Health inspection·September 10, 2021

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, clinical record review, staff interview and facility policy and procedure review, the facility failed to meet professional standards of quality by failing to assess one (Resident #130) of 28 sampled residents, when blood was observed oozing from the resident's urethra surrounding the urinary catheter tubing. The facility also failed to notify the physician regarding possible trauma to the resident's urethra, and the medical record lacked documentation of Resident #130's observed change in condition. This exposed the resident to a delay in treatment and potential clinical complications. Residents Affected - Few Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The Florida Nurse Practice Act, Chapter 464.003, (3)(a) in part defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Additionally, the Act defines the practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. The findings include: On 09/07/21 at 2:11 PM, Resident #130 was observed seated in his wheelchair in his room. He appeared to be watching television and leaning to his right side. A urinary catheter bag and tubing were observed hanging on his chair. On 09/08/21at 9:56 AM, Resident #130 was observed with a urinary catheter bag hanging on his chair. Page 1 of 8 105745 105745 09/10/2021 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/09/21 at 9:15 AM, wound care was observed for Resident #130, which was being performed by Registered Nurse (RN)/Wound Care (WC) Nurse E, Certified Nursing Assistant (CNA) F, and the Assistant Director of Nursing (ADON). Appropriate hand hygiene and use of Personal Protective Equipment (PPE) was performed throughout the entire procedure. Resident #130 was repositioned, and his brief was removed revealing a large amount of stool in the brief. Staff performed peri care prior to continuing with wound care. Once peri care was completed, wound care was performed according to the physician's orders. Upon repositioning the resident after the wound care, it was observed that Resident #130 had a bloody discharge from his penis oozing from around the indwelling catheter. The WC RN cleansed the area and stated she would notify the assigned nurse of the finding. A review of the resident's Comprehensive Minimum Data Set (MDS) assessment, dated 08/31/21, revealed the resident was admitted on [DATE]. His diagnoses included metabolic encephalopathy, sepsis, diabetes type II, unspecified protein-calorie malnutrition, gastrostomy status, muscle weakness, difficulty walking, dysphasia oropharyngeal phase, major depressive disorder, benign prostrate hyperplasia without lower urinary tract symptoms, anemia in chronic kidney disease, adult failure to thrive, hypertension, unspecified dementia without behavioral disturbance, chronic kidney disease, hyperlipidemia, pain, and glaucoma. He was assessed as having an indwelling urinary catheter. (Copy obtained) A review of the care plan, dated 8/20/21, revealed a focus area of: Unstageable Sacral Wound. Revised on 09/01/21. Resident has a Foley (indwelling urinary) catheter. Interventions included: Catheter care per policy, Monitor/record/report to physician signs or symptoms of urinary tract infection, pain, burning, blood tinged urine, deepening of urine color, cloudiness, no output, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Secure catheter to reduce friction. Check tubing for kinks. (Copy obtained) A review of the nursing notes and clinical record from the resident's admission through 09/10/21 at 8:55 AM, did not reveal documentation by the Wound Care nurse verifying that she had notified the assigned nurse or the resident's physician of the blood coming from the resident's urethra. (Photographic evidence obtained) On 09/10/21 at 9:00 AM during an interview with the Wound Care nurse, she stated she did not notify the resident's physician; she verbally notified a nurse. She stated she was not sure which nurse it was that she notified. She confirmed that she did not document it. On 09/10/21 at 9:10 AM during an interview with RN Unit Manager (UM) H, she reviewed Resident #130's electronic medical record and confirmed that she could not see any nursing progress notes or assessments related to the observation of blood oozing from Resident #130's urethra during the wound care treatment performed on 09/09/21. She stated she was not aware that the WC nurse had observed the blood. On 09/10/21 at 4:09 PM, during an interview with the ADON, she stated she was not aware that there were no notes/documentation by RN I, who was assigned to Resident #130 on 09/09/21 during the day shift. There was no documentation in the record indicating RN I had called the resident's physician to notify him of bleeding from the urethra, which had been observed by the Wound Care nurse. After the ADON was made aware of the lack of documentation in the record, she interviewed the WC nurse about what transpired. The WC nurse stated the blood was seen by those in the resident's room after she had left the room to take the soiled dressing and waste out. (This