygen at 3 liters per minute via nasal cannula. Staff B confirmed that oxygen was being administered to the resident at 3.5 liters per minute via nasal cannula. 2. During an observation on 5/17/2022 at 2:15 PM, Resident #2 was being administered oxygen via nasal cannula at a flow rate of 2 liters per minute. During an observation with Staff A, LPN, on 5/18/2022 at 9:14 AM, Resident #2 was being administered oxygen at 2 liters per minute via nasal cannula. During an interview on 5/18/2022 at 9:15 AM, Staff A, LPN, stated, If a resident is receiving oxygen via nasal cannula, I ensure that the rate is running correctly by comparing the physician's order to the rate of oxygen. The oxygen rate is currently flowing at 2 liters. I will review the physician's order to double-check if it is correct right now. Review of Resident #2's physician's order with Staff A, LPN, showed, 1 liter via nasal cannula continuously. Resident may remove adlib. During an interview on 5/18/2022 at approximately 9:17 AM, Staff A, LPN, stated, The correct oxygen flow rate should be at 1 liter of oxygen, not 2 liters. During an interview on 5/18/2022 at 12:30 PM, the Director of Nursing stated it was her expectation that the nursing staff would follow the physician's order for the administration of oxygen. 105652 Page 3 of 4 105652 05/19/2022 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled, Oxygen Administration with a review date of 1/25/2022, reads, Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Residents Affected - Few 105652 Page 4 of 4