Health inspection·February 9, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident was assessed to safely self-administer medications for 1 of 1 resident reviewed for self-administration of medications, from a total sample of 45 residents (#67). Residents Affected - Few Findings: Resident #67's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, lung cancer, congestive heart failure, and depression. The resident's Minimum Data Set (MDS) quarterly assessment with assessment reference date 12/23/2022 identified the Brief Interview for Mental Status score as 13 out of 15, indicating the resident was cognitively intact. There were no indications of psychosis, behavioral symptoms, or rejection of care noted. On 2/06/2023 at 10:49 AM, resident #67 said the Combivent inhaler she kept on her overbed table was just taken away by the nurse. The resident described the inhaler had an orange top and turn base. She explained she also took Trelogy Ellipta for COPD, and Flonase nasal spray for allergies. She placed her hand on the overbed table and stated the medications were always on top where she could reach and use them when she needed to, and emphasized she always used the medications when she needed them since she came to the facility, 7 months prior. The resident stated, I'm very upset they took my Combivent. Resident #67's medications, ordered 2/06/2023, included Combivent Respimat Aerosol Solution 20-100 micrograms (mcg.) 1 puff inhale orally every 8 hours as needed for shortness of breath/cough, ok to leave at bedside may self-admin, Flonase Suspension 50 mcg. 1 spray in both nostrils every 12 hours as needed for allergies, and Trelogy Ellipta Aerosol Power breath activated 200-6.25-25 mcg. 1 inhalation orally one time a day for COPD exacerbation, may self-administer and keep at bedside. Resident #67's medical record did not contain a completed assessment for safe self-administration of medications. The comprehensive care plan did not indicate the resident self-administered medications. On 2/07/2023 at 10:15 AM, resident #67 held a Combivent inhaler and said, I keep my Combivent right here because it's my rescue inhaler. On 2/07/2023 at 5:11 PM, licensed practical nurse (LPN) B said she saw medications on resident Page 1 of 17 105754 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #67's overbed table in the morning on 2/06/2023. She stated the resident was upset when the medications were taken away by the Unit Manager. LPN B explained she thought the medications were kept on the overbed table because she was using them. On 2/08/2023 at 5:40 PM, the Director of Nursing stated the resident's self-administration of medications required completion of a self-administration of medication evaluation. The facility's policies and procedures, Clinical Forms Manual, Subject: Self-Administration of Medications read in part, 1. If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a Self-Administration of Medication Evaluation . 7. Storage of self-administered medications will comply with state and federal requirements for medication storage. 105754 Page 2 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

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 interview and record review, the facility failed to ensure showers were provided per schedule/preference for 1 of 12 residents reviewed for choices, of a total of 45 residents (#4). Findings: Resident #4's medical record revealed she was admitted to the facility on [DATE], with her most recent readmission on [DATE]. The resident's diagnoses included paraplegia, generalized muscle weakness, contracture, other myelitis, and multiple sclerosis. Resident #4's annual Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/04/22 revealed the resident's cognition was intact with a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the resident did not have any cognitive impairment. She did not have any mood/behavior, and resident required extensive assistance of 1 person for bed mobility, dressing, and toilet use. The resident's care plan for Activities of Daily Living self-care performance deficit related to paraplegia, multiple sclerosis, and limited mobility with lower extremities, initiated on 12/13/17 with revision on 2/07/23, indicated the resident required assistance of one staff for bathing/showering. On 2/06/23 at 10:07 AM, resident #4 stated she would prefer to have two showers per week, but had only been getting one shower on Tuesday. She stated she has not had her hair washed in three months. On 2/07/23 at 4:26 PM, the East Wing Registered Nurse (RN) Unit manager (UM) stated resident showers were scheduled three days per week, unless the resident has some cardiac issue, and required daily showers. The UM explained that if the resident refused their scheduled shower, the residents' Certified Nursing Assistant (CNA) would report to the nurses. Nurses would then talk with the residents, and if the bath/shower was still refused, the refusal would be documented on the resident's shower sheet, and a bed bath would be offered if that was preferred. The UM stated that when resident #4 was given a shower, it would be documented in the CNA's