Health inspection·August 11, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to conduct and submit a discharge Minimum Data Set (MDS) assessment within 14 days after completion to the Centers for Medicare Services System, including a subset of items upon a resident's transfer, or discharge for 2 (Resident #1 & Resident #2) out of 3 residents sampled for MDS assessment completion. Residents Affected - Few Findings include: Review of the admission Record for Resident #1 documented an admission date of 03/30/22 with diagnoses including cerebral infarction (disruption of blood flow to the brain), Type II Diabetes Mellitus (high levels of sugar in the blood), cardiomyopathy (heart muscle disease), depression and muscle weakness. Review of Resident #1's progress notes documented on 04/21/22, [Resident #1's Name] will discharge home accompanied by son . Review of Resident #1's Minimum Data Set (MDS) assessments documented an admission Medicare - 5 Day Assessment completed on 4/19/22 and accepted on 04/25/22. There was no discharge MDS Assessment located in Resident #1's electronic file. Review of the admission Record for Resident #2 documented an admission date of 3/28/22 with diagnoses including unspecified fracture of third lumbar vertebra, spinal stenosis (spinal narrowing) lumbar region, Type II Diabetes Mellitus (high levels of sugar in the blood), asthma, acute kidney failure and atrial fibrillation (irregular heart beat). Review of Resident #2's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note dated 4/25/22 at 2:00 PM documented Recommendations of Primary Clinicianssend out to hospital. Review of Resident #2's Minimum Data Set (MDS) assessments documented an admission Medicare - 5 Day Assessment completed on 4/20/22 and accepted on 04/25/22. There was no discharge MDS Assessment located in Resident #2's electronic file. During an interview conducted on 08/09/22 at 01:42 PM with the MDS coordinator she confirmed that Residents #1 and #2 did not have a discharge MDS in their electronic files. Review of the facility policy titled MDS 3.0 Completion undated and reviewed on 01/11/22 read, .f. Discharge Assessment - completed using the discharge date as the ARD (Assessment Reference Date). Page 1 of 11 105696 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0640 Must be completed within 14 days of the discharge date /ARD. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105696 Page 2 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide care and services that meet professional standards of quality related to the application of compression stockings for 1 (Resident #86) out of 1 resident sampled for use of compression stocking and performing wound dressing care for 1 (Resident #202) out of 3 residents sampled for wound care. Residents Affected - Few Findings Include: 1. Review of the admission Record for Resident #86 documented the resident was initially admitted to the facility on [DATE] and has a diagnosis of heart failure (a condition that causes fluid buildup in the feet, arms, lungs, and other organs). Review of the physician orders for Resident #86 documented an order placed on 05/12/2022 that read compression stockings two times a day for edema. During an observation on 08/08/2022 at 9:47 AM, Resident #86 was not wearing compression stockings. During an observation on 08/09/2022 at 9:23 AM, Resident #86 was not wearing compression stockings. During an interview on 08/09/2022 at 8:29 AM, Resident #86 stated, I have noticed increased swelling in my lower legs, especially my ankles and feet. My doctor told me that it is essential to wear compression stockings to help reduce the swelling in my legs, but I need help putting them on. Unfortunately, I never receive assistance from the nursing staff, and I want to wear them. During an interview on 08/09/2022 at 1:29 PM, after reviewing the physician's order, Staff C confirmed Resident #86 was not wearing compression stockings and stated, I was not aware of the order for [Resident #86 name] to wear compression stockings twice a day. During a follow-up interview on 08/09/2022 at 1:35 PM Staff C stated, I went in to put the compression stockings on [Resident #86 name], but they did not fit. During an interview on 08/09/2022 at 1:41 PM, the Director of Nursing confirmed the orders and stated, It is my expectation [Resident #86 name] should be wearing compression stockings as the physician ordered. When asked for the facility's policy regarding following physician orders, on 08/10/2022 at 9:46 AM, the Director of Nursing stated, There is no policy regarding following physician orders because it is a standard of care. 2. During an observation conducted on 8/8/2022 at 12:41 PM Resident #202 was sitting in bed with a right lower leg dressing dated 8/4/2022. During an interview conducted on 8/8/2022 at 12:41 PM Resident #202 stated, I haven't had that changed in a couple of days. They can't put the wound vac on until they check for something. I had the wound vac in the hospital and haven't had one on since I got here. 105696 Page 3 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0658 Level of Harm - Minimal harm or potential for actual harm Review of the admission