Health inspection·February 20, 2020

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review the facility failed to honor the bathing preference of a shower for one resident (#75) of forty nine sampled residents. Findings included: On 2/17/2020 at 9:35 a.m. a family member was observed at the 100-unit nursing station asking the nurse, Is my father going to get his shower this morning. She then asked the nurse for towels as she was heard saying my father has food in his beard. At 10:37 a.m. an interview was conducted with Resident #75's daughter and she said that she had concerns with her father getting his weekly showers since he had been admitted . Resident #75's daughter stated, My father is supposed to get two showers a week and that has not been happening. The daughter was asked if she had told anyone about her concerns, she stated, I told his nurse today. I went to the desk this morning and had to ask for towels. My father had food in his beard this morning when I got here. I know he didn't get his shower this morning. Resident# 75's daughter said that she comes to the facility every day to make sure he gets out of bed and that he gets his showers. She said that it takes two people to give him a shower. It takes a long time because he is a mechanical lift. His shower is normally in the morning. I don't know why he hadn't had his shower today. She went on to say his last shower was last week on Monday. He was scheduled for one on Thursday, and I know that he didn't get it. I can tell he didn't get it just by his hair and beard. She was asked if her father has ever refused. She said that he is confused and will resist at times. But I told them I am just eight minutes down the road, and to call me and I will come in and help with my father whenever they need help. Resident #75 was observed in a chair during the interview and would not verbalize. A review of the admission Record for Resident #75 revealed an original admission date of 3/8/18 and a re-admission date of 2/1/20. The diagnoses included morbid obesity, unspecified dementia with behavioral disturbance, sepsis, unspecified mood disorder, arthritis due to other bacteria, right hip and difficulty in walking. A review of the Minimum Data Set (MDS) dated [DATE] revealed in Section F-Preferences for Customary Routine and Activities that choosing between a tub bath, shower, bed bath, or sponge bath was very important to Resident #75. The Shower Schedule sheet indicated Resident #75's showers were scheduled on Mondays and Thursdays on the day shift (7:00 a.m. - 3:00 p.m.). The documentation in the Task Section for 2/3/20 - 2/17/20 showed that only one shower was provided. The bathing was documented as follows: Page 1 of 7 105697 105697 02/20/2020 East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764

F 0561 2/3/2020 - a bed bath was given Level of Harm - Minimal harm or potential for actual harm 2/6/2020 - marked as not applicable 2/7/2020 - a bed bath was given Residents Affected - Few 2/10/2020 - a shower was given 2/13/2020 - a bed bath was given 2/17/2020 - a bed bath was given On 2/18/20 at 4:38 p.m. an interview was conducted with the Director of Nursing (DON) and Nursing Home Administrator related to the concern of Resident #75's daughter with her father not getting his scheduled showers. The Nursing Home Administrator said we look at assignments. It's something that we look at and if it has more to do with the patient. She said that he was not always cooperative with staff. Resident #75's current care plan revised on 2/3/2020 was reviewed and did not reveal a plan of care was in place related to the resident refusing showers and or being resistant with staff during care. A review of the nursing progress notes revealed a note dated 2/3/2020 at 7:18 (a.m.), Upon admission alert with confusion . Requires total assist with adl's [activities of daily living] with mechanical transfers . history of noncompliance and refusal of care with behaviors .he was admitted with a diagnosis of sepsis hypernatremia and uti . Vancomycin IV thru 2/11/2010 for sepsis and uti . Bactroban ointment to nares for colonized mrsa (Methicillin-Resistant Staphylococcus Aureus). On 2/20/20 9:58 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN) that confirmed she use to be the unit manager on the unit and still works on the unit. She confirmed Resident #75's daughter has always told the staff to call her if they needed help. She said, I have seen her a lot of times here helping get him in the shower. She said that she was aware the daughter had come in the evening shift to help them out. She said that he is adamant at times. If he doesn't want to do something. On 2/20/20 at 10:09 a.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). She said he (Resident #75) had one today. She said on Monday (2/17/2020) we gave him a bed bath. Staff C, CNA stated, After he came back from the hospital and had that infection, I wasn't sure if I could take him in to the shower room, because the infection in his urine and they say he pees a lot. I didn't want to spread whatever he had in the shower. So, we gave him bed baths. She stated that his daughter wants us to get him up every day. Even when he doesn't want to. He is very time consuming when we give him a shower. We have to do multiple [mechanical] lifts. She denied that he was physically aggressive. On 2/20/20 at 11:39 a.m. an interview was conducted with Staff B, CNA. She confirmed that she had cared for Resident #75 every day, before he went to the hospital. After he came back from the hospital he was on a different assignment. She stated, I still help him with his showers, it takes two people. Staff B, CNA was asked about the documentation in the Task section on the Shower Sheet. She said that she knew after he came back from the hospital, he had MRSA (Methicillin-Resistant Staphylococcus Aureus), so we had to gown up and gave him a bed bath. She went on to say that the resident's (#75) daughter told her it was okay for a bed bath instead of a shower. Staff B, CNA stated, The 105697 Page 2 of 7 105697 02/20/2020 East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764