statement is in opposition to what transpired during observation of wound care.) The WC nurse further stated she instructed the floor 105745 Page 2 of 8 105745 09/10/2021 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse to notify the physician, and she then continued with her wound care rounds. She did not follow up with the floor nurse to ensure the physician was notified. The ADON stated the floor nurse assigned to the resident went home sick yesterday, and did not give report to the next nurse or document any notes. On 09/10/21 at 5:01 PM during an interview with the ADON, she stated the UM did go and assess the resident's catheter this morning after being made aware of the resident's change of condition by this surveyor. She stated the assigned nurse should have conducted an assessment, notified the physician, obtained any new orders, and then monitored for bleeding, assess vital signs, and made sure the resident was safe. She should have ensured staff were taking care not to put stress on or pull on the catheter tubing. A review of the facility's policy and procedure entitled Change in a Resident's Condition or Status, Version 2.3, revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changed in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; e. need to alter the resident's medical treatment; i. specific instruction to notify the physician of changes I the resident's condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. (Copy obtained) . 105745 Page 3 of 8 105745 09/10/2021 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

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, clinical record review, staff interview and facility policy and procedure review, the facility failed to provide care and services in accordance with professional standards of practice, by failing to assess one (Resident #130) of 28 sampled residents, when blood was observed oozing from the resident's urethra surrounding the urinary catheter tubing. The facility also failed to notify the physician regarding possible trauma to the resident's urethra, and the medical record lacked documentation of Resident #130's observed change in condition. This exposed the resident to a delay in treatment and potential clinical complications. Residents Affected - Few The findings include: On 09/07/21 at 2:11 PM, Resident #130 was observed seated in his wheelchair in his room. He appeared to be watching television and leaning to his right side. A urinary catheter bag and tubing were observed hanging on his chair. On 09/08/21at 9:56 AM, Resident #130 was observed with a urinary catheter bag hanging on his chair. On 09/09/21 at 9:15 AM, wound care was observed for Resident #130, which was being performed by Registered Nurse (RN)/Wound Care (WC) Nurse E, Certified Nursing Assistant (CNA) F, and the Assistant Director of Nursing (ADON). Appropriate hand hygiene and use of Personal Protective Equipment (PPE) was performed throughout the entire procedure. Resident #130 was repositioned, and his brief was removed revealing a large amount of stool in the brief. Staff performed peri care prior to continuing with wound care. Once peri care was completed, wound care was performed according to the physician's orders. Upon repositioning the resident after the wound care, it was observed that Resident #130 had a bloody discharge from his penis oozing from around the indwelling catheter. The WC RN cleansed the area and stated she would notify the assigned nurse of the finding. A review of the resident's Comprehensive Minimum Data Set (MDS) assessment, dated 08/31/21, revealed the resident was admitted on [DATE]. His diagnoses included metabolic encephalopathy, sepsis, diabetes type II, unspecified protein-calorie malnutrition, gastrostomy status, muscle weakness, difficulty walking, dysphasia oropharyngeal phase, major depressive disorder, benign prostrate hyperplasia without lower urinary tract symptoms, anemia in chronic kidney disease, adult failure to thrive, hypertension, unspecified dementia without behavioral disturbance, chronic kidney disease, hyperlipidemia, pain, and glaucoma. He was assessed as having an indwelling urinary catheter. (Copy obtained) A review of the care plan, dated 8/20/21, revealed a focus area of: Unstageable Sacral Wound. Revised on 09/01/21. Resident has a Foley (indwelling urinary) catheter. Interventions included: Catheter care per policy, Monitor/record/report to physician signs or symptoms of urinary tract infection, pain, burning, blood tinged urine, deepening of urine color, cloudiness, no output, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Secure catheter to reduce friction. Check tubing for kinks. (Copy obtained) A review of the nursing notes and clinical record from the resident's admission through 09/10/21 at 8:55 AM, did not reveal documentation by the Wound Care nurse verifying that she had notified the assigned nurse or the resident's physician of the blood coming from the resident's urethra. 