Health inspection·January 7, 2022

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one (Resident #11) of five residents sampled for skin conditions (pressure and non-pressure related) received weekly skin assessments. Residents Affected - Few Findings included: The policy titled, Weekly and As Needed (PRN) Skin Check, copyright 2008, identified the purpose was To provide care to reduce the risk of pressure ulcers and to manage the treatment and to promote healing. The Weekly and PRN Skin Check is used to document skin condition through the Resident's stay in the facility. It is recommended that designated staff members of the nursing team complete the weekly skin checks for Residents in order to ensure continuity. If a new area of impairment is, it should be documented on the Weekly and PRN Skin Check and the appropriate Weekly Skin Grid initiated. A review of the policy procedure indicated that A Weekly Skin Grid will be initiated when an area of skin impairment is identified. The procedure instructed staff that a Skin check should be documented on the Weekly and PRN Skin Check. If a new area is identified the appropriate Weekly Skin Grid should be initiated and to Document actions taken based on the Skin Check. a) Check new skin impairment if new are identified, B) no new areas of skin impairment, c) Weekly Skin Grid pressure or other for both previously identified and newly identified areas, d) Nursing Progress Note document skin impairment. Resident #11 was admitted on [DATE]. The admission Record did not identify any medical diagnoses for the resident. The Quarterly Minimum Data Set (MDS), dated [DATE], identified the resident's Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS indicated the resident had not rejected care, was at risk of developing pressure ulcers, did not have any unhealed pressure ulcer or injuries, venous/arterial ulcers, and did not have any skin issues on the feet. The care plan for Resident #11 identified the resident had a potential for further impaired skin integrity. The focus indicated that the resident was admitted to the facility with MASD (Moisture Associated Skin Damage) to bilateral buttocks, back, thighs, groin, open area to left and right buttock, left hip, and a surgical incision to left lower leg. The plan was initiated on 9/29/21 and revised on 1/7/22. The care plan included an intervention, initiated 9/29/21 that instructed staff to administer treatments as ordered and monitor for effectiveness. The focus identified that on 12/20/21 a blister was identified on the top of the residents left foot. During an interview and observation, on Tuesday 1/04/22 at 12:25 p.m., with the resident, it was identified that the resident was wearing a black orthotic boot on the left lower extremity (LLE). Resident #11 stated that a blister had opened up on the left foot, under the boot. An observation Page 1 of 8 105730 105730 01/07/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated that the area under the boot was wrapped in an elastic bandage. The resident stated that the blister had opened up on Saturday and was told that the wound physician would visit on Wednesday (1/5/22). The resident identified that he had been admitted following a broken ankle. A review, on 1/6/22 at 2:49 p.m., of Resident #11's clinical record indicated that the most recent Weekly Skin Observation Tool was completed on 11/29/21. The record indicated that the Weekly Skin Grid Pressure - Non-pressure was 38 days overdue. Photographic evidence obtained. An observation, on 1/6/22 at 2:54 p.m. revealed that Resident #11 was not in his room. On 1/6/22 at 2:56 p.m., Staff B, Licensed Practical Nurse (LPN), stated that Resident #11's blister looked normal and was unable to report whether the blister was intact, fluid-filled, blood-filled, or how big the blister was. The Director of Nursing (DON) stated, at 3:01 p.m. on 1/6/22, that Staff B doesn't remember how big the blister was and reported that weekly skin evaluations were to done for Resident #11 on Mondays during the 3:00 p.m.-11:00 p.m. shift. On 1/6/22 at 3:02 p.m., Staff A, Unit Manager (UM), stated that she had put the order (for skin prep) in the electronic record after the nurse told her about the blister. On 1/6/22 at 3:02 p.m. the DON stated that there was documentation of Resident #11 having redness and discoloration but was unable to report the location of the redness and discoloration. The UM stated that the weekly skin evaluations were documented under the clinical tab of Evaluations. The DON and UM reviewed the Weekly Skin Tool Evaluations and would not confirm that the last skin assessment was completed on 11/29/21. A review of Resident #11's progress notes and evaluations for 12/20/21 did not include a description and/or measurement of the residents left foot blister. A Quarterly Nursing Evaluation, dated 12/20/21 and signed by Staff C on 12/28/21, indicated that the resident was at risk for pressure ulcers and had excoriation/MASD. The