Health inspection·May 25, 2023

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and a review of the facility's policy and procedure for Enteral Tube Feeding via Continuous Pump, the facility failed to maintain acceptable parameters of nutritional status, by failing to 1) Obtain resident weights with the frequency prescribed by the physician, and 2) Provide enteral feeding formula as ordered to address the resident's nutritional needs for one (Resident #346) of one resident reviewed for enteral nutrition, from a total of 22 sampled residents. Residents Affected - Few The findings include: On 05/22/23 at 12:36 PM, Resident #346 was observed sitting in a wheelchair receiving enteral nutrition via tube feeding (feeding tube used to supply liquid nutrition) by pump. Resident #346 was non-verbal. He mumbled in response to attempts to engage him in conversation and was unable to be interviewed. The enteral formula bag documented a handwritten date and time when the feeding was started: 5/22/23 at 9:00 AM. The name of the formula on the label read, Nutren 1.5. (Photographic evidence obtained) Pump settings observed were as follows: Feeding rate 250 ml/hr. (milliliters per hour), flush 150 ml every 1 hr. On 05/23/23 at 10:20 AM, Resident #346 was observed resting in bed with his eyes closed. The feeding tube was not connected. The enteral formula bag was hanging on the pole. The label read, Nutren 1.5. On 05/24/23 at 12:17 PM, Resident #346 was observed sitting in his wheelchair. He responded to greetings with unintelligible mumbling. The feeding pump was running and delivering nutrition to Resident #346. The label on the nutrition bag read, Nutren 1.5. On the back of the bag was a handwritten date and time of 05/24/23 at 7:00 AM. (Photographic evidence obtained) Pump settings observed were as follows: Feeding rate 250 ml/hr., flush 150 ml every 1 hr. (Photographic evidence obtained) On 05/25/23 at 11:56 AM, Resident #346 was observed sitting in his wheelchair receiving enteral nutrition. The label on the nutrition bag read, Nutren 1.5. A review of Resident #346's medical record found he was originally admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included unspecified sequelae of cerebral infarction (stroke), type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, severe protein-calorie malnutrition, acute posthemorrhagic anemia, muscle weakness (generalized), aphasia following cerebral infarction, dysphagia following cerebral infarction, hypovolemic shock, iron deficiency anemia, gastro-esophageal reflux disease without esophagitis, encounter for attention to gastrostomy, and duodenal ulcer unspecified as acute or chronic, without hemorrhage or perforation. Page 1 of 7 105745 105745 05/25/2023 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Medicare 5-Day Minimum Data Set (MDS) assessment, dated 05/13/23, revealed that Resident #346 had a brief interview for mental status (BIMS) score of 6 out of a possible 15 points, indicating severe cognitive impairment. The resident was documented as totally dependent on staff for eating with use of a feeding tube. A review of the resident's active physician's orders revealed an order dated 05/07/23, which read: Weight on admission, repeat x 3 days. The Order Summary read as follows: Weight on admission, repeat x 3 days, every day shift for 3 weeks. Weight on admission, repeat weekly x 3 weeks. A physician's order dated 05/08/23, read: Four times a day, give 1 carton Nutren 2.0 via bolus over 1 hour (250 ml/hr.). This order was discontinued on 05/24/23. A new order, dated 05/24/23, read: Four times a day give 1 carton Nutren 1.5 (250 ml) via bolus to be infused over 1 hour five times daily. A review of one of Resident #346's care plans, initiated on 04/14/23 and revised on 05/23/23, revealed that he required tube feeding for nutrition related to his diagnosis of dysphagia (difficulty swallowing). Review of another care plan, initiated on 05/08/23, revealed that he was at nutritional risk related to his nothing by mouth (NPO) status due to dysphagia with tube feeding (TF) to meet estimated nutritional needs with a diagnosis of protein-calorie malnutrition. Interventions included diet/TF as ordered, monitor weights as ordered. (Copy obtained) A review of Resident #346's weights from 05/07/23 to 05/15/23, revealed a weight loss of more than 4% for that period of time (8 days): On 05/07/23, the resident's recorded weight was 140.0 lbs. (pounds) On 05/12/23, the resident's recorded weight was 134.5 lbs. On 05/15/23, the resident's recorded weight was 134.2 lbs. These three weights were the only recorded weights for this resident between the dates of 05/07/23 and 05/24/23. (Copy obtained) A review of the resident's electronic medication administration record (eMAR) for the month of May 2023 (05/08 to 05/24), revealed that twelve different nurses signed off as having administered Nutren 2 via bolus over 1 hour (250 ml/hr.) four times a day during that time. (eMAR copy obtained) A Nutritional Risk Review, dated 05/08/23, revealed: [Resident #346] is at nutritional risk related to NPO due to dysphagia with TF to meet estimated nutritional needs. Diagnosis: protein-calorie malnutrition. Goal: Meet estimated nutritional needs with adequate oral food/beverage intake. Recommend: 1. Discontinue Nutren 1.5. 2. Give Nutren 2.0 via bolus 4 cartons/day to provide 2000 kcals (kilocalories), 84 g (grams) protein, 692 ml (milliliters) water. 