Health inspection·June 24, 2021

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation, record review, staff and resident interviews the facility failed to follow physician's orders and consistently implement therapy recommendations to prevent a decrease in range of motion for 1 (Resident # 49) of 3 residents reviewed with limited range of motion. The findings included: The facility's Policy titled Prevention of Decline in Range of Motion implemented on 11/3/2020 and revised 3/2021 noted . Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion . Based on the comprehensive assessment, the facility would provide interventions, exercises and/or therapy to maintain or improve range of motion. The facility would provide treatment and care in accordance with professional standards of practice. This included but was not limited to: 1. Appropriate services (specialized rehabilitation, restorative, maintenance). 2. Appropriate equipment (braces or splints). 3. Assistance as needed (active assisted, passive, supervision) . A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition and did not reject care. Resident #49 required extensive assistance with all Activities for Daily Living (ADL) except eating. Resident #49 had a diagnosis of hemiplegia or hemiparesis (muscle weakness or partial paralysis) affecting one side of her body. Resident #49 received occupational therapy from 3/4/21 through 5/13/21. The Physician's order summary report dated 5/28/21 included an order dated 5/19/21 for Resident #49 to wear a left upper extremity (LUE) splint in the daytime and off at hours of sleep (HS) as tolerated. Resident #49 also had an active order dated 5/12/21 for a Restorative Nursing Program (RNP) splint program. The Care Plan initiated on 2/5/21 noted Resident #49 had a diagnosis cerebrovascular accident (CVA) with hemiparesis of left side and required extensive assistance with activities of daily living (ADLs). The goals initiated on 5/12/21 included to maintain level of range of motion (ROM) to LUE. The Page 1 of 5 105683 105683 06/24/2021 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

F 0688 listed interventions dated 5/12/21 included the Certified Nursing Assistant (CNA) to encourage the resident to participate in RNP splint program. Level of Harm - Minimal harm or potential for actual harm The interventions initiated on 5/19/21 included to wear LUE splint in the daytime and off at HS as tolerated. Residents Affected - Few The care plan included specific directions of how to apply the splint during the day and off at HS. The occupational therapy (OT) evaluation and plan of treatment for certification period 3/4/21 through 4/2/21 noted Resident #49's long-term goals included safe wear of a functional splint to position LUE left fingers and left wrist for up to seven hours to decrease developing contractures (Shortening and hardening of tissues leading to rigidity of joint) and improve quality of life. The OT Discharge summary dated [DATE] noted Resident #49 would safely wear a functional splint to position LUE left fingers, left hand, and left wrist for up to seven hours to decrease developing contractures and improve quality of life. The summary noted Resident #49 was discharged to a RNP with instructions on don (applying)/doffing (removing) the splint. The purpose of the splint for the LUE was to prevent further fixing contractures and soft tissue tightness, simple ADLs, and functional transfers. The discharge summary was signed by OT Staff S . The therapy referral for restorative nursing program care giver instructions for Resident #49 dated 5/12/21 noted the overall goal of the restorative program was to improve/maintain range of motion on LUE to decrease potential fixing contractures and further soft tissue tightness. On 6/21/21 at 10:30 a.m., Resident #49 was observed in bed, awake, and alert. She said she had a stroke that affected her left side. She pulled her left hand from below her blanket to display contractures of her left wrist, hand, thumb and four fingers. Resident #49 was not wearing a splint and said staff did not assist her with it. On 6/23/21 at 10:47 a.m., Resident #49 was in her room in bed, awake, and alert. She was not wearing a splint on her left hand. She said staff did not assist her to wear the splint yesterday or today and she could not apply it herself. She pointed to the splint on her nightstand. She said when she was getting therapy, the therapist applied the splint for her, but she was discharged from therapy over a month ago. She said the splint did not bother her and she wanted to wear it. *Photographic Evidence Obtained * On 6/23/21 at 2:23 p.m., Certified Nursing Assistant (CNA) Staff R said he had taken care of Resident #49 a lot. He said there was never a time when Resident #49 refused care or did not like to get out of bed. He checked the CNA [NAME] (Instructions to safely care for residents) system on the wall. He said according to the computer, Resident #49 refused to wear the splint today. On 6/23/21 at 2:42 p.m., in an interview CNA Staff J said she took care of Resident #49 today and she refused to wear her splint or get out of bed. On 6/24/21 at 9:50 a.m., Resident #49 was observed in her room. She was not wearing the splint and 105683 Page 2 of 5 105683 06/24/2021 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