evaluation did not indicate the location of the resident's MASD. The Quarterly Evaluation did not identify that the resident had a blister. A review of the Weekly Skin Observation Tool that was provided by the facility indicated that a Weekly Skin Observation Tool, dated 12/6/21 and signed by Staff D, Registered Nurse, on 1/7/22, identified Resident #11 had a surgical wound and discoloration that was pre-existing and did not have any new areas of skin irregularities. The review of the Weekly Skin Grid Pressure- Non Pressure Evaluation indicated one was completed on 10/14/21 and then at 5:21 p.m. on 1/6/22. The Pressure/Non-pressure Evaluation, dated 1/6/22, identified that the resident had a blister measuring 3 x 2 x 0 centimeter (cm) that was non-pressure related, in-house acquired, and identified on 12/20/21. 105730 Page 2 of 8 105730 01/07/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

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 observations, record reviews, and interviews, the facility failed to ensure the medical records of two (Residents #107 and #11) of 41 sampled residents were complete and accurately documented in regards to the management and description of a pressure-related skin injury, non-pressure skin injury, and providing a treatment as documented. Findings included: The policy titled, Weekly and As Needed (PRN) Skin Check, copyright 2008, identified the purpose was To provide care to reduce the risk of pressure ulcers and to manage the treatment and to promote healing. The Weekly and PRN Skin Check is used to document skin condition through the Resident's stay in the facility. It is recommended that designated staff members of the nursing team complete the weekly skin checks for Residents in order to ensure continuity. If a new area of impairment is, it should be documented on the Weekly and PRN Skin Check and the appropriate Weekly Skin Grid initiated. A review of the policy procedure indicated, A Weekly Skin Grid will be initiated when an area of skin impairment is identified. The procedure instructed staff that a Skin check should be documented on the Weekly and PRN Skin Check. If a new area is identified the appropriate Weekly Skin Grid should be initiated and to Document actions taken based on the Skin Check. a) Check new skin impairment if new are identified, B) no new areas of skin impairment, c) Weekly Skin Grid pressure or other for both previously identified and newly identified areas, d) Nursing Progress Note document skin impairment. 1. Resident #107 was admitted on [DATE]. The admission Record included diagnoses not limited to Fournier gangrene, morbid (severe) obesity due to excess calories, Type 2 Diabetes Mellitus without complications, non-pressure chronic ulcer of other part of left foot with unspecified severity, and non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity. A review of Resident #107's December Treatment Administration Record (TAR) indicated a physician order for the treatment of the resident's left buttock as follows: L Buttocks: cleanse with normal saline, pat dry, apply medi-honey and calcium alginate, and cover with dry clean dressing (DCD) daily until resolved, every night shift for wound care. Start Date - 12/09/2021 2300 (11:00 p.m.) The January TAR for Resident #107 indicated that the staff continued to apply medi-honey and calcium alginate to the resident's left buttock until the night shift on 1/5/22. An observation was conducted on 1/7/22 at 8:45 a.m., of Resident #107's left buttock. The area had zinc oxide covering a reddish-purple area. Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM), stated that the treatment was changed last night (1/6/22) because there wasn't anything there. Staff A stated that a TeleHealth visit was done with the wound physician and that the order for Medi-honey and calcium alginate was discontinued. A review of the Skilled Evaluation notes, indicated that on 12/8/21 at 1:57 a.m., Resident #107's skin was warm and dry, skin color within normal limit (WNL), mucous membranes moist, turgor normal. The Skin/Wound note, dated 12/8/21 at 3:42 p.m., indicated an unstageable non-pressure wound to 105730 Page 3 of 8 105730 01/07/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0842 Level of Harm - Minimal harm or potential for actual harm Resident #107's perineal area, measuring 10 x 18 x 3 centimeter (cm). The note identified that the family was notified of the skin condition and the wound physician assessed the area. The Skilled Evaluation note, 12/9/21 at 1:57 a.m., identified that Resident #107's skin was skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. Residents Affected - Few The review of the Skin Check notes for Resident #107 revealed on 12/5/21 at 12:15 a.m., staff noted pre-existing discoloration, pre-existing surgical wound. Resident skin check completed with previous areas noted; No new areas of skin irregularities noted on completion of skin check. The Skin Check notes