Health inspection·February 2, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and family interview, the facility failed to ensure advanced directives were accurately documented in the clinical record for 1 (Resident #29) of 3 residents reviewed for Advanced Directives from a total sample of 29 residents reviewed. This failure could impact quality of care at the end of life for the residents. The findings included: Review of Resident #29's Order Summary Report as of [DATE] revealed a Full Code order on [DATE], indicating the facility would initiate cardiopulmonary resuscitation (CPR) if Resident #29's heart stopped or if the resident stopped breathing. Review of Resident #29's Care Plan initiated on [DATE] revealed the Care Plan matched the Order Summary noting Resident #29 was a Full Code. Review of Resident #29's electronic health record revealed a Determination of Incapacity on [DATE] and a Health Care Surrogacy on [DATE]. A Do Not Resuscitate (DNR) order was signed by the Health Care Surrogate on [DATE]. This DNR order conflicted with Resident #29's Care Plan and the Order Summary Report (both indicating Resident #29 was a Full Code). On [DATE] at 8:41 a.m., during a telephone conversation with Resident #29's Health Care Surrogate, she said Resident #29 was incapacitated and unable to make any of his health care decisions. She confirmed she was the Health Care Surrogate and that she signed the DNR paper for Resident #29 on [DATE]. On [DATE] at 10:05 a.m., Social Services Director (SSD) Staff S said she's worked at the facility for approximately one year and has been a social worker for 3 years. She said she is responsible for auditing the residents' electronic health records for Code Status accuracy. Staff S verified the discrepancy between the Order Summary, Care Plan and the DNR order (indicating Resident #29 was not to be resuscitated.) Staff S said the Care Plan did not contain accurate information. Page 1 of 8 105683 105683 02/02/2023 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

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 Based on observations, record review, review of policies and procedures, resident and staff interviews, the facility failed to ensure 1 (Resident #39) of 3 residents reviewed for continuous activities of daily living (ADLs) received completed care on a routine basis. Residents Affected - Few The findings included: On 1/30/23 at 2:15 p.m., Resident #39 was observed in his bed wearing a hospital gown. Via observation Resident #39's hair appeared uncombed, and his fingernails were long, extending approximately one quarter of an inch from the base, uneven, and had dark matter underneath each nail. On 1/30/23 at 2:15 p.m., Resident #39 said he doesn't remember the last time staff washed and comb his hair and doesn't remember the last time staff trimmed and cleaned under his fingernails. On 1/31/23 review of Resident #39's medical records revealed his most recent admission date was 12/6/2022. Resident #39's plan of care for ADLs had a revision date of 12/14/22 and stated Resident #39 required assistance for most ADLs. Resident #39 required extensive assistance with bed mobility, transfers, toileting, grooming/hygiene, and bathing. On 1/31/23 at 10:38 a.m., Resident #39's son said since admission he had noted his father's hair had not been washed and combed and his father's fingernails were long and uneven with dark black matter under each fingernail. He said he had asked the nursing staff who was responsible to cut his father's hair and fingernails and the staff told him, it was the family's responsibility to cut his father's hair, and trim and clean his father's toenails and fingernails. On 1/31/23 review of the Certified Nursing Assistant (CNA) job description dated April 2020; the summary stated the CNAs were to perform direct resident care under supervision of licensed nursing personnel. One of the CNAs job duties and responsibilities were to provide personal care (i.e., grooming, bathing, dressing, oral care, etc ) of residents daily and as needed. On 1/31/23 review of the undated Activities of Daily Living (ADLs) policy, it stated care and services would be provided for the following activities of daily living to include bathing, dressing, grooming and oral care. On 1/31/23 review of the undated Care of Fingernails/Toenails policy, it stated the purpose of fingernails and toenails care is to clean the resident's nail bed, and to keep the nails trimmed/to prevent infections. On 2/2/23 at 9:48 a.m., CNA Staff T said Resident #39 was cooperative and did not refuse his daily routine ADL care. She confirmed part of routine resident's ADL care included resident nail care. She said she didn't remember when ADL nail care was completed for Resident #39. On 2/2/23 at 10:00 a.m., Licensed Practical Nursing (LPN), Staff D said the resident daily ADL care included nail care. On 2/2/23 at 10:05 a.m., Staff D's observation of Resident #39's fingers confirmed Resident #39's fingernails were very long, uneven, with a dark substance under each of Resident #39's fingernails. She said it appeared Resident #39's fingernails had not been trimmed or cleaned in a long time. 105683 Page 2 of 8 105683 02/02/2023 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