electronic record or on the resident's shower sheet. On 2/08/23 at 11:06 AM, CNA A stated resident #4 was scheduled for showers on Tuesdays and Fridays, and she gave the showers and documented on the resident's shower sheet. CNA A stated she did not work on Fridays, and if the resident refused showers, it would be documented on the shower sheet. On 2/08/23 at 1:37 PM, resident #4 denied refusing her showers, she said that on Fridays, there was always someone new who did not know what to do. She explained that on her shower days, she had to be placed back to bed to be dressed, and her showers took time. She said she would prefer to have two showers weekly but stated that was not possible if she had a new CNA. On 2/08/23 at 1:56 PM, the East Wing UM stated resident #4 was scheduled for showers on Tuesdays, Fridays, and Saturdays, on the 7 AM - 3 PM shift, and when showers were given, a skin check form was to be completed by the CNA. The form had the date, time, resident's name, nurse's signature, CNA's signature, areas to document/check if the resident's skin was intact, or if the resident refused 105754 Page 3 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0561 his/her shower. The UM verbalized that showers would also be documented on the CNA electronic record. Level of Harm - Minimal harm or potential for actual harm The resident's skin check forms provided by the UM, revealed a bed bath was given on seven days: 11/22/22, 12/13/22, 12/27/22, 1/03/23, 1/10/23, 1/17/23, 1/24/23. This was confirmed by the UM. Other skin check forms could not be identified. Residents Affected - Few On 02/08/23 at 2:06 PM, CNA A stated that in January 2023, bed baths were provided for the resident because the resident told her she was on bedrest, due to a wound to her sacrum. She stated nurses were aware. On 02/08/23 at 2:23 PM the skin check forms were reviewed with the UM. She confirmed that documentation indicated bed baths were given, and there was no documentation to indicate the resident refused her showers. The UM stated bed rest did not mean no showers, and stated she did not know what was in the CNAs electronic record notes. A 30-day look back on the CNA's notes revealed the resident received bed baths; showers were not documented as given. This was confirmed by the UM. Review of the facility's Follow Up Question Report for bathing indicated the resident was scheduled for showers on Tuesdays, Fridays, and Saturdays. Documentation indicated the type of bath the resident received. For the period October 1, 2022, to January 31, 2023, the resident received two showers on 10/11/22 and 10/18/22. Bed baths were documented 18 times: 10/08/22, 10/29/22,11/01/22, 11/05/22, 11/12/22, 11/15/22, 11/18/22, 11/22/22, 12/02/22, 12/10/22, 12/16/22, 12/17/22, 12/23/22, 12/30/22, 1/14/23, 1/19/23, 1/20/23, and 1/21/23. Documentation indicated the resident refused her bath/shower on 10/14/22, 10/28/22, 11/22/22 and was not available on 11/08/22, 11/29/22, 12/06/22, and 1/28/23. She received one shower on 2/06/23. 105754 Page 4 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a clean and homelike environment in 1 of 32 rooms on the [NAME] wing (219A). Findings: On 02/07/23 at 4:12 PM, an observation in 219A revealed the wall behind the head of the bed with multiple dry brown streaks from the ceiling down the wall to the floor. On 02/08/23 at 9:45 AM, the [NAME] Wing Unit Manager confirmed the multiple brown streaks on the wall behind the head of the bed. She stated, The wall should not look like that. At 9:50 AM, the Maintenance Director observed the wall in room [ROOM NUMBER]A and stated, The wall should not look like that. Housekeeping is responsible for cleaning of the resident rooms. At 10 AM the Regional Director of Clinical Services observed the wall in room [ROOM NUMBER]A and stated, That should not be on the wall. He then attempted to remove the brown substance from the wall with water but the substance was not able to be removed. On 02/08/23 at 10:55 AM, the Housekeeping Manager explained that the housekeeper assigned to the room is responsible for the daily cleaning of the room. Cleaning includes floors, bathrooms, furniture, and walls. He stated, The wall should not look like that. On 02/08/23 at 11:00 AM, Housekeeper H stated she had worked on the unit yesterday and she was assigned to room [ROOM NUMBER]. She said, I am responsible for cleaning the room which includes doorknobs, furniture, bathrooms, floors, and the walls. Housekeeper H then observed the wall behind 219A's bed and stated, The wall was dirty and I did not see it today or yesterday. Review of the Housekeeping's 8-Step Room Cleaning Procedure, read, . Step 5. Horizontal and Vertical Cleaning: walls, doors, dressers, cabinets, furniture, windows, overbed tables . On 02/09/23 at 9:16 AM, an interview with the Administrator revealed the facility has a Guardian Angel Program. Management staff are assigned to a resident, and they are responsible for visiting the resident daily. They complete the Guardian Angel Rounds Checklist which is then turned in to the Administrator daily or weekly. The Administrator explained the checklist includes what items