F 0561 Level of Harm - Minimal harm or potential for actual harm daughter helps us bathe him and she wanted him to have a shower. Staff B, CNA was asked how often the daughter visits and she said that she comes here every day. Staff B, CNA stated, It takes a lot for us to get him ready. He grabs the railing of the bed and he won't let it go. She said sometimes it takes a half an hour before he will let go of the railing. She was asked if he is aggressive during this time. Staff B said that he will get mad by showing you his fists. That's about all he does. Residents Affected - Few On 2/20/2020 at 2:30 p.m. during an interview with the facility's Infection Control Preventionist and DON it was relayed that the CNAs confirmed they had been providing bed baths to Resident #75 instead of showers due to not wanting to spread his infection (MRSA) in the shower. The DON said we have things for that (indicating the shower can be cleaned). He stated, The resident could have had a shower. 105697 Page 3 of 7 105697 02/20/2020 East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based upon observation, interviews, and record review the facility failed to appropriately secure medications in two medication carts (#2 East Hall, #1 [NAME] Hall) of four medication carts sampled. Findings included: A review of the facility policy titled, Medication Storage in the Facility, Page 48, with a revision date of August 2014, reads under Procedures: A. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States (USP). Medications are kept in these containers. C. All Medications dispensed by the Pharmacy are stored in the container with the pharmacy label. On 02/20/2020 at 11:25 a.m., an observation of the East Hall Medication Cart #2 was conducted. The second drawer from the top of the medication cart contained a one-half (½) loose orange tablet, and in the back of the drawer it was observed that one-half (½) of a pink tablet was also loose amongst the punch cards in the drawer. Staff D, Registered Nurse (RN) confirmed the presence of the unsecured tablets. (Photographic Evidence Obtained) On 02/20/2020 at 11:40 a.m., an observation of the [NAME] Hall Medication Cart #1 was conducted. The fourth drawer from the top of the medication cart was pulled out and it was observed to contain, behind the drawer, a loose one-quarter (¼) white tablet. Staff E, Licensed Practical Nurse (LPN) reached behind the drawer and confirmed the presence of the unsecured tablet. On 02/20/2020 at 12:00 p.m., an interview with the Director of Nursing (DON) was conducted. He was informed of the observations made, and indicated he was made aware of the loose and unsecured tablets by both Staff D,RN and Staff E, LPN prior to the interview. He stated, My expectation is that there are no loose or unsecured pills in the medication carts. 105697 Page 4 of 7 105697 02/20/2020 East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764

