Health inspection·January 16, 2020

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review and interviews the facility failed to provide the necessary treatment and services to promote healing, and prevent infection related to wound care for one resident (#53) out of 22 sampled residents. Residents Affected - Few Findings included: A review of the medical record revealed that Resident #53's most recent admission to the facility was on 10/19/19 with the diagnosis of sepsis,and other pertinent diagnoses included but were not limited to diabetes mellitus with unspecified complications, peripheral vascular disease and adult failure to thrive. A review of the active January 2020 physician orders revealed orders to include a daily dressing consisting of a Dakins solution flush followed by an Iodoform packing and a 4x4 gauze border, this order was written on 11/26/19 and replaced another treatment for this wound that was located on the Resident's upper back. A review of the active care plan with a target date of 2/28/20, revealed a focus of wound care management for wounds to the left heel and the mid-upper back. The interventions included the administering of treatments as ordered. On the morning of 1/16/20 at 8:40 a.m. an observation of the dressing change for Resident #53´s upper back wound revealed that the wound was uncovered, the lesion consisted of a small round crater-like wound of approximately ¼ inch in diameter, there was no odor to the wound, the depth was not able to be assessed, but it was exuding a small amount of serous drainage that could be visualized on the pillowcase, that had been behind the reclining resident. The Assistant Director of Nursing (ADON), who was performing the dressing change, could not offer an explanation as to why the wound was not covered by a dressing. A review of the November 2019 treatment record for Resident #53 revealed that beginning 11/26/19 and for the rest of November 2019 the Iodoform dressing was completed daily. A review of the December 2019 treatment record for Resident #53 revealed that for the period of December 1st to December 10th no treatment was performed on this wound, and then on December 11th through to December 31st the Iodoform treatment was completed daily. A review of the December assessment made by the wound care physician´s assistant on 12/31/19 documented for the back wound, .daily Dakins cleanse with Iodoform packing and dry dressing discussed with RN (registered nurse)-must pack undermining entirely!! ., the accompanying wound sheet documented the wound as 0.6 cm (centimeters) L (length) x 0.6 cm W (width) x 0.2 cm D (depth) with a small Page 1 of 8 105725 105725 01/16/2020 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0686 amount of serosanguinous drainage. Level of Harm - Minimal harm or potential for actual harm A review of the January 2020 treatment record made no mention of a treatment for the upper back, but it did mention, which was dated on 10/19/19, a skin assessment was to be done weekly on Thursdays. The skin assessment was due, but was not done on 1/09/20 and no documentation of any physician notification was documented. Residents Affected - Few The Director of Nursing (DON) was asked if she had any additional information to submit for review on 1/16/20 at 3:30 p.m. concerning the wound care for Resident #53 and she stated that she had none. 105725 Page 2 of 8 105725 01/16/2020 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 on observations and interviews the facility did not ensure that the Controlled Substance Emergency Drug Kits which contained 22 different forms of Schedule II medications, was locked and stored in a permanently affixed compartment separate from other medications such as an over the counter (OTC) cough medication, in two of two medication storage rooms sampled during the performance of the facility task of Medication Storage and Labeling. Findings included: On 1/16/20 at 11:55 a.m. during the performance of the medication storage and labeling task the locked medication room on 2 [NAME] was accessed by Staff M, Licensed Practical Nurse (LPN). On an upper-level shelf and next to another medication case was the controlled substances medication case, this case measuring approximately 16 inches long, 20 inches wide, and 1.5 inches thick was retrieved, the box was closed and secured with plastic tie wraps at either end of the handle, there was no lock on the box. The label on the box identified it as the Controlled Substance Emergency Drug Kit (EDK), the box displayed a card label which displayed the contents as 22 forms of Schedule II controlled substance medications, 6 forms of Schedule IV controlled substance medications and 1 form of Schedule V controlled substance medications. Staff M, LPN was asked if this was the usual place for the storage of the Controlled Substance EDK kit and she stated that it was. An inspection of the medication room located on 1 East was conducted at 12:15 p.m. with the Director of Nursing (DON) and revealed that the Controlled Substance EDK kit was stored in the same fashion in this medication room. The DON was asked if this was the usual place that the EDK was stored, and she replied that it was. She was asked if it should be in a permanently affixed compartment separate from other medications, and she replied that this was where they always kept the EDK and that she was not aware that it should be kept separate from the other medications. 