Record for Resident #202 documented the resident was admitted to the facility on [DATE] with the following diagnoses: cellulitis of right lower limb, type 2 diabetes mellitus with foot ulcer, gastro esophageal reflux disease, gastrointestinal hemorrhage, peripheral vascular disease, peripheral vascular angioplasty, acute kidney failure, essential (primary) hypertension, and acquired absence of left leg above knee. Residents Affected - Few Review of the Physician Orders dated 8/3/2022 reads Wound Vac (negative-pressure wound therapy) in place to right ankle and anterior RLE (right lower extremity). every day shift every Mon, Thu, Fri (Monday, Thursday, Friday) for Wound. Cleanse area with NS (normal saline). Place foam into wound. Apply skin prep to intact skin on periwound. Cover with occlusive dressing and secure tubing per manufacturer's guide. Wound vac setting at 125mmHG (millimeters of mercury) intermittent suction and as needed for leaking or loss of suction. Cleanse area with NS. Place foam into wound. Apply skin prep to intact skin on periwound. Cover with occlusive dressing and secure tubing per manufacturer's guide. Review of Physician Orders dated 8/3/2022 reads, If wound vac needs to be turned off for any care, tests/procedures, or for transport: remove the dressing in its entirety, cleanse wound with NS and apply hydrogel gauze and secure with abd (abdominal) pad as needed for temporary removal. Review of Treatment Administration Record for August 2022 revealed no documented dressings for wounds. Review of the medical provider note dated 8/4/2022 reads: L (left) AKA (above the knee amputation), dressings to RLE (right lower extremity) are clean, dry, and intact. Wed-to-dry dressing removed and replaced by author today using saline moistened gauze, Abd pads, and gauze roll dressing. Wound bed on anterior R leg and foot is pink/red with white fascia showing. Minimal serosanguinous drainage noted. No odor. No surrounding erythema, edema, or tenderness. Assessment/Plan: 6 mm (millimeter) ringed PTFE (polytetrafluoroethylene) graft with additional debridement of skin, subcutaneous tissue of right leg and foot wound with wound VAC placement: F/U (follow up) with vascular surgery in 2-3 wks (weeks). Wound care nurse and provider to evaluate. Wound vac at intermittent -125mmhg. Daptomycin (an antibiotic) 450mg IV (intravenously) daily until 09/05/22. Wet-to-dry wound dressings daily and PRN (as needed) until wound vac supplies obtained. During an interview conducted on 8/8/2022 at 1:15 PM Staff A, Licensed Practical Nurse (LPN) stated, The dressing is dated 8/4/2022 and I don't know his wound care orders, I will need to check them. They are for a wound vac, I don't know why he has not gotten the wound vac, I would need to check on that. I don't know what wound care orders we need if we can't put on a wound vac. During an interview conducted on 8/10/22 at 3:30 PM the Director of Nursing (DON) stated, We have not done the dressings daily, the wound vac has not been on, and we should be completing dressings and letting the doctor know that we can't put the wound vac on and obtain orders for daily dressings. I do not see the wound measurements on the admission assessment, they should be documented. Review of the policy and procedure titled, Negative Pressure Wound Therapy approval date of 1/11/2022 reads, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced based treatments in accordance with current standards of practice and physician orders. This policy addresses the use of negative pressure wound therapy (NPWT) for the treatment and management of wounds. Policy Explanation and Compliance Guidelines: 10. Whenever therapy 105696 Page 4 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0658 Level of Harm - Minimal harm or potential for actual harm cannot be resumed within 2 hours, remove the dressing, and apply a moist wound dressing. Notify physician for specific orders. 12. The physician shall be notified of any complications associated with the use of NPWT. Residents Affected - Few 105696 Page 5 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

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, interview, and record review the facility failed to provide care for central venous access devices in accordance with professional standards of practice for 1 (Resident #25) of 2 central venous access devices out of a total sample of 43 residents. Residents Affected - Few Findings include: During an observation on 8/9/2022 at 9:27 AM Resident #25 was sitting in a wheelchair and there was a right upper arm midline catheter with 4 x 4 gauze under a transparent dressing that was dated 8/6/2022. During an observation on 8/9/2022 at 10:40 AM Resident #25 was sitting up in a wheelchair. Resident had a right upper arm midline catheter with 4 x 4 gauze under a transparent dressing dated 8/6/2022. During an observation of medication administration conducted on 8/9/2022 at 10:40 AM Staff C, Licensed Practical Nurse (LPN) was observed administering 0.9% normal saline flush to Resident #25's midline catheter. Staff C, LPN cleaned the needleless connector for 2 seconds with alcohol and immediately administered the normal