did not indicate any further Skin Check notes until 12/27/21. The review of Resident #107's Skin/Wound Progress notes identified on 12/8/21 at 15:42 (3:42 p.m.), the resident had an unstageable non-pressure perineal wound that measured 10 x 18 x 3 centimeters (cm). The note did not indicate that the resident had a wound to the left buttock or was assessed by the Wound physician. The sequential Skin/Wound note, dated 12/15/21 at 1:42 a.m., indicated that the resident had a surgical excision to the groin and a Stage II pressure wound to the left buttock. The note indicated that the left buttock pressure wound shows improvement and was present on admission. The Weekly Skin Grid Pressure Non-pressure notes, indicated that on 12/5/21 (two days after admission) that Resident #107 had the following skin conditions: Other - surgical incision, right neck. Abdomen surgical incision measuring 11 cm x 0.1 cm x 0. Other - Coccyx redness, Abdomen surgical incision, Bilateral lower extremity dry skin, and surgical incisions to the groin, R side of neck, and abdomen. The Weekly Skin Grid, dated 12/8/21, identified an unstageable perineal area measuring 10 x 18 x 3.0 cm. The Weekly Skin Grid, dated 12/15/21 identified a surgical excision to the groin and a stage II pressure area to the left buttock. The skin grid on 12/15/21 did not include measurements of the stage II area on the left buttock. The Weekly Skin Grid, dated 12/27/21, indicated a pressure area on the left buttock. The skin grid, dated 12/27/21 did not identify a stage or measurements for the left buttock. The review of progress notes and Skilled Evaluations for Resident #107 did not include a description or measurements of the wound to the resident's stage II pressure area located on the left buttock. On 1/6/22 at 4:21 p.m., Staff A reviewed Resident #107's skin grids and documentation and confirmed there was no measurements for the residents left buttock wound. She elaborated that the nurse informed her that it was not opened, just red. She stated that the staff must have forgotten to discontinue the order to apply medi-honey and calcium alginate to a wound that was closed. The Director of Nursing stated on 1/6/22 at 4:23 p.m., that she knew measurements were done on the left buttock wound. A review of the Wound physician notes, dated 12/8, 12/15, 12/20/21, and 1/5/22 did not identify that the physician has assessed the left buttock wound. A wound physician Telemedicine note, dated 1/6/22, indicated that an Initial Evaluation of the Moisture Associated Dermatitis to an unknown area was completed with the order to please discontinue current treatment and apply zinc oxide ointment to the affected area every (q) shift and as needed (prn). A Skin/Wound note on 1/7/22 at 7:18 a.m., indicated that a TeleHealth visit with Wound MD to reassess resident skin issue to buttocks/coccyx. Previous wound treatment (tx) discontinued. Diagnosis 105730 Page 4 of 8 105730 01/07/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (dx) is Moisture Associated Dermatitis/Skin Irritation. Tx to start will be to apply zinc oxide to affected area q shift and prn. Orders noted. The DON stated, on 1/7/22 at 12:36 p.m, that the Wound MD was overseeing all treatment orders. She stated it was not a wound, just a masceration. The Regional Director of Clinical Services (RDCS) stated that the Interdisciplinary Team (IDT) did document that the resident had an area to the left buttock. The DON stated that Medi-honey and Calcium Alginate would have been laid on top of the (intact) skin of the buttock. The DON reviewed the clinical record of Resident #107 and stated she did not find any measurements of the area and would not have due to it being redness. An interview was conducted on 1/7/22 at 12:48 p.m., with the wound physician. The physician stated he was seeing Resident #107 for the groin wound but then he was asked to assess the left buttock wound yesterday. He stated he had not seen the left buttock wound until yesterday and that was through TeleMedicine. The wound physician stated the wound was not open, was not draining, and that the use of Medi-honey and calcium alginate was not appropriate for the left buttock. He reported that a wound would have to be full-thickness for the use of Medi-honey and calcium alginate. Resident #107's care plan identified that the resident had the potential for impaired skin integrity related to impaired mobility secondary to muscle weakness, difficulty in walking, dx: morbid obesity, and use of anticoagulant medication. admitted to facility with surgical incision to upper abdomen, right side of neck, and labia/perineal area, Suspected Deep Tissue Injury (SDTI) to left buttock and left foot, left lower extremity (LLE)/foot venous ulcer, MASD under bilateral breasts, and under bilateral arms. 1/6/22 - left buttock irritation r/t moisture dermatitis. The focus of this care plan was initiated on 12/8/21 and revised on 1/7/22. The interventions included: - Administer treatments as ordered and monitor for effectiveness, initiated 12/8/21. - Weekly skin checks per facility protocol, initiated 12/8/21. 