F 0677 Level of Harm - Minimal harm or potential for actual harm On 2/2/23 at 10:30 a.m., the DON said the CNA's Job Description, the policy for Care of Fingernails and Toenails, and Activities of Daily Living stated the nursing staff were required to ensure each resident's ADL care to include fingernail and toenail care. Residents Affected - Few 105683 Page 3 of 8 105683 02/02/2023 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

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 observation, record review and staff interview, the facility failed to coordinate care and ensure 1 (Resident #33) of 1 sampled resident receiving intravenous antibiotics received care and services in accordance with professional standards of care and the physician's orders. Residents Affected - Few The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses including a right sided mastectomy (surgical removal of the breast). The physician's orders with an effective date of 11/25/22 specified, No Blood Pressures or Blood Draw to right arm. Review of the progress notes revealed documentation Resident #33's blood pressure was taken on the right arm on 12/8/22, 12/9/22, 12/10/22, 12/11/22, 12/14/22, 12/16/22 and 12/17/22. On 1/30/23 at 2:00 p.m., Licensed Practical Nurse (LPN) Staff D was observed administering an intravenous antibiotic to Resident #33 through a midline catheter (catheter inserted in the upper arm with the tip located just below the axilla) inserted into the resident's right arm. On 1/31/23 at 9:36 a.m., resident #33 was observed awake, lying on her back, with a midline catheter in her right upper arm. Resident #33 was not able to answer any question related to the midline catheter. On 1/31/23 at 12:03 p.m., the nurse documented in a progress note Resident #33's right upper arm was edematous (swollen). The midline was pulled from the right arm without difficulty. On 2/1/23 at 9:34 a.m., LPN Staff D stated she was aware of the physician's order specifying, no blood pressures or blood draws on the right arm due to the mastectomy to the right side. On 2/1/23 at 9:53 a.m., the attending physician stated it was preferable not to do anything to the affected side (right mastectomy) such as blood pressure or blood draws unless we don't have a choice. On 2/1/23 at 10:25 a.m., the Advanced Practice Registered Nurse (APRN) said standards of practice would be to avoid placing a midline catheter on the affected side. She said she was not notified of the swelling to the resident's right upper arm. On 2/1/23 at 11:47 a.m., the Minimum Data Set (MDS) Coordinator verified Resident #33's care plan and the [NAME] (Information of needs for each resident) did not reflect the right side mastectomy and the physician's orders for no blood pressure or blood draws to the right arm. She said, It is absolutely fair to say it should be on the care plan and I'll add it now. On 2/1/23 at 12:41 p.m., in a telephone interview Registered Nurse Staff P who inserted the midline catheter said the facility nurse did not inform her Resident #33 had a previous right side mastectomy. She said, if a resident has had a mastectomy, I can't insert the intravenous line on that side. 105683 Page 4 of 8 105683 02/02/2023 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

F 0684 Level of Harm - Minimal harm or potential for actual harm On 2/1/23 at 3:20 p.m., The Director of Nursing (DON) verified the order for no blood pressures or blood draws had been in place to flag the nurses not to use the right side to obtain vital signs, including blood pressure. Residents Affected - Few 105683 Page 5 of 8 105683 02/02/2023 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

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, interview, and record review, the facility failed to implement care and services to prevent a decline in range of motion for 1 (Resident #6) of 1 resident reviewed for the application of a splinting device. The findings included: Review of Resident #6's quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #6 had paralysis on the left side of his body, required extensive assistance with dressing, and was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. Review of Resident #6's Order Summary Report as of 2/2/2023 revealed an active physician's order, As of 8/9/22, elbow splint to be worn 2 hours daily on the left elbow every day shift. Review of Resident #6's Activities of Daily Living (ADL) Care Plan initiated on 6/5/22 revealed the resident required extensive assistance for bed mobility and dressing. There were no goals or interventions for applying the splint. Review of Resident #6's Care Plans did not indicate Resident #6 refused to wear the splint. Review of Resident #6's Task List Report dated 2/2/23 (a list of tasks for the Certified Nursing Assistant) did not include applying the splint. Review of Resident #6's Treatment Administration Record for January 2023 and February 2023 revealed nursing signed-off the left elbow splint was applied on 1/30/23, 1/31/23, 2/1/23, and 2/2/23. On 1/30/23 at 10:35 a.m., Resident #6 was observed in his bed, not wearing his splint. His left elbow was bent, and his hand was near his chest. He verified he could not move his left arm and the position of the elbow was permanent. Resident #6 said the facility had an elbow splint made for him, but staff do not apply the splint, and it has been a long time since he wore it. Resident #6 said he does not refuse to wear the splint and cannot apply it himself. The resident said there was a Certified Nursing Assistant (CAN) who used to work at the facility and applied the brace for him every day. On 1/31/23 at 9:29 a.m., 2/1/23 at 11:11 a.m., 2/2/23 at 8:55 a.m., 2/2/23 at 3:00 p.m. and 4:04 p.m., Resident #6 was observed in his bed, not wearing his splint. During those observations, Resident #6 reiterated staff were not applying the splint or asking him to apply it. A splint was observed on the resident's nightstand. Photographic evidence obtained. On 2/1/23 at 11:30 a.m., the Occupational Therapist (OT) Staff I said Resident #6 was discharged from therapy in December 2022 and therapy does not apply the splint. He said Resident #6 was referred to the Restorative Nursing Program. The Occupational Therapist said daily wearing of the splint would not repair the left elbow contracture, but it would help to prevent further tightening of the 105683 Page 6 of 8 105683 02/02/2023 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