saline. Staff C, LPN did not let the needleless connector air dry or verify line placement prior to administering the medication. Review of the admission Record documented that Resident #25 was admitted to the facility on [DATE] with the following diagnoses type 2 diabetes mellitus, mood disorder, unspecified dementia, osteoarthritis, anemia, essential (primary) hypertension, hypothyroidism, hyperlipidemia. anxiety disorder, and major depressive disorder. Review of the Physician Orders dated 8/6/2022 reads, Insert midline with lidocaine one time for 1 day. Review of the Physician Orders dated 8/8/2022 reads, Observe midline catheter site during dressing changes. Review of the Physician Orders dated 8/8/2022 reads, Normal Saline Flush Solution 0.9% (Sodium Chloride Flush). Use 10 cc (cubic centimeter) intravenously every shift for midline to right arm every shift. During an interview on 8/9/2022 at 10:55 AM Staff C, LPN stated, The dressing is dated 8/6/22 and doesn't need to be changed. Well, it does have a gauze under the dressing, but it is in date. Sometimes the wound nurse does the dressing change, so I really don't know. I should have cleaned the needleless connector for longer and I should have checked for a blood return, and I didn't. I should have. During an interview on 8/9/2022 at 11:00 AM the Director of Nursing (DON) stated, The gauze should not be under the dressing, it should be changed within 48 hours. The dressing should have been changed yesterday. Review of the policy and procedure titled PICC/Midline/CVAD dressing change approval date 1/11/2022 105696 Page 6 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reads, It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physicians' orders will specify type of dressing and frequency of changes. Review of the policy and procedure titled Central Venous Catheter Flushing, Locking, Removal approval date of 1/11/2022 reads, Policy: It is the policy of this facility to ensure that central venous access catheters are flushed, locked, and removed consistent with current standards of practice. Policy Explanation: Central venous access devices are catheters that are placed into central circulation with the tip located in the superior vena cava or the inferior vena cava depending upon location. These are commonly known as 'central lines.' These devices may be used for longer durations of time but are not without their inherent risk of infection. Compliance Guidelines: 3. Central venous access catheters will be flushed and aspirated for blood return prior to each infusion to assess catheter functionality and prevent complications. Flushing: 1. Perform hand hygiene. 2. Gather supplies. 3. [NAME] gloves. 4. Disinfect needleless connector with an antiseptic solution using a vigorous mechanical scrub for 5 seconds and allow to air dry completely. 7. Slowly aspirate for a blood return to confirm device patency. 105696 Page 7 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 08/08/22 at 8:32 AM Resident #47 was observed lying on her left side in bed with oxygen being administered at 1 liter via nasal cannula. Residents Affected - Few During an observation on 08/09/22 at 10:27 AM Resident #47 was observed sitting in bed with oxygen being administered at 1 liter via nasal cannula. Review of the admission Record for Resident #47 documented the resident was admitted to the facility on [DATE] with the following diagnosis: chronic respiratory failure (Low oxygen levels that impact breathing) and congestive heart failure (the heart cannot pump enough blood to meet the body's needs). Review of the Physician Orders for Resident #47 dated 6/7/22 reads: Oxygen 2-4 liters/min to maintain oxygen % (percentage) saturation above 92% as needed for shortness of breath/low oxygen level. During an interview on 8/10/22 at 11:57 AM Staff D, LPN confirmed that the order was for oxygen at 2-4 liters of oxygen for Resident #47. During an interview on 8/10/22 at 2:07 PM the DON stated, Nurses are to check and adjust oxygen rate as per physician orders during resident assessments on each shift. Based on observation, interview, and record review the facility failed to provide respiratory care services in accordance with professional standards of practice for 2 (Resident #201 and #47) of 3 residents reviewed for oxygen administration out of a total sample of 42. Findings include: 1. During an observation on 8/8/22 at 10:40 AM Resident #201 was sitting in bed with oxygen being administered at 4 liters per minute via nasal cannula. The oxygen concentrator was set on 4 liters per minute. During an observation on 8/9/22 at 7:40 AM Resident #201 was resting in bed with oxygen running at 4 liters via nasal cannula. Review of the admission Record for Resident #201 documented the resident was admitted to the facility on [DATE] with the following diagnoses: atrioventricular block, complete (a condition that occurs when the electrical impulses that control the beating of the heart muscles are disrupted), chronic obstructive pulmonary disease, Non-Hodgkin lymphoma (a cancer of the white blood cells), dysphagia (inability to swallow), fibromyalgia, chronic pain syndrome, Sjogren syndrome (a disorder of the immune