2. Resident #11 was admitted on [DATE]. The admission Record did not identify any medical diagnoses for the resident. The Quarterly Minimum Data Set (MDS), dated [DATE], identified the residents Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS indicated the resident had not rejected care, was at risk of developing pressure ulcers, did not have any unhealed pressure ulcer or injuries, venous/arterial ulcers, and did not have any skin issues on the feet. During an interview and observation, on Tuesday 01/04/22 at 12:25 p.m., with the resident, it was identified that the resident was wearing a black orthotic boot on the left lower extremity (LLE). Resident #11 stated that a blister had opened up on the left foot, under the boot. An observation indicated that the area under the boot was wrapped in an elastic bandage. The resident stated that the blister had opened up on Saturday and was suppose to see the wound physician on Wednesday (1/5/22). The resident identified that he had had a broken ankle. A review, on 1/6/22 at 2:49 p.m., of Resident #11's clinical record indicated that the most recent Weekly Skin Observation Tool was completed on 11/29/21. Photographic evidence obtained. The review of Physician Order Summary Report, active as 1/6/22, indicated an order, dated 12/20/21, that instructed staff to Skin Prep Wipes Miscellaneous - Apply to top L foot topically every shift for blister evaluation (eval) for pain prior to, during, and after treatment (tx), and medicate as 105730 Page 5 of 8 105730 01/07/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed (prn). Monitor site for signs/symptoms (s/s) of infection and notify MD prn. A review of the Treatment Administration Record (TAR) indicated that during the day shift on 1/6/21, skin prep had been applied to the blister on top of Resident #11's left foot. On 1/6/22 at 2:54 p.m., an observation revealed that Resident #11 was not in his room. An interview was conducted with Staff C, Licensed Practical Nurse (LPN), on 1/6/22 at 2:54 p.m., who identified he worked the 3:00 p.m.-11:00 p.m. shift and had not gotten report from Staff B, LPN. Staff B stated, at 2:56 p.m. on 1/6/22, Resident #11's blister looked normal, confirmed the application of skin prep to the area, and was unable to report whether the blister was intact, fluid-filled, blood-filled, or how big the blister was. The Director of Nursing stated, at 3:01 p.m. on 1/6/22, that Staff B doesn't remember how big the blister was and reported that weekly skin evaluations were to done for Resident #11 on Mondays during the 3:00 p.m. 11:00 p.m. shift. On 1/6/22 at 3:02 p.m., Staff A, Unit Manager (UM), stated that she had put the order (for skin prep) in the electronic record after the nurse told her about the blister. The DON stated there was documentation of redness and discoloration but was unable to report the location of the redness and discoloration. The UM stated the weekly skin evaluations was documented under the clinical tab of Evaluations:. The DON and UM reviewed the Weekly Skin Tool Evaluations and would not confirm that the last skin assessment was completed on 11/29/21. A review of Resident #11's January Treatment Administration Record (TAR) on 1/6/22 at 3:23 p.m., indicated Staff B had applied skin prep to the blister on the resident's left foot. An interview was conducted at 3:26 p.m. on 1/6/22 with Staff B and Staff A. Staff B stated he had not applied skin prep to the blister as noted on the TAR. He stated he had made a mistake by pre-documenting that he had done it and would apply it later. An observation of Resident #11's left foot was conducted with Staff A and Staff E (LPN/UM) on 1/7/22 at 9:01 a.m. Resident #11 stated the blister had popped a week ago and red/black pus had come out of the area and the skin appeared to be healed. The observation with the staff members indicated an approximately quarter-sized flat reddened area under a foam dressing. A review of Resident #11's progress notes and evaluations for 12/20/21 did not include a description and/or measurement of the residents left foot blister. A Quarterly Nursing Evaluation, dated 12/20/21 and signed by Staff C on 12/28/21, indicated that the resident was at risk for pressure ulcers and had excoriation/Moisture-Associated Skin Damage (MASD). The Quarterly Evaluation did not identify that the resident had a blister to the top left foot. A review of the Weekly Skin Observation Tool that was provided by the facility indicated that a Weekly Skin Observation Tool, dated 12/6/21 and signed by Staff D, Registered Nurse, on 1/7/22, identified Resident #11 had a surgical wound and discoloration that was pre-existing and did not have any new areas of skin irregularities. The review of the Weekly Skin Grid Pressure- Non Pressure Evaluation indicated one was completed on 10/14/21 and then