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, record review and review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure that direct caregivers (Staff G, Staff I and a Therapy Tech) followed standard infection control precautions related to artificial nails and nail length. Residents Affected - Few Findings included: On 2/17/20 at 12:15 p.m. lunch trays were being distributed to residents in the 100-hallway. Staff G, Certified Nursing Assistant (CNA) was observed delivering meal trays to multiple resident rooms. She was observed to have fingernails approximately one inch in length from the nail bed. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On 2/17/20 at 2:00 p.m. Staff G, CNA was observed leaving a resident room in the 100-hallway. She was carrying a clear colored plastic bag that contained an incontinent product. She went to the soiled utility room as she disposed of the bag. She was observed to have fingernails approximately one inch in length from the nail bed. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On 2/18/2020 at 11:00 a.m. a therapy tech was observed in the 100-hallway exiting a room while pushing a resident in a wheelchair. She went to the therapy room with the resident. She shortly left the therapy room. She was observed walking up to a resident and touched her left shoulder with her left hand. The therapy tech was observed with long artificial nails approximately one inch in length. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On 2/19/2020 at 12:21 p.m. Staff G, CNA was observed in the main dining room as she delivered soup to a resident. She was observed to have fingernails approximately one inch in length from the nail bed. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. Staff G was observed to walk over to a large serving tray and picked up a plate of food with her right hand. As she walked over to a table, she transferred the plate of food to her left hand, in doing this her left thumb nail was touching the roast beef on the plate. She then placed the plate of food in front of the resident to eat. On 2/19/2020 at 1:50 p.m. Staff I, CNA was observed on the 100-hallway walking toward the nursing station. She was noted to be carrying a clear plastic bag. She entered the soiled utility room. Her fingernails appeared to be over an inch in. She was observed to use a hand sanitizer as she rubbed the front and back of her hands with no care to the front or under sides of her fingernails. On 2/19/2020 at 2:30 p.m. an interview was conducted with the Director of Nursing (DON) as he was asked about the facility policy on staff members and their fingernails. He was asked to observe Staff G's fingernails. Staff G was in the 100-hallway and she was asked how long her fingernails were and she confirmed that they were about an inch in length and were artificial. She confirmed that they were long and added, it's time to get them cut and down again. Staff H,CNA was also observed on 100-hallway using a computer screen. The DON was asked what Staff H's job position was. He said that she is a nursing assistant. He confirmed that she provided direct 105697 Page 5 of 7 105697 02/20/2020 East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care to the residents at the facility. Her nails were observed to be over an inch in length that contained multiple different colored glistening jewels. On 20/20/20 at 12:55 p.m. an interview related to hand hygiene and the length of direct care staff fingernails was conducted with the Infection Control Preventionist Nurse. She stated that artificial nails are not recommended. She provided a copy of her random audits that she performs in the facility. A review of the undated audit titled, Handwashing and Hand Hygiene Surveillance Audit, showed an area of maximum points awarded. Listed under hand hygiene 1. No artificial nails or nail enhancements. Max points awarded 50. 2 Natural nails are short and well- groomed points awarded 25. The facility's Dress Code Guideline, documented, The facility expects you to maintain a neat, well-groomed appearance at all times. This means good personal grooming habits and the proper attire for your position with the facility. The following guidelines have been established to assist you in understanding the Facility's basic standards. Please note this guideline is in effect as of February 1,2017 . *Fingernails should be kept short to below the fingertip with smooth edges in order to maintain infection control and prevent injury. *Associates working in dietary cannot wear acrylic, gel or other nail extensions. The facility's undated Certified Nursing Assistant job description showed: Position Overview . Competencies of Position: Safety Awareness .consistently follows infection control and universal precautions and other guidelines . Centers for Disease Control and Prevention guidelines for Skin and Nail Care (https://www.cdc.gov/handhygiene/providers/index.html) showed: Fingernail care and jewelry *Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing * It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms) *Keep natural nail tips less than ¼ inch long . Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf, updated July 2019, pages 50 - 51, revealed: The effectiveness of hand hygiene can be reduced by the type and length of fingernails 559, 718, 719. Individuals wearing artificial nails have been shown to harbor more pathogenic organisms, especially gram negative bacilli and yeasts, on the nails and in the subungual area than those with native 105697 Page 6 of 7 105697 02/20/2020 East Bay Rehabilitation Center 4470 E Bay Dr Clearwater, FL 33764

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nails720, 721. In 2002, CDC/HICPAC recommended (Category IA) that artificial fingernails and extenders not be worn by healthcare personnel who have contact with high-risk patients due to the association with outbreaks of gram-negative bacillus and candida infections as confirmed by molecular typing of isolates30, 31, 559, 722-725.The need to restrict the wearing of artificial fingernails by all healthcare personnel who provide direct patient care or by healthcare personnel who have contact with other high risk groups (e.g., oncology, cystic fibrosis patients), has not been studied, but has been recommended by some experts20. 105697 Page 7 of 7