system), and essential (primary) hypertension, polymyositis (an inflammatory disease that causes muscle weakness), and anemia. Review of the Physician Orders for Resident #201 dated 8/4/22 reads, Oxygen at 2 liters/min (minute) via nasal cannula every shift and as needed. Review of the nursing progress notes for Resident #201 do not document any change in condition that would require an increase in oxygen rate. 105696 Page 8 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/9/22 at 8:05 AM Staff B, Licensed Practical Nurse (LPN) stated, I don't know what the oxygen is supposed to be set on. I will check. It is ordered at 2 liters. I will check the amount of oxygen my residents get when I give my medications and I haven't given them yet. During an interview on 8/10/22 at 11:25 AM the Director of Nursing (DON) stated, I expect that all staff will follow physician orders as they are written. Review of the policy and procedure titled, Oxygen Administration approval date of 1/11/22 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 105696 Page 9 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

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 maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during medication administration in 5 of 6 observations of medication administration. Residents Affected - Some Findings include: During an observation of medication administration on 8/9/2022 at 8:19 AM Staff A, Licensed Practical Nurse (LPN) prepared medication for Resident #67 without performing hand hygiene, donned personal protective equipment (PPE), and put on gloves without performing hand hygiene, entered the resident's room and administered the medications. Staff A did not perform hand hygiene after removing PPE, returned to the medication, and began preparing medications for another resident. During an interview on 8/9/2022 at 10:25 AM Staff A, LPN stated, I should have used the hand sanitizer before I got the PPE and gloves on, I should have washed my hands when I took it [PPE] off. During an observation on 8/9/2022 at 8:28 AM Staff C, LPN was observed in hallway checking Resident #56's blood pressure, staff was observed removing gloves and without performing hand hygiene began preparing medications for Resident #56 and administered the medications in the hallway. After administering the medications Staff C did not perform hand hygiene and began preparing medications for another resident. During an observation of medication administration on 8/9/2022 at 8:33 AM Staff C, LPN began preparing medications for Resident #54 without performing hand hygiene. Staff C administered the medications to the resident at the medication cart per resident request and did not perform hand hygiene after administering medications and beginning to prepare medications for another resident. During an observation of medication administration on 8/9/2022 at 8:55 AM Staff C, LPN began preparing medications for Resident #11 without performing hand hygiene. Staff C entered the resident's room without performing hand hygiene, assisted Resident #11 to reposition in bed and administered the medications. Staff C, left the room, returned to the medication cart, and began preparing medications for another resident without performing hand hygiene. During an observation of medication administration on 8/9/2022 at 10:40 AM Staff C, LPN completed an accucheck on Resident #25, staff assembled all equipment and entered the resident's room without performing hand hygiene, donned gloves, performed the accucheck, removed gloves, and without performing hand hygiene returned to the medication cart, obtained the medications from the cart, and returned to the resident's room. Staff C donned gloves without performing hand hygiene administered insulin subcutaneously in the right abdomen, pulling up the resident's shirt with a gloved hand. After administering the insulin, Staff C opened the 0.9% normal saline syringe, cleaned the resident's right midline catheter needleless connector for 2 seconds and administered 0.9 % normal saline, without changing gloves or performing hand hygiene between the administrations. During an interview on 8/9/2022 at 10:55 AM Staff C, LPN stated, I should have cleaned the needleless connector for longer. I should have changed my gloves and washed my hands before I flushed the midline dressing. I should use hand sanitizer before I poured meds [medications] and when I go in or out of the resident's rooms to give them meds. 105696 Page 10 of 11 105696 08/11/2022 Windsor Health and Rehabilitation Center 602 E Laura St Starke, FL 32091

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the policy and procedure titled Hand Hygiene approval date of 1/11/2022 reads Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations in the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 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. Review of the policy and procedure titled Medication Administration approval date of 1/11/2022 reads Policy. 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 Explanation and Compliance Guidelines: 4. Wash hands prior to administering medications per facility protocol and product. 105696 Page 11 of 11