Health inspection·October 7, 2021

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 interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment regarding hospice services for 1 of 3 residents reviewed for hospice services, of a total sample of 35 residents, (#17). Residents Affected - Few Findings: Resident #17 was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included cerebral atherosclerosis, Alzheimer's disease, dementia, and anxiety disorder. A physician order dated 7/07/21 revealed the resident was on hospice services for diagnosis of cerebral atherosclerosis. Review of the resident's clinical records revealed documentation by hospice staff of visits made, and services provided for the residents from 7/06/21- September 2021. Documentation in the resident's physical chart revealed the name, the team number, and contact information of the hospice provider for services rendered to resident #17. The admission MDS assessment with ARD 7/12/21 revealed the question in section J1400 prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded 0 meaning No. Hospice care was not checked in Section O- Special treatments, procedures, and programs. On 10/07/21 at 2:10 PM, Registered Nurse (RN) MDS Coordinator D stated assessments were completed by doing a 7 day look back, review of the resident's physician orders, medication administration record (MAR), observation of activities of daily living (ADLs) as needed, and interviews of resident/family /nurse as needed. The MDS Coordinator stated if the resident was on hospice services, hospice documentation, contract, and certification would be reviewed. The resident's admission MDS was reviewed with the MDS Coordinator. She stated that section J1400 should have been coded 2' meaning yes, and hospice care should have been checked in section O. She acknowledged the assessment was not accurate. The facility's policy MDS 3.0 Completion revised 7/20 read, According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity. Page 1 of 7 105757 105757 10/07/2021 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

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 interview and record review, the facility failed to develop a person-centered care plan for hospice and ensure care plans reflected the goals of hospice services for 1 of 3 residents reviewed for hospice services, (#17); and failed to develop a person-centered care plan for intravenous antibiotic therapy for 1 of 1 resident reviewed for antibiotic therapy, (#34), of a total sample of 35 residents. Findings: 1. Resident #17 was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included cerebral atherosclerosis, Alzheimer's disease, dementia, and anxiety disorder. A physician order dated 7/07/21 revealed the resident was on hospice services for diagnosis of cerebral atherosclerosis. Review of the resident's clinical records revealed documentation by a hospice agency of visits made and services provided for the resident from 7/06/21 through September 2021. Documentation in the resident's medical record revealed the name, the team number, and contact information of the hospice agency that provided services for resident #17. Progress notes dated 7/31/21 and 8/08/21 revealed the resident Continued on hospice service. On 10/05/21 at 12:47 PM, the resident's family member stated she was on hospice care for comfort. On 10/06/21 at 1:54 PM, Registered Nurse (RN) B stated resident #17 was on hospice services and hospice staff visited her on a weekly basis. RN B stated hospice documentation was in the resident's medical record under the hospice tab along with their contact information On 10/07/21 at 2:10 PM, RN Minimum Data Set (MDS) Coordinator D stated care plans were developed using the Care Assessment Areas triggered by the MDS assessment, observation, and review and discussion of the resident's clinical record in the Interdisciplinary Team (IDT) meetings. She stated all care plans, except dietary, social services, and activities were developed by MDS staff. Resident #17's care plans were reviewed with the MDS Coordinator D, and a care plan for hospice services was not identified. She explained a care plan was usually developed for residents on hospice services. She stated social services would document hospice services, and the MDS coordinator would ensure a care plan was developed for hospice, and that other care plans for the resident were in line with the hospice agency's goals. MDS Coordinator D validated a hospice care plan was not developed for the resident, and her other care plans, specifically the care plan for pain, did not incorporate or reflect hospice services. On 10/07/21 at 2:34 PM, the 2nd floor Assistant Director of Nursing (ADON) stated MDS staff developed and updated care plans. The ADON reviewed resident #17's clinical records and confirmed although the resident was on hospice services, a care plan was not developed to reflect hospice services. On 10/07/21 at 3:04 PM, the Interim DON stated if the resident was on hospice services, a care plan for hospice should be developed. 105757 Page 2 of 7 105757 10/07/2021 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #34 was admitted to the facility on [DATE] with diagnoses including joint replacement for left hip fracture. The Quarterly MDS assessment dated [DATE] indicated the resident was cognitively intact. On 10/04/21 at 10:34 AM, during a joint observation of resident #34 with the 3rd floor ADON, he validated the resident had a midline intravenous (IV) catheter inserted in his right upper arm. Review of the physician orders reflected the midline catheter was inserted on 9/15/21. Another order dated 9/17/21 read, Change IV dressing every week and as needed. On 10/07/21 at 11:20 AM, the Infection Preventionist stated new orders were reviewed in daily clinical meetings. She explained the clinical ADON checked the orders to ensure they were entered correctly. She stated the MDS Coordinator would then create a care plan. The Infection Preventionist said, The care plan gives the nurses guidance on how to care for each individual resident. A review of the resident's care plans noted no care plan was developed for IV midline catheter care. On 10/07/21 at 2:11 PM, MDS Coordinator RN J stated resident #34 should have a care plan with goals and interventions for the midline IV catheter. She explained the care plan process involved review of new orders, and creation or revision and updating of care plans to reflect the resident's individual needs. MDS Coordinator RN J stated it was important to create and update care plans in a timely manner so that staff would have all information to provide necessary care and services for residents. The policy Comprehensive Care Plans reviewed in July 2020 read, The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team . will also be addressed in the plan of care. The document indicated each resident would have a comprehensive person centered care plan to meet all needs identified in assessments. 