are to be reviewed in the resident's room and what questions are to be addressed with the resident. Issues are then discussed at the daily morning meeting and assigned to the proper department head so the issue can be resolved. The Administrator said the Human Resources Director was assigned to room [ROOM NUMBER]. The Guardian Angel Rounds Checklist included inspecting Walls, jambs, equipment, furniture, doorknobs, privacy curtains, holes . On 02/09/23 at 4:38 PM, the Human Resources Coordinator explained she was the Guardian Angel assigned to room [ROOM NUMBER]. She explained that she had used the Guardian Angel Rounds form when doing her room rounds. She said, On Monday and Tuesday I completed room [ROOM NUMBER]'s room rounds in the morning, but I did not see the brown streaks on the wall. Once the brown streaks were brought to my attention, I saw them. 105754 Page 5 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level 1 screen for newly evident possible Serious Mental Illness (SMI) for 1 of 1 resident reviewed for PASRR from a total sample of 45 residents (#9). Findings: Resident #9's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of schizophrenia, epilepsy, brain disorders, speech and language deficits following stroke, dependence on renal dialysis, type 2 diabetes mellitus, and chronic osteomyelitis. A level I PASRR screen was completed on 1/31/2022 by hospital staff. Section I noted, Depressive Disorder based on documented history, behavioral observations, and medications. The medical record showed a diagnosis of schizophrenia, unspecified was added to resident #9's plan of care, effective 2/01/2022. On 2/08/2023 at 5:23 PM, the Director of Nursing (DON) said the resident's PASRR was reviewed for accuracy on readmission by the Interdisciplinary Team (IDT). She explained residents who receive antipsychotic medications and may have possible SMI are reviewed during monthly meetings. On 2/09/2023 at 2:06 PM, the DON stated a level 1 PASRR screen for newly evident or possible SMI with a diagnosis of schizophrenia was not completed for resident #9. The DON said the diagnosis of schizophrenia was valid for a while. On 2/09/2023 at 2:10 PM, the DON said the facility did not have a policy and procedure for the PASRR regulation. 105754 Page 6 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address the use of 4 side rails for 1 resident reviewed for restraint, of a total sample of 45 residents (#10). Findings: Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including quadriplegia, contracture, neuromuscular dysfunction of bladder, and generalized muscle weakness. The resident's Quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 1/02/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15/15. The resident required extensive assistance with physical assistance for bed mobility and dressing and total dependence with two persons physical assistance for transfer. A physician's order for resident #10 dated 1/02/18 was (4) 1/4 side rails. Review of the Side Rail Screen, completed for the resident in 2013, indicated the type of side rail checked was for Full Rail. The Nursing Quarterly Evaluation, dated 1/10/23, read, Is the resident totally immobile and unable to change position without assistance? The answer was Yes. On 2/06/23 at 11:26 AM, resident #10 sat up in bed. Four side rails were up, with the bilateral bottom side rails padded. On 2/06/23 at 3:36 PM, resident #10 stated he was paraplegic, gets spasms and shakes, and needed 4 side rails up to prevent falls. On 2/07/23 at 4:08 PM, Licensed Practical Nurse (LPN) D stated resident #10 was awake, alert and oriented, and was able to make his needs known. His diagnoses included quadriplegia, and he required total assistance from staff with all activities of daily living (ADLs). Observation with LPN D showed 4 side rails up, with the bilateral lower rails padded. This was confirmed by the LPN. On 2/07/23 at 4:18 PM, Certified Nursing Assistant (CNA) E stated resident #10 required total assistance for all his ADLs, and always had 4 side rails in place. On 2/07/23 at 4:23 PM, the East Wing Unit Manager (UM) confirmed that 4 side rails were used for resident #10. When asked if 4 side rails were considered a form of restraint, the UM stated that for the resident it was not considered a restraint. She verbalized that the resident had been using 4 side rails for years, and stated a physician order and care plan was required for the use of 4 side rails. On 2/07/23 at 5:01 PM, and on 2/08/23 at 10:00 AM, the Director of Nursing (DON) stated resident #10's diagnoses included quadriplegia, and the 4 side rails did not restrict his movement. She stated a physician order for 4 side rails had been in place since 1/02/18. The DON stated it was the 105754 Page 7 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's preference to have 4 side rails although he did not move by himself in bed because he had a fear of falling out of bed. The DON stated the use of side rails were reviewed quarterly by the Interdisciplinary Team (IDT), and a decision made regarding the use, or continuation of the intervention. The decision would be documented in the