105745 Page 4 of 8 105745 09/10/2021 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0684 (Photographic evidence obtained) Level of Harm - Minimal harm or potential for actual harm On 09/10/21 at 9:00 AM during an interview with the Wound Care nurse, she stated she did not notify the resident's physician; she verbally notified a nurse. She stated she was not sure which nurse it was that she notified. She confirmed that she did not document it. Residents Affected - Few On 09/10/21 at 9:10 AM during an interview with RN Unit Manager (UM) H, she reviewed Resident #130's electronic medical record and confirmed that she could not see any nursing progress notes or assessments related to the observation of blood oozing from Resident #130's urethra during the wound care treatment performed on 09/09/21. She stated she was not aware that the WC nurse had observed the blood. On 09/10/21 at 4:09 PM, during an interview with the ADON, she stated she was not aware that there were no notes/documentation by RN I, who was assigned to Resident #130 on 09/09/21 during the day shift. There was no documentation in the record indicating RN I had called the resident's physician to notify him of bleeding from the urethra, which had been observed by the Wound Care nurse. After the ADON was made aware of the lack of documentation in the record, she interviewed the WC nurse about what transpired. The WC nurse stated the blood was seen by those in the resident's room after she had left the room to take the soiled dressing and waste out. (This statement is in opposition to what transpired during observation of wound care.) The WC nurse further stated she instructed the floor nurse to notify the physician, and she then continued with her wound care rounds. She did not follow up with the floor nurse to ensure the physician was notified. The ADON stated the floor nurse assigned to the resident went home sick yesterday, and did not give report to the next nurse or document any notes. On 09/10/21 at 5:01 PM during an interview with the ADON, she stated the UM did go and assess the resident's catheter this morning after being made aware of the resident's change of condition by this surveyor. She stated the assigned nurse should have conducted an assessment, notified the physician, obtained any new orders, and then monitored for bleeding, assess vital signs, and made sure the resident was safe. She should have ensured staff were taking care not to put stress on or pull on the catheter tubing. A review of the facility's policy and procedure entitled Change in a Resident's Condition or Status, Version 2.3, revealed: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changed in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; e. need to alter the resident's medical treatment; i. specific instruction to notify the physician of changes I the resident's condition. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. (Copy obtained) . 105745 Page 5 of 8 105745 09/10/2021 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to post the nurse staffing data specified in paragraph (g)(1) of this section [ (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.] on a daily basis at the beginning of each shift for 3 of 4 days observed. Residents Affected - Few The findings include: On 9/07/2021 at 3:23 p.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 8/18/2021. On 9/08/2021 at 2:21p.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 9/7/2021. On 9/09/2021 at 11:58 a.m., the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 9/8/2021. During an interview and observation of the posted nurse staffing data on 9/09/2021 at 12:13 p.m. with Employee L, Staffing Coordinator, she stated each day she posted the staffing for the day before, so that she didn't have to make corrections on the form if someone didn't show up. The documentation was reviewed with her, pointing out the area that specifically stated daily staffing. She stated she had not noticed that information prior to this, and she had been doing staffing for about a month now. She stated she received limited training in the position. She was referred to the Administrator and/or Director of Nursing for additional education. . 105745 Page 6 of 8 105745 09/10/2021 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on kitchen food service observations, staff interviews, and facility document review, the facility failed to ensure that all essential equipment in the kitchen was maintained in safe operating condition. The dish machine was not sanitizing the dishes properly. The facility failed to ensure that the dietary staff were trained and knowledgeable about the proper procedures for the safe operation of the dish machine. Failing to sanitize the dishes could lead to negative health outcomes for the residents who receive meals from the kitchen. Residents Affected - Many The findings include: On 09/07/2021 at 11:10 AM, Dietary Employee A was observed operating the dish machine. The wash cycle temperature was 150 degrees Fahrenheit (F) to 153 degrees F, and the rinse temperature was 159 degrees F. The Registered Dietician (RD) and Certified Dietary Manager (CDM) explained that the dish machine was a hybrid machine. It could run as a high-temperature machine or a