105725 Page 3 of 8 105725 01/16/2020 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to honor the preference for the breakfast meal related to a beverage for one resident (#59) of 22 residents sampled. Residents Affected - Few Findings included: A review of Resident #59's medical record revealed an admission date to the facility with hospice care on 12/3/19. The diagnoses included peripheral vascular disease, unspecified Type 2 diabetes mellitus without complications, senile degeneration of brain, not elsewhere classified, and chronic kidney disease, Stage 3 (moderate). The admission Minimum Data Set Assessment, dated 12/12/19, showed in Section C, for Cognitive Patterns, a Brief Interview for Mental Status score of 14 (cognitively intact) and in Section G, Functional Status - ADLs (Activities of Daily Living), Resident was coded for supervision with set-up only when eating. An observation of Resident #59 on 1/14/20 at 11:16 a.m. revealed vomit was on the bed blanket. Resident #59 stated, This morning they gave me eggs and that is what I threw-up. She stated she does not like the eggs. Resident revealed she was supposed to have Lactose Free milk and they gave her whole milk. On 1/15/20 at 8:35 a.m., Resident #59 was observed in bed with a breakfast tray in front of her. There was no milk on her tray. A review of the January 2020 physician's orders, dated 1/1/20, revealed a dietary order for dysphagia advanced (foods), and thin liquids. A review of the Resident Profile Details form, with no date and printed on 1/15/20, showed Resident #59's Breakfast Special Requests, included preferences for, 6 Oz (ounces) Cold Cereal of Choice Everyday, and 8 Oz [Lactose Free] Milk Everyday. A review of Resident #59's Initial Care Plan, dated 12/17/19, revealed a focus for nutrition or potential nutritional problem related to diet restrictions and diagnoses included Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 3, and Hypothyroidism. The interventions, dated 12/17/19, included, .Provide, serve diet as ordered. Monitor intake and record q (every) meal. Further review of the Initial Care Plan, dated 12/17/19, revealed a focus for resident has dehydration or potential fluid deficit related to Diuretic use. The interventions included, Educate the resident/family/caregivers on importance of fluid intake. An interview was conducted on 1/15/20 at 1:45 p.m. with the Registered Dietician (RD). She stated, Resident #59's diet for diabetes, chronic kidney disease, stage 3 and hypothyroidism is dysphagia pureedregular and thin liquids. The RD stated the 12/16/19 note by speech therapy indicated a diet change from pureed to dysphagia advanced. She stated the Certified Dietary Manager completed the preferences for Resident #59. She said, The preference for Lactose Free Milk is on the meal ticket. On 1/15/20 at 2:33 p.m., an interview was conducted with the Certified Dietary Manager (CDM)/CFPP 105725 Page 4 of 8 105725 01/16/2020 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0806 Level of Harm - Minimal harm or potential for actual harm (Certified Food Protection Professional). She stated that she completed the dietary preferences for resident. She stated she was not aware that Resident #59 was on hospice and will re-assess the resident for preferences. The CDM revealed two dietary aides are on the tray-line and one is responsible for checking the meal ticket against the meal on the tray. The CDM stated she does have in-services for tray accuracies and to check trays since there are many diets being offered to residents. Residents Affected - Few A review of the 5:30 a.m. Dietary Aide-AMA responsibilities, no date noted, revealed from 5:35 a.m. to 7:00 a.m. to cut tickets and attach select menus for breakfast and lunch. From 7:00 - 8:00 a.m., work on tray line and pay attention to special requests. A review of the 5:30 a.m. Dietary Aide-AMB responsibilities, no dated noted, revealed from 7:00 - 7:05 a.m. to temp drinks and milk and record in temp log. (All beverages must be on ice). From 7:05 -8:00 a.m., work on tray line and pay attention to special requests. An interview was conducted on 1/15/20 at 5:52 p.m. with Resident #59's daughter, while visiting her mother during dinner time. Resident #59 was seated in her specialized lounge chair eating her meal. The daughter stated and verified her mother does not drink regular milk. She stated her mother has always drank Lactose Free Milk in the mornings. She stated the regular milk makes her mother's stomach upset. An interview was conducted on 1/16/20 at 9:54 p.m. with Staff A, Assistant Director of Nursing (ADON). She verified and stated, The nurse is responsible for reading the meal tickets before the trays are handed to the resident and should be checked by the nurse on all three meal services. She stated her expectation was that the nurse and CNA (Certified Nursing Assistant) will check the resident's tray and ask the resident if she got the correct beverage. On 1/16/20 at 10:12 a.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN). She stated if she is in the dining room, she checks the meal ticket for orders against the meal. Staff E stated, For residents being served a meal in their rooms, the hallway nurse will check the meal ticket against the order, and if a new diet order is needed, I communicate with dietary. There is a communication sheet that we use. The LPN stated, If problem with swallowing they can contact the speech department and dietary to perform a consult. She continued, In the meantime, the nurse can down grade resident's meals and report it on the 24-hour sheet. On 1/16/20 at 10:20 a.m., an interview was conducted Staff D, CNA. She stated one day she went to the dietary kitchen and got the Lactose Free Milk for the resident and on the second day, the CNA called the dietary department and they brought up the Lactose Free Milk milk. Staff D stated that