3. Flush PEG (feeding tube) with 150 ml water before and after each bolus administration (300 ml each administration x 4 administrations = 1200 ml). 105745 Page 2 of 7 105745 05/25/2023 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0692 4. Clarify Juven order to be mixed with 8 oz. (ounces) water at each administration BID (twice daily). Level of Harm - Minimal harm or potential for actual harm 5. Speech Therapy (ST) consult. Monitor: TF tolerance, wound healing, weight trends, labs as indicated. Registered Dietitian (RD) to follow. Residents Affected - Few A review of a Skin/Wound Note, dated 05/19/23, revealed: Patient seen by Wound Care MD (physician) and Nursing Practitioner. Right heel unstageable pressure wound measures L (length): 1.5 cm (centimeters) x W (width) 0.5 cm x D (depth): unstageable full thickness skin or tissue loss - depth unknown (UTD - unable to determine). Right hip unstageable pressure measures L: 3.5 cm x W: 2.5 cm x D: UTD. Continue treatment plan. Offloading implemented. A review of a Nursing Progress Note, dated 05/20/23, revealed: Patient is admitted after cerebrovascular accident (CVA - stroke) affecting right side. Patient receives G-tube feedings. Medications are crushed and given via G-tube (feeding tube). Patient is alert and oriented to person. A review of a Physician's Progress Note, dated 05/24/23, revealed: Per staff, patient has been receiving incorrect feeding. Patient was originally to be on Nutren 2.0. No injuries to report, will monitor. (Copy of progress notes obtained) A Nutritional/Dietary note, dated 05/24/23, revealed: RD notified of inability to receive Nutren 2.0. Nutren 1.5 available and will be substituted. Current BW (05/15) 134.2 lbs. Note trend down (<5%) since admission weight os 140 lbs. Receiving treatment for US to R heel and R hip. Increased nutrient needs to promote wound healing. BMI WNL (Body Mass Index Within Normal Limits). Estimated nutrition needs (61 kg (kilograms): 1830-2135 kcals (30-35 kcals/kg), 91-122 g protein (1.5-2 g/kg - grams per kilogram), 1830 ml fluid (30 ml/kg). Recommendations: 1. DC (discontinue) Nutren 2.0 2. Give Nutren 1.5 (250 ml) via bolus to be infused over 1 hour five times/day. This will provide 1875 kcals, 85 g protein, 955 ml water. 3. Give 175 ml water flush every 4 hours. 4. Give 30 ml Prosource Plus once/day via feeding tube. This will provide an additional 15 g protein and 100 kcals. total nutrition provided (TF + Prosource Plus + flushes) will be: 1975 kcals, 100 g protein, 955 ml water (TF) + 1050 ml (flush) = 2005 ml water. 5. Obtain weight every Monday, Wednesday, and Friday. On 05/24/23 at 12:17 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. She was asked what type of enteral nutrition and calorie density Resident #346 was receiving. LPN A stated she had nothing to do with calorie density; the Registered Dietitian calculated that. She was asked to compare the formula that was hanging and running with the one ordered by the resident's physician. She opened the computer and stated, It is Nutren 2. Are those the calories? It is just the name of 105745 Page 3 of 7 105745 05/25/2023 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0692 Level of Harm - Minimal harm or potential for actual harm the formula. The kcals (kilocalories) per milliliter was explained to LPN A. She was then asked where she obtained the enteral nutrition if she needed it. She stated, From the nutrition room. They brought two (bags) last night. She was asked to point out the enteral nutrition designated for Resident #346. She stated there was none in the nutrition room. I work 7 to 7 shift and administer the tube feeding for [Resident #346] three times. Residents Affected - Few On 05/24/23 at 12:42 PM, an interview was conducted with LPN B/Unit Manager. She was asked how she knew what type of formula should be administered to a resident receiving enteral nutrition. She stated, I verify the order, and if questionable, I talk to the RD. When asked where she obtained the enteral nutrition if needed, LPN B replied, Normally we keep it in central supply. She was asked to look at the formula that was hanging and that Resident #346 was receiving. She went into the resident's room and confirmed that the name of the nutritional formula was Nutren 1.5. She was asked to verify the doctor's order for Resident #346's tube feeding and she confirmed it was Nutren 2. She stated she was not aware of the situation and had to verify that with the dietitian. If we don't have 2.0, we use 1.5. LPN B was asked what the process was for weighing residents on her unit. She stated there should be one weight obtained on admission and then one weight weekly for three weeks. She was asked to look at the order for obtaining Resident #346's weights. She confirmed that thus far, for the resident's 17-day stay, he had three weights recorded in his chart. On 05/24/23 at 1:11 PM, an interview was conducted with the Central Supply Coordinator (CSC). He was asked to describe the process for sending enteral nutrition to the nursing units, and if the formula for a resident was changed, how that was addressed. The CSC stated the RD and/or admission Coordinator sent him an email and text about formula needs, and/or if there was a change in the formula. He then sent the formula to the nursing units. The CSC said there were supplier issues with Nutren 1.5. He was asked to provide a copy of the email communication regarding the enteral nutrition