low-temperature machine. Currently, they were operating it as a low-temperature machine with a chemical sanitizer, chlorine bleach. A digital thermometer was run through the machine and read 157 degrees F. The CDM tested the water using a chlorine bleach test strip. The test strip remained white, indicating no bleach in the water. She confirmed it was 0 parts per million (ppm). She looked up at the dispensing unit on the wall and stated the tubing for the bleach sanitizer was not attached to the dispensing unit. She stated she was unaware that the tubing had become detached from the dispensing unit. She was not sure how long it had been detached. On 09/08/2021 at 8:55 AM during an interview with Dietary Employee A, he stated he had worked in this facility for 11 years. There was a language barrier and several questions had to be reworded so that he understood the questions. He stated he had had training on how to run the dish machine. When asked what type of sanitizer was used and what type of machine the facility used, he hesitated and then when asked if the machine was a high-temperature machine or low-temperature machine, he stated it was a low-temperature machine which used chlorine bleach. He stated he knew how to use the test strips. He stated he thought the chemical tubing was unhooked from the dispensing unit three or more months ago when the representative from the contracted dish machine maintenance company was in the kitchen working on the machine. On 09/09/2021 at 11:15 AM a second tour of kitchen was conducted. The dish machine was tested by Employee C, Dietary Director (DD). The first time he used the test strip it remained white, indicating no chlorine bleach in the water. He then reached up to the dispensing pump on the wall and pushed the button twice to prime the pump. He stated the machine worked fine and sometimes needed to be primed as he just demonstrated. He then tested the water again and the test strip was a dark purple, indicating the water was toxic. He stated he would run the machine a couple of times to dilute the sanitizer. He ran it two more times and the test strip showed 100 ppm. The dish machine operator, Dietary Employee A, was then asked to test the machine. He was not able to demonstrate an understanding of exactly what to do with the test strips. He was cued by the Director about how to do it. He then put the test strip on the coffee cup and the test strip turned a light shade of green indicating 100 ppm. Dietary Employee A did not hold the test strip up to the canister indicator chart to verify the amount of sanitizer on the test strip. The Director instructed him to hold the test strip up to the canister and then to record it on the clip board. Dietary Employee A then documented the amount of chlorine on the test strip in the wrong column on the log. He wrote 100 in the column for the temperature reading of the water. The CDM observed that the readings were documented inaccurately on the log, and she immediately changed them and initialed the log. 105745 Page 7 of 8 105745 09/10/2021 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 09/10/2021 the dish room employees were observed from 12:40 PM until 1:10 PM. The CDM was asked to test the dish machine sanitizer. The first test strip registered 0 ppm. She then took a test strip from another vial of test strips, and it registered 0 ppm. The DD then pushed the primer button on the pump attached to the wall above the dish machine. A new rack of pans was sent through the machine. The DD used another test strip to test the sanitizer level. It registered between 50-75 ppm. The DD was asked who else had been trained in the dietary department on the operation of the dispensing pump on the wall. He stated no one else had been trained. When asked who would know when to push the pump to prime it if the sanitizer level got low, he stated he was always at the facility and he was the one to prime it. He had not conducted any type of training for the dietary staff on how to run the primer pump. He had no policy and procedure for the operation of the dispensing unit on the wall. On 09/10/2021 at 2:53 PM during an interview with the DD, RD, and Nursing Consultant, they provided the logs for the dish machine and a new log for the staff to use to record the testing of the sanitizer level of the dish machine. The DD stated they were going to start having the dish machine workers test the sanitizer level at least two times during each meal service. The DD stated the service provider for the dish machine was at the facility right now. They were not sure why the sanitizer did not come into the machine consistently. A review of the dietary in-service, dated 07/29/2021, revealed that Dietary Employee A had received training entitled Temperature Log/Procedures, that included completion of the temperature logs, reading thermometers, recording temperatures, and reporting any variance in temperature of 1-2 degrees to a supervisor for review. No documentation was provided verifying that Dietary Employee A had received training on how to test the machine for the sanitizer level. . 105745 Page 8 of 8