resident's clinical record. The resident's care plan ADL self-care performance deficit related to quadriplegia initiated on 11/02/17, with revision on 5/14/21 was reviewed with the DON. Interventions documented were, Resident uses 1/4 side rails up x 2 for (bed mobility, transfers, resident representative request), 1/4 side rails to assist with positioning. The care plan did not identify the resident's reason/preference for 4 side rails, and documentation could not be identified regarding the continued use of 4 side rails for resident #10. This was confirmed by the DON. The care plan contradicted the side rail screen conducted on 1/10/23, which indicated the resident did not use the side rails for positioning, support, or bed mobility. On 2/08/23 at 11:41 AM, resident #10 stated his hands were not good, and he could not use the side rails for positioning. He stated he wanted all 4 side rails up, due to shaking, was afraid of falling out of bed, and he believes the side rails would prevent him from falling. However, this was not reflected in the resident's ADL care plan, and no other care plan could be identified that addressed the use of the 4 side rails. The facility's policy Baseline, Resident Centered Comprehensive Care Plans & Care Plan Summary copyright 2018 read, Comprehensive Care Plans must be developed within 7 days after completion of the comprehensive assessment (Admission, Annual or Significant Change in Status) and review and revise the care plan after each assessment. 105754 Page 8 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

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 Based on observation, interview, and record review, the facility failed to ensure follow-up wound care and services were provided to 1 of 3 residents reviewed for non-pressure skin conditions from a total sample of 45 residents (#568). Residents Affected - Few Findings: Resident #568's medical record revealed the resident was admitted to the facility from an acute care hospital on 1/27/2023 with diagnoses including dementia, type 2 diabetes mellitus, peripheral vascular disease, anemia, deficits following stroke, and chronic kidney disease. The resident had a history of falling, The Minimum Data Set (MDS) admission assessment was in progress. The Baseline Care Plan Summary, dated 1/28/2023, identified the resident had been admitted to the facility after being hospitalized for a fall with laceration to the head, and required, Special Treatments/Procedures Wound Care: head/hand lacerations. On 2/06/2023 at 3:37 PM, resident #568 was observed in his room sitting in a wheelchair. The resident had multiple healing wounds at various stages on his face. There was a peeling foam type dressing dated 2/05/2023 with a penny sized dark red breakthrough stain attached to the resident's head where sutures were intact, and 2 bandaid type dressings covered the left hand between the thumb and fingers. The resident said he had fallen at home and sustained injuries after hitting his head on a rock. Review of the physician's orders included to Check dressing to posterior left hand and posterior occipital area every shift for intactness. Check surrounding skin for any signs and symptoms of infection or pain every shift, start date 1/27/2023 at 11:00 PM, Hydrogel to left hand and occipital area topically every 2 days for skin management, monitor site for signs and symptoms of infection and notify MD as needed. Cleanse wound with normal saline (NS) then apply skin prep wipes to periwound skin and apply hydrogel. Cover with border gauze until resolved, start date 1/28/2023 at 3:00 PM, NS apply to top of head topically every day shift for skin management. Monitor site for signs and symptoms of infection and notify MD as needed. Cleanse area with NS and apply betadine solution, start 1/31/2023 at 7:00 AM, discontinue 2/06/2023 at 3:33 PM. It was restarted on 2/09/2023 at 7:00 AM. Care of the scalp sutures was not addressed in the physician's orders. Review of the medical record did not contain follow-up documentation or physician's orders to address care of the suture area and the removal of the sutures on the resident's scalp. On 2/08/2023 at 12:15 PM, the East Wing Unit Manager stated there were no physician's orders or progress notes for follow-up about removal of resident #48's scalp sutures. On 2/08/2023 at 5:50 PM, the Director of Nursing (DON) said the expectation for residents admitted with suture wounds is for nurses to contact the previous provider for removal and/or referral care recommendations. Provider notes were requested and the facility's wound care physician was asked to assess resident #48 on 2/08/2023. She said the wound required softening of the tissue and the wound doctor indicated the sutures were to be removed during the next visit the following week. The facility's policy and procedure Clinical Guideline Manual, Skin Integrity, dated 09/2017, read, PURPOSE To provide consistent assessment and evaluation, monitoring, documentation, and implementation of therapeutic interventions to heal and maintain skin integrity . Documentation should address: 105754 Page 9 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0684 Level of Harm - Minimal harm or potential for actual harm The progress toward healing and identification of potential complications . 