for Resident #346. (Copies obtained) On 05/24/23 at 1:33 PM, an interview was conducted with the Registered Dietitian (RD). She stated Resident #346 was switched from Nutren 1.5 to Nutren 2 due to the supplier's issues, not due to an increase in caloric needs. She was not aware of how long Resident #346 was on the Nutren 1.5. She stated she needed to reassess Resident #346's nutritional needs, and they would need to re-up the current Nutren 1.5, increasing the frequency of feedings to compensate for the caloric difference. On 05/24/23 at 1:57 PM, an interview was conducted with the DON. She stated Resident #346 originally came to the facility with the Nutren 1.5 order, and they switched him to Nutren 2 due to supplier issues with the Nutren 1.5. From the 8th of May he was receiving Nutren 2. The DON was asked where the facility obtained the cartons of Nutren 1.5 if there was a shortage, and how long was Resident #346 receiving the Nutren 1.5. She stated, I don't know. We have to do some investigation. Officially we switched him to 1.5 today. On 05/24/23 at 4:18 PM, an interview was conducted with Agency LPN C. She was asked how she knew what type of enteral nutrition formula she had to use for a resident receiving tube feedings. We go by orders. If no formula is available, we call the doctor or RD for something compatible. A review of email documentation from 05/08/23 between the RD and CSC revealed that the CSC wrote, We have everything except the Nutren 1.5. We have the cartons of Nutren 2. The RD wrote, Ok, thank you! I will convert the orders for [Resident #346] to reflect 2.0. (Copies obtained) A review of the facility's policy and procedure titled Enteral Tube Feeding via Continuous Pump 105745 Page 4 of 7 105745 05/25/2023 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (revised in November 2018) revealed, 2. Check the enteral nutrition label against the order before administration. Check the following information: b. Type of formula. Documentation: the person performing this procedure should record the following information in the resident's medical record: 3. Amount and type of enteral feeding. According to the National Library of Medicine website at ncbi.nlm.nih.gov/pmc/articles/PMC5930532 (accessed on 05/27/23 at 2:40 PM), Nutritional status plays a central role in the process of wound healing. Malnutrition accompanies a poor outcome and brings about higher morbidity and mortality. Malnutrition should be recognized rapidly and treated accordingly in all patients suffering from pressure ulcers. Malnutrition impedes pressure ulcer healing. While the optimal nutrient intake to promote wound healing is unknown, increased needs for energy, protein, zinc and Vitamins A, C, and E have been documented. . 105745 Page 5 of 7 105745 05/25/2023 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper food safety and sanitation practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to ensure food preparation equipment was clean and maintained. Food safety and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A follow-up tour of the kitchen was conducted on 5/24/23 at 10:52 a.m. The bottom of the oven and door was covered with food grime. The can opener pixel was greasy and filled with food debris. The inside door area and left side of the convection oven next to the fryer was covered with food grime and grease buildup. The right and left side of the fryer sitting next to the convection oven was covered with grease build up. The right and left side of the tilt skillet was covered with grease build up, and two oven trays were filled with food debris. (Photographic evidence obtained) Another tour of the kitchen was conducted on 5/25/23 at 10:04 a.m. The observations of the kitchen equipment noted above at 10:52 a.m. were made again. (Photographic evidence obtained) An interview was conducted on 5/25/23 at 10:28 a.m. with Kitchen Coordinator/Cook D. When asked who was responsible for cleaning kitchen equipment such as stoves, ovens and oven trays, she replied, The cooks are responsible for cleaning kitchen equipment weekly. An interview was conducted on 5/25/23 at 10:44 a.m. with [NAME] E, who reported she had worked for the facility for two years. When asked who was responsible for cleaning kitchen equipment such as stoves, ovens, and oven trays, she replied, Cooks clean as we go. Ovens are not cleaned often enough. Most deep cleaning is completed by the night shift. The outside of the oven is sprayed down at night, and the inside of the oven is cleaned every three weeks or as needed. An interview was conducted on 5/25/23 at 11:24 a.m. with Certified Dietary Manager (CDM) F, who confirmed that the Dining Supervisor was responsible for ensuring kitchen equipment was cleaned daily. The kitchen Cleaning Schedule dated from 4/30/23 to 6/1/2023 did not identify cleaning of the stove or oven. (Copy obtained) A review of the facility's policy and procedure titled Cleaning Schedules (Undated), revealed: The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on 5/31/23) Chapter 4. Equipment, Utensils, and Linens. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 4-20. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be 105745 Page 6 of 7 105745 05/25/2023 Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224

F 0812 Level of Harm - Minimal harm or potential for actual harm kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. . Residents Affected - Many 105745 Page 7 of 7