F 0688 said staff did not assist her with it. Level of Harm - Minimal harm or potential for actual harm On 6/24/21 at 9:55 a.m., in an interview OT Staff S said she worked with Resident #49 and created the splint for the Resident #49's left hand contracture. She said Resident #49 completed therapy and the referral to the Restorative Nursing Program (RNP) was made on 5/12/21. She said the resident was agreeable to the splint and motivated to wear the splint to keep the contractures from progressing. OT Staff S said she instructed the nursing staff on the purpose of the splint and how to apply it. OT Staff S said Resident #49 required staff assistance to apply the splint and facility staff should be applying the splint every day. Residents Affected - Few On 6/24/21 at 10:00 a.m., observed OT Staff S into Resident #49's room. She confirmed the splint was not on Resident #49's hand. She said staff must apply the brace daily or the fingers will tighten. She said Resident #49's fingers and wrist were beginning to tighten. OT Staff S used a warm damp towel to massage Resident #49's left hand and fingers open and applied the splint to the resident's hand. She confirmed Resident #49 was motivated to wear the splint when she was discharged from therapy. She said it was staffs' responsibility to ensure residents wear their splints once the resident was discharged from therapy. On 6/24/21 at 11:09 a.m., Licensed Practical Nurse (LPN) Staff M said she had been the unit manager since February 2020, and was responsible for Resident #49. She said she was aware of Resident #49's left hand contracture and the physician's order to wear the splint every day. She said it was the CNA's responsibility to assist Resident #49 with the splint every day. LPN Staff M provided the CNA task print-out for the month. She said according to the printout, Resident #49 wore the splint for a total of 50 minutes over the last 30 days. LPN Staff M said there was only one progress note where Resident #49 refused the RNP on 6/23/21. LPN Staff M said she has been to Resident #49's room during the day when she was not wearing the splint, but she did not ask the resident about it or assist Resident #49 to wear it. 105683 Page 3 of 5 105683 06/24/2021 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

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. Based on record review, observation, staff and resident interviews, the facility failed to have documentation of appropriate care and services to manage and prevent complication of indwelling catheter for 1 (Resident #8) of 1 resident with urinary tract infection. The findings included: The facility's policy titled Catheter Care with a revised date of March 2021, stated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy explanation stated, Catheter care will be performed every shift and as needed by nursing personnel. Document care and report any concerns noted to the nurse on duty. On 6/21/21 at 2:45 p.m., Resident #8 was observed in bed with a Foley Catheter ( Indwelling Catheter inserted in the bladder to drain urine) with a urine collection leg bag strapped to the right leg. Review of Resident #8 clinical record showed a readmission date of 6/18/21 with active diagnoses including, urinary tract infection (UTI) and sepsis (bacteria in the bloodstream). The current physician's orders for June 2021 included two different intravenous antibiotics for bacteremia (bacteria in the blood stream) and UTI. The physician's orders did not include catheter care. Review of the progress notes revealed on 6/19/21 at 2:48 a.m., and 6/20/21 at 4:02 a.m., the nurse documented Foley care given as ordered. No other entry was found in the progress notes or the Treatment Administration Record (TAR) from 6/18/21 through 6/21/21 of nursing interventions related to catheter care. On 6/22/21 at 4:23 p.m., in an interview Licensed Practical Nurse (LPN) Staff A confirmed Resident #8 had an indwelling urinary catheter (Foley catheter). LPN Staff A said, All residents with urinary catheters get catheter care each shift and when completed we document the care in the TAR for the resident. On 6/22/21 at 4:40 p.m., in an interview LPN Staff N said she was unable to find any urinary catheter orders, interventions, or urinary catheter documentation on the TAR for Resident #8. LPN Staff N said, She should have had orders and documentation entered. On 6/22/21 at 4:52 p.m., in an interview the Director of Nursing (DON) said she was unable to find documentation on Resident #8's TAR for catheter care from 6/18/21 to 6/21/21. The DON said, It is expected to have the catheter care documentation each shift and the orders for the indwelling catheter entered on readmission to the facility. On 6/23/21 at 11:07 a.m., in an interview Unit Manager Staff L confirmed Resident #8 was currently on two antibiotics for a urinary tract infection and bacteremia. 105683 Page 4 of 5 105683 06/24/2021 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview the facility failed to have a complete medical record including advance directives documentation for 1 (Resident #376) of 13 residents reviewed for advance directives. This has the potential to lead to confusion as to the proper care to be delivered. The findings included: The facility's policy titled Residents' Rights Regarding Treatment and Advance Directives dated 11/2020 and revised 3/2021 stated, It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives. The Policy Guidelines stated, On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive . Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to staff. On [DATE] at 12:25 p.m., clinical record review revealed Resident #376 was admitted to the facility on [DATE]. Resident #376 was a Hospice patient, and the code status (refers to the level of medical interventions a person wishes to have started if their heart or breathing stops) was listed as Do Not Resuscitate (DNR). There was no yellow DNR form in the clinical record to identify Resident #376's wish to not be resuscitated in the event of respiratory or cardiac arrest. On [DATE] at 12:30 p.m., Licensed Practical Nurse (LPN) Staff M said the DNR forms were kept in the hard chart. On [DATE] at 3:20 p.m., LPN Staff A stated she would check paper chart for yellow DNR. If it was not on chart, she would check EMR for doctor's order. On [DATE] at 3:21 p.m., LPN Staff O stated, we go by the yellow DNR an original order in the chart. If there is no yellow in the chart or in the computer, you start CPR (cardiopulmonary resuscitation). On [DATE] at 3:22 p.m., Staff P LPN stated, we go to the chart and look for the yellow DNR form and we look at the order. On [DATE] at 3:25 p.m., in an interview the Director of Nursing said in case of cardiac arrest her nurses were trained to look in the chart for the yellow DNR. If not in the chart, they would verify by checking doctors' orders. If it was a verbal order, it must be signed by two Registered Nurses. On [DATE] at 3:28 p.m. Registered Nurse/Staffing Educator Staff Q said the nurses completed an advanced directive course on the computer. She said, We look for the yellow paper in the chart and an order. The computer will say do not resuscitate, but if we do not have that, we would do CPR. 105683 Page 5 of 5