7. A weekly IDT note will be documented to address current areas, any new areas, progress of healing and any changes to treatments or interventions. Residents Affected - Few 105754 Page 10 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure specialty respiratory Chest Percussion Therapy (CPT) care and services were provided in accordance with professional standards of practice for 1 of 2 residents reviewed for respiratory care from a total sample of 45 residents (#48). Residents Affected - Few Findings: Resident #48's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, atrial fibrillation, type 2 diabetes mellitus, hemiplegia and dysphagia following stroke, and dementia. The Minimum Data Set (MDS) 5-day assessment with Assessment Reference Date (ARD) of 1/24/2023 identified the resident had memory problems, was severely cognitively impaired, required extensive staff assistance for activities of daily living (ADLs), and no special treatments, procedures, or programs for Respiratory Therapy were provided during the look back period. On 2/07/2023 at 4:42 PM, Certified Nursing Assistant (CNA) I said she worked the 3 to 11 PM shift, and said nurses used the CPT device located in resident #48's room. Review of resident #48's current orders did not contain any physician's orders for CPT. The resident's Treatment Administration Record (TAR) did not contain documentation that CPT was given to the resident. On 2/07/2023 at 4:48 PM, Licensed Practical Nurse (LPN) D stated the CPT device is regularly administered by nurses to resident #48 in the evening before bed. The LPN said CPT required physician's orders and nurses sign off for administration on the TAR. LPN D checked the medical record software and acknowledged there were no physicians' orders or TAR for treatment and monitoring of CPT for the resident, and said, There should be. On 2/07/2023 at 4:56 PM, the Director of Nursing (DON) said CPT was a specialty respiratory therapy that required physician's orders and nurse documentation on the TAR if treatments were administered. The DON explained resident readmissions are reviewed for order reconciliation during daily clinical meetings. She acknowledged the medical record did not include physician's orders or a TAR for CPT for resident #48. The facility respiratory policy and procedures Oxygen Therapy did not include respiratory therapy and services other than oxygen. The facility assessment dated as completed and updated 1/2023, included Special Treatments and Conditions for Respiratory Treatments included, Oxygen therapy, Suctioning, Tracheostomy Care, BIPAP/CPAP. 105754 Page 11 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nursing documented behavior monitoring and side effects for antipsychotic medication for 1 of 5 residents reviewed for unnecessary medication review out of a total sample of 45 resident (#19). Residents Affected - Few Findings: Resident #19's medical record revealed the resident was initially admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses of type 2 diabetes, dementia, hypertension, and rheumatoid arthritis. The entry assessment minimum data Set (MDS) with assessment reference date of 1/28/23 did not indicate a Brief Interview of Mental Status (BIMS) score, cognitive skills level or behaviors. The care plan showed focus for risk of adverse reactions related to psychotropic medications use of antipsychotic. The intervention read, Administer ANTI-PSYCHOTIC medications as ordered by physician. Monitor for side effects and effectiveness Q shift. Date Initiated 1/28/23. Physician orders for February 2023 included Risperdal 1 milligram (mg.) by mouth at bedtime for bipolar depression. Risperidone (Risperdal) is used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, irritability associated with autistic disorder). Risperidone belongs to a class of drugs called atypical antipsychotics. It works by helping to restore the balance of certain natural substances in the brain. (retreived on 2/13/2023 webmd.com). Risperdal was ordered on 1/28/23. Resident #19's medication administration records (MARs) for January and February 2023 did not contain documentation for adequate behavior or side effect monitoring. On 2/07/23 at 4:00 PM, the Director of Nursing (DON) stated behavior monitoring for psychotropic medications is included in the batch orders for residents and batch orders are added to the MARs with new orders for medications. She stated nursing documentation is reviewed by MDS staff and unit mangers. She stated the unit manager is responsible for monitoring nursing documentation. On 2/08/23 at 10:46 AM, Licensed Practical Nurse (LPN) B stated any resident receiving antipsychotic medications have to have behavior monitoring; the questions address behaviors and side effects. On 2/09/23 at 12:06 PM, LPN J stated resident behavior monitoring and side effects are documented in the computer. LPN J stated she did not have any behavior monitoring for resident #19. She confirmed resident #19 should have behavior and