at 5:21 p.m. on 1/6/22. A provider progress note, dated 12/8/21, identified that Resident #11 had a tibia and fibula fracture status post (s/p) open reduction and internal fixation (ORIF). The note identified that the Resident complained of generalized edema and the assessment revealed a diagnosis of anasarca (generalized swelling throughout the body) and was morbidly obese. The care plan for Resident #11 identified the resident had a potential for further impaired skin integrity. The focus indicated that the resident was admitted to the facility with MASD to bilateral 105730 Page 6 of 8 105730 01/07/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few buttocks, back, thighs, groin, open area to left and right buttock, left hip, and a surgical incision to left lower leg. The focus identified that on 12/20/21 a blister was identified on the top of the residents left foot. The plan was initiated on 9/29/21 and revised on 1/7/22. The interventions instructed staff to administer treatments as ordered and monitor for effectiveness, initiated on 9/29/21. The job description for Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) identified the position Provides care to residents in accordance with care plan as directed by physician's orders, manages and directs nursing employees assigned to unit, and follows the direction of nursing administration in accordance with laws, regulations, and facility guidelines. The job duties for the LPN/LVN includes: - Conducts ongoing assessments of residents to identify care needs and makes needed revisions to the care plan based on changes in resident condition. - Accurately documents nursing care notes in resident charts in a timely manner. - Monitors progress of the residents and makes suggestions regarding treatment plans which may further meet their care needs. - Monitors residents' skin to identify the risk of pressure sores and promptly reports to the nursing supervisors. 105730 Page 7 of 8 105730 01/07/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on record reviews and interviews, the facility failed to notify the resident representatives and families of four (Residents #11, #107, #61, and #416) sampled residents of confirmed COVID-19 cases in the facility in a timely manner. Residents Affected - Some Findings included: On 1/4/22 at 9:42 a.m., during the entrance conference, it was identified that seven employees had tested positive for COVID between 12/31/21 and 1/3/22. A review of the testing log for employees confirmed that five employees had tested positive for COVID on 12/31/21 and two employees had tested positive on 1/3/22. During record reviews of Resident #11, #107, #61, and #416, it was noted that the records indicated no notification was sent to the representatives or family members from 12/30/21 to 1/5/22 of the positive COVID-19 cases. On Friday, 1/7/22 at 10:22 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She confirmed she was the person who notified representatives of residents and family members by electronic method and the notifications were automatically loaded into the residents' electronic clinical documents. She said the department heads were the residents' Guardian Angels who met with the residents twice a day and notified them when there was a positive case of COVID in the facility. The residents were also notified by the electronic method through the cell phone with the automated message. The Administrator stated that the electronic method was usually sent out within 24-48 hours, I try to get (it) out within 24 hours, residents are notified that day by Guardian Angels. The NHA confirmed that the facility had seven positive staff members during the period of 12/31/21 to 1/3/22. She stated that two staff had tested positive on Wednesday (1/5/22), So I will be sending it out today. The NHA reported that due to the holiday, 1/1/22, notifications were not sent till Tuesday. She confirmed that the facility had seven positive staff between 12/31/21 and 1/3/22 and representatives were not notified until Wednesday 1/5/22. She said, But the residents were notified. The NHA confirmed that not all residents were self-responsible or alert and oriented. The NHA stated she did not know the regulation regarding notification to residents, representatives, or family members of COVID positivity in the facility. On 1/7/22 at 11:58 a.m., the NHA stated, with the Director of Nursing and the Regional Director of Clinical Services (RDCS) in attendance, that she believed she sent out an electronic message on Saturday (1/1/22) . The RDCS stated she remembered a text from the NHA stating she was going to send one. The NHA stated she did not know why it did not show up in the electronic medical record of the residents. The facility provided the policy for Staff and Resident Testing, copyright date 2020. The policy did not identify when the facility should notify residents, the representatives, and/or family members of its COVID status. 105730 Page 8 of 8