she checks the meal against the meal ticket to make sure the resident gets what she should. An interview was conducted on 1/16/20 at 11:26 a.m. with the Director of Nursing. She verified and stated, The staff is checking if it (lactose free milk) is on the ticket; it should be on the tray. The kitchen should provide what is on the meal ticket and the CNAs and nurses are checking the meal tickets before they pass the trays to resident. An interview was conducted on 1/16/20 at 4:36 p.m. with Staff G, Dietary Aide. She stated she works the tray-line, calls the tickets, places silverware and plates. The cook sends the plate down the tray line. She stated, Juice, nectar, milk and desserts are at the bottom of the tray line. The person (stationed) at the bottom of the tray line re-reads the meal ticket to make sure the items are correct on the meal tray. She stated she has not had an in-service recently on the meal tickets. 105725 Page 5 of 8 105725 01/16/2020 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of facility Policy and Procedure on Food Preferences, dated May 2014, revealed in the Policy Statement, It is the center policy that individual food preferences are identified for all residents/patients. Action Step, #3., revealed, Food allergies, food tolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in menu management software system. Action Step, #4., revealed, The individual tray assembly will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. 105725 Page 6 of 8 105725 01/16/2020 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The fourth observation of the performance of blood glucose sampling was done on 1/16/20 at 11:22 a.m. with Staff M, LPN on 2 West. The observation revealed that Staff M, LPN used the facility's designated germicidal wipe to clean the meter after its use. Staff M, LPN wiped down the front and back of the blood glucose meter after its use using a germicidal wipe for approximately 20 seconds then discarded the wipe. Staff M, LPN then placed the blood glucose meter on top of the medications cart to air dry. Residents Affected - Some The CDC's recommendation for the cleaning of medical equipment directs the Long-Term Care Facility staff to follow the manufacturer's instructions. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html#rec7g Based on observation, interview and review of the facility's policy, the facility failed to maintain an effective infection control program related to not cleaning the blood glucose meter after its use according to the facility's policy, and the manufacturer's instructions for the germicidal disposable wipes, or in a manner that follows professional standards of practice as recommended by the Center for Disease Control and Prevention (CDC) during four of four observations while performing the task of Medication Administration. Findings included: 1. Three of the four observations of the performance of blood glucose sampling performed by three different nurses each on a different hall revealed that Staff E, Licensed Practical Nurse (LPN), Staff K, Registered Nurse (RN) and Staff L, RN used the facility's designated germicidal wipes to clean the blood glucose meter after each use. The observations were as follows: - On 1/15/20 at 11:36 a.m. room [ROOM NUMBER] with Staff E, LPN, the nurse wiped the blood glucose meter front and back for approximately 7 seconds then placed the blood glucose meter on the medication cart to dry. - On 1/16/20 at 11:33 a.m. room [ROOM NUMBER]-A with Staff K, RN using the facility designated germicidal wipes the nurse wiped the blood glucose meter front and back for approximately 10 seconds then set the meter on napkins placed on the medication cart to dry. - On 1/16/20 at 3:53 p.m. room [ROOM NUMBER]-B with Staff L, RN without wearing gloves the nurse used the facility designated germicidal wipes and wiped the blood glucose meter front and back for approximately 7 seconds then set the meter on napkins placed on the medication cart to dry for 5 seconds. An interview was conducted on 1/15/20 at 11:39 a.m. with Staff E, LPN, and the nurse stated, I clean the glucose meter and let it dry for 5 to 10 minutes. Review of facility's policy titled, Infection Prevention and Control Manual General Policies, Cleaning and Disinfecting Blood Glucose Meters, dated 2017, revealed procedure to include 12 steps. Step 11 showed, Use of disinfectants, antiseptics, and germicides are by manufacturers' instructions and EPA or FDA label specifications to avoid harm to staff, residents and visitors and to ensure 105725 Page 7 of 8 105725 01/16/2020 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some effectiveness. All nursing staff is trained in the proper procedure, protective equipment required (if any), and safety precautions. Step 12 showed, All products and processes used for cleaning, disinfection, and sterilization are approved by Infection Control Committee/Infection Preventionist. Additional instruction showed, NOTE: When selecting a disinfecting cleaning product, review the required contacted time. Nursing is to understand and demonstrate the necessary length of time the disinfectant must be in contact with the glucometer. Each disinfectant has specific instructions. Review of the manufacturer's instructions for the facility's approved germicidal wipes showed, Germicidal Wipe Name (1) TECHNICAL DATA BULLETIN EPA (Environmental Protection Agency) Reg. No. 9480-4 revealed Pages 1 and 2. BACTERIAL ORGANISM EFFICACY a 2 minutes exposure time, VIRAL ORGANISM (enveloped viruses) a 2 minutes exposure ,(non -enveloped viruses) a 2 minutes exposure, PATHOGENIC FUNGI EFFICACY 2 minute exposure. 105725 Page 8 of 8