side effect monitoring for anti-depressant medication. She stated once the medication is entered into the computer, the batch order should be checked so the resident's behavior is monitored. On 2/09/23 at 12:17 PM, the [NAME] Unit Manager Registered Nurse (RN) stated that to ensure orders are not missed, physician orders are checked by the unit managers the next day and then orders go to the DON. She validated resident #19 did not have any documentation for behavior monitoring on the MAR. She stated unit managers are responsible for checking physician orders. On 2/09/23 at 2:13 PM, the Regional Nurse provided a copy of the facility Using Order Sets Quick Reference Guide. It read, This quick reference guide provides the steps required to create orders using order sets. She stated instructions are covered in orientation with nursing on inputting batch 105754 Page 12 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0757 orders. Level of Harm - Minimal harm or potential for actual harm The DON's signed Position Overview, dated 8/20/18, read, Essential Job Duties . 1. Responsible for overall supervision of the Nursing Department and providing guidance to both management and non-management Nursing Staff . 4. Recruits, selects and orients qualified team members for the Nursing Department . 7. Directs and develops the nursing department to ensure the delivery of high quality care and services in accordance with all laws, regulations and facility guidelines. Residents Affected - Few The facility's policy Psychotropic Medication Evaluation & Monitoring read, PURPOSE: To administer, and monitor the effects of psychotropic medications . and did not have an effective date. The facility assessment completed/updated 1/2023 read, Caring for Residents with Mental and Psychosocial disorders . All staff upon hire during general orientation and annually during All Staff meetings and/or scheduled in-services. Individual training done if/when the need arises. 105754 Page 13 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly inform the physician of a laboratory report for 1 of 3 residents reviewed for hospitalization, of a total sample of 45 residents (#4). Findings: Resident #4's medical record revealed the resident was admitted to the facility on [DATE] and readmitted recently on 2/04/23. The resident's diagnoses included paraplegia, generalized muscle weakness, contracture, other myelitis, and multiple sclerosis. On 2/06/23 at 10:07 AM, resident #4 revealed she had an indwelling catheter in place to prevent her sacral wound from getting infected. She stated she did not like how her urine looked, and mentioned to her nurse that it looked as if she had a urinary tract infection (UTI). Resident #4 stated she believed the nurse got a urine sample, but she heard nothing about the results. She stated she became unresponsive on 1/28/23, was hospitalized for a week, and returned to the facility on 2/04/22. She said she believe that if staff had acted sooner, she would not have been so sick. On 2/07/23 at 4:04 PM and at 4:26 PM, the East Wing UM stated a urine analysis (UA) was completed on 1/23/23. The facility received the report on 1/25/23, which showed mixed gram negative and gram-positive flora. The UM stated she did not think any treatment was started, since she could not identify any order for any new medication on 1/25/23. When asked if the physician was made aware of the UA results, the UM stated, I can't prove to you that the physician was made aware. On 2/07/23 at 5:08 PM, the Director of Nursing (DON) stated the primary nurse had the responsibility to review lab results, then communicate with the physician. On 2/07/23 at 5:55 PM, the DON provided a copy of the resident's UA report dated 1/23/23 at 11:20 AM and stated she could not say if the lab result was reviewed by the physician. There was no documentation on the report to indicate the lab was reviewed. This was confirmed by the DON. On 2/08/23 at 9:20 AM, the DON provided another copy of the resident's UA results. Documentation on the report read, No new orders and explained that it was signed by the physician. However, a date was not on the form. The DON stated the physician visited on 1/26/23, and reviewed the lab result, but did not visit the resident. The resident's clinical record was reviewed with the DON; physician documentation could not be identified for 1/26/23. On 2/08/23 at 11:21 AM, the resident's primary care physician (PCP) stated she reviewed the resident's UA results Around the time the resident went to the hospital. The PCP verbalized that she saw the resident monthly and depended on communication from staff pertaining to the residents. She verbalized the last time she saw the resident was on 1/12/23 but visited the facility weekly. The PCP stated the facility has her phone number and could always communicate with her or the answering service. She said, If someone is having symptoms, it could be identified, and could help to prevent hospitalization. On 2/09/23 at 11:41 AM, Licensed Practical Nurse (LPN) B stated the nurse who received the report should notify the physician, discuss the results with the resident, and document communication with 105754 Page 14 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0773 the physician in the resident's medical record. Level of Harm - Minimal harm or potential for actual harm LPN B reviewed resident #4's medical record and confirmed documentation was not seen to indicate the physician and resident were notified of the UA result when the report was received. Residents Affected - Few The facility's policy Notification of Change in Condition, copyright 2016, read, The licensed nurse is to document the notification of change to the family/legal representative/resident and Health Care Provider in the medical record. 105754 Page 15 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