F 0688 muscles involved in the contracture. Level of Harm - Minimal harm or potential for actual harm Review of the Occupational Therapy (OT) Discharge Recommendations and Status signed by OT Staff I on 12/14/22 revealed the Restorative Nursing Program was not indicated at this time. Residents Affected - Few On 2/2/23 at 1:18 p.m. Certified Nursing Assistant (CNA) Staff J said she was familiar with Resident #6 and was assigned to him from 7:00 a.m. to 3:00 p.m. Staff J said she did not know Resident #6 had a splint because it was not on her task list and the nurse did not tell her to apply it. On 2/2/23 at 1:39 p.m., Restorative CNA Staff K said Resident #6 was not in the Restorative Nursing Program and the CNA assigned to Resident #6 should apply the splint. On 2/2/23 at 3:12 p.m. Licensed Practical Nurse Staff M said she was assigned Resident #6 this week and did not apply the splint or instructed the CNA to apply it. She said she signed off on the Treatment Administration Record (TAR) the splint was applied but did not see the resident wear it. On 2/2/23 at 3:28 p.m., CNA Staff G said she was assigned to Resident #6 on 2/1/22, and she did not apply the splint to Resident #6's left elbow. She said the nurse did not tell her to apply the splint and she does not know where it is. On 2/2/23 at 3:55 p.m., LPN Unit Manager Staff C said she is responsible for updating and adding care plans according to resident needs and physician orders. Staff C reviewed Resident #6's Care Plans and verified they did not include interventions for applying the splint. Staff C reviewed Resident #6's Order Summary Report and verified the order for daily day shift application of Resident #6's left elbow splint. Staff C acknowledged the Care Plans were not reflective of the physician orders. On 2/2/23 at 4:04 p.m., Registered Nurse Staff N said he was assigned to Resident #6 and did not apply the splint. He said he did not tell the CNA to apply the splint or see the Resident #6 wearing the splint. He said he signed the TAR today indicating Resident #6 wore the splint even though the resident had not. 105683 Page 7 of 8 105683 02/02/2023 Labelle Health and Rehabilitation Center 250 Broward Ave Labelle, FL 33935

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on clinical record review, review of the Florida Board of Nursing requirement for intravenous administration for Licensed Practical Nurses, and staff interview the facility failed to ensure 1 (Licensed Practical Nurse Staff D) of 3 Licensed Practical Nurses reviewed had the required certification and competency prior to administer Intravenous Medication. The findings included: The Florida Board of Nursing Chapter 64B9-12, Administration of intravenous therapy by Licensed Practical Nurses noted the course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV (Intravenous) therapy shall be not less than thirty (30) hour post-graduate level course teaching aspects of IV therapy with content as specified by the Board of Nursing. Review of the clinical record for Resident #33 showed on 1/26/23 a midline catheter (catheter inserted in the upper arm with the tip located just below the axilla) was inserted into the resident's right arm to administer intravenous (IV) antibiotics for an infected wound. On 1/30/23 at 2:00 p.m., Licensed Practical Nurse (LPN) Staff D was observed administering an intravenous antibiotic to Resident #33 through a midline catheter inserted in the resident's right arm. On 2/1/23 at 9:34 a.m., LPN staff D stated she had completed her IV competency training a long time ago but did not have record of the certification. On 2/2/23 at 11:53 a.m., The Assistant Director of Nursing (ADON) stated LPNs are required to complete a 30 hours IV certification in Florida to administer intravenous medications. On 2/2/23 at 12:26 p.m., the Director of Nursing (DON) said she was unable to provide documentation LPN Staff D completed the required training, or competency to administer intravenous medications. 105683 Page 8 of 8