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** Based on observation, interview, and record review the facility failed to ensure Personal Protective Equipment (PPE) was discarded appropriately to prevent transmission of highly contagious microorganisms for 1 of 1 resident requiring Transmission Based Precaution on the [NAME] Wing (#520). Residents Affected - Few Findings: Resident #520's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Methicillin Resistant Staphylococcus Aureus (MRSA), Bacteremia, and post-surgical intervention for Psoas Muscle Abscess. Physician orders included contact isolation for diagnosis of MRSA, correct door signage and equipment present and Teflaro Intravenous Solution 600 milligrams (mg.) every 8 hours for Psoas infection until 03/23/2023. The Psoas muscles are up to 16 inches long and extend from each side of your lower spine through your hips and connect to your upper thigh bone, called the femur. (Retrieved 2/23/23 webmd.com). MRSA stands for methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics . MRSA can cause severe problems including blood stream infections, pneumonia, surgical infections, sepsis, and death. MRSA is usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers. (Retrieved on 2/23/23 cdc.gov Centers for Disease Control and Prevention). On 02/07/23 at 10:41 AM, an observation in resident #520's room revealed PPE supplies on the door with signage for Contact Precautions. After visiting with resident #520, the resident's bathroom was entered. Discarded gloves were on the sink countertop and a discarded isolation gown was on the bathroom floor. An interview with resident #520's roommate revealed he uses the bathroom for washing up. On 02/07/23 at 10:44 AM, the [NAME] Wing Unit Manager confirmed that used PPE should not be on the floor and on the countertop in the bathroom. She stated, Used PPE should be discarded into the covered PPE container to contain infectious microorganisms and to prevent exposure to staff and the other resident in the room. On 02/08/23 at 5:15 PM, the Infection Control Practitioner (ICP) explained that staff discarding used PPE on the sink countertop and on the floor in the bathroom was not appropriate infection control practice. She stated, All PPE is to be discarded into a covered container to prevent other residents, staff, family members and vendors from exposure to infectious microorganisms. On 02/09/23 at 3:30 PM, an observation in resident #520's room now revealed 2 open waste baskets. The waste basket in the entry to the room contained multiple discarded gloves and the waste basket in the bathroom contained multiple discarded gowns. On 02/09/23 at 3:35 PM, Licensed Practical Nurse (LPN) F explained that resident #520 was on contact isolation for MRSA which required the use of PPE. LPN F stated, This is wrong. The used PPE should have been discarded into the covered step on container to prevent cross-contamination and exposure to MRSA. 105754 Page 16 of 17 105754 02/09/2023 Conway Lakes Health & Rehabilitation Center 5201 Curry Ford Road Orlando, FL 32812

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/09/23 at 3:40 PM, the ICP observed the discarded PPE in the open baskets. She stated All used PPE is required to be discarded into the covered container located just inside the room door to prevent exposure to any infection. On 02/09/23 at 4:45 PM, Certified Nursing Assistant (CNA) G said she was the CNA assigned to resident #520 that day. She explained he was on isolation, and she needed to use PPE when caring for him. CNA G stated, I discarded my used PPE into the open baskets. She then said that she should have discarded the used PPE into the covered container to prevent exposure to infection. The facility's Isolation - Isolation Precautions Overview Policy, dated 2013, read, Purpose to provide a system of isolation precautions to prevent the transmission of infection and to prevent transmission of infectious disease . Transmission-Based Precautions - Consists of measures designed to be used in addition to Standard Precautions to further reduce the risk of disease transmission . Contact Precautions designed to reduce the risk of epistemologically important microorganisms by direct or indirect contact: I. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host. II. Indirect-contact transmission involves contact from a susceptible host with a contaminated object in the environment . 105754 Page 17 of 17