105757 Page 3 of 7 105757 10/07/2021 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide nail care for 1 of 4 dependent residents reviewed for activities of daily living (ADL) care, of a total sample of 35 residents, (#59). Residents Affected - Few Findings: Resident #59 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, contractures of both hands and his left upper arm, and stroke with partial paralysis. The quarterly Minimum Data Set (MDS) assessment with assessment reference date of 8/26/21 revealed resident #59's cognition was moderately impaired, with a Brief Interview for Mental Status score of 12/15. Resident #59 was assessed as being totally dependent on staff for personal hygiene and he required extensive assistance with dressing. Resident #59 had functional limitation in range of motion and impairments of his upper and lower extremities on both sides. On 10/04/21 at 9:57 AM, and on 10/05/21 at 9:36 AM, resident #59 sat in his motorized wheelchair. The resident's fingernails on both hands were long and untrimmed, and there was a dark substance noted underneath the left thumbnail and the fingernails of his contracted right hand. Resident #59 stated his fingernails needed trimming. On 10/05/21 at 5:46 PM, the 2nd floor Assistant Director of Nursing (ADON) stated nail care was provided by the Certified Nursing Assistants (CNAs), Occupational Therapy staff, and nurses. On 10/05/21 at 5:55 PM, CNA G stated she worked on the 3 PM to 11 PM shift, and resident #59's nail care was scheduled to be done on the 7 AM to 3 PM shift. On 10/05/21 at 5:56 PM, the resident's fingernails were observed with the ADON and CNA G. They both acknowledged his fingernails were untrimmed and dirty. The ADON stated nail care was not confined to any specific shift and could also be provided upon the resident's request. Resident #59 again stated he wanted his fingernails to be trimmed. On 10/06/21 at 10:15 AM, the Interim Director of Nursing stated nail care was provided by the CNAs. She explained there was no specific time scheduled for nail care, and nurses should supervise residents' ADL care to ensure the required care was provided. On 10/06/21 at 1:41 PM, CNA F stated resident #59 did not resist care and was able to make his needs known. CNA F confirmed nail care was a part of ADL care and should be provided as needed. She stated she was assigned to resident #59 on 10/05/21 but did not provide nail care for him that day. On 10/06/21 at 1:54 PM, Registered Nurse (RN) B stated resident #59 was alert and oriented, could make his needs known, and was dependent on staff for all his ADL care. RN B stated nail care was provided on shower days and as needed by CNAs or nurses, and the intervention should be in the resident's care plan. The resident's care plan for self-care deficit related to diagnosis of cerebral palsy, history of stroke with paralysis, and contractures was created 3/10/21. The interventions included assist with grooming and provide nail care as needed. 105757 Page 4 of 7 105757 10/07/2021 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0677 Level of Harm - Minimal harm or potential for actual harm The policy Providing Nail Care reviewed/revised in July 2020 read, Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. Residents Affected - Few 105757 Page 5 of 7 105757 10/07/2021 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure wheelchair anti-tippers were positioned correctly to prevent accidents for 1 of 5 residents reviewed for falls and accident hazards, of a total sample of 35 residents, (#44). Findings: Resident #44 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and diabetes. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status evaluation was not done because the resident was rarely or never understood. The MDS assessment noted resident #44 required extensive assistance of one staff member for transfers and locomotion on the unit and used a wheelchair for mobility. On 10/04/21 at 3:34 PM, resident #44 was seated in his wheelchair in the third-floor common area. The back of the resident's wheelchair had anti-tippers that were not positioned correctly. The anti-tipper devices were positioned upwards, pointing towards the ceiling instead of downwards, towards the floor. Wheelchair anti-tippers keep a wheelchair from tipping over backwards and prevent users from having accidents and being injured by falling over backwards (retrieved on 10/19/21 from www.wheelchairparts.com). Further review of resident #44's medical record revealed there was no physician's order for the wheelchair anti-tippers nor were the anti-tippers addressed on the resident #44's Fall/Accident care plan. On 10/6/21 at 12:05 PM, resident #44 was seated in his wheelchair in the atrium. The wheelchair anti-tippers were still positioned incorrectly, pointing upwards towards the ceiling. On 10/07/21 at 11:01 AM, the resident was again seated in his wheelchair in the atrium, with the wheelchair anti-tippers still incorrectly positioned. On 10/07/21 at 12:54 PM, during an observation of resident #44's wheelchair with the Therapy Manager (TM), he validated the anti-tippers were not in the correct position. He stated the anti-tippers should point downward, toward the floor. The Therapy Manager looked around the atrium and acknowledged resident #44 was the only resident in the area whose wheelchair anti-tippers were positioned incorrectly. He did not explain if nursing staff were responsible for ensuring residents' safety devices were in the correct position, and stated he could not speak to that. He was not able to provide an explanation as to why resident #44's anti-tippers were not correctly placed. 105757 Page 6 of 7 105757 10/07/2021 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0694 Provide for the safe, appropriate administration of IV fluids 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 provide dressing changes for a midline intravenous (IV) catheter according to current professional standards of practice, for 1 of 1 resident reviewed for IV catheters of a total sample of 35 residents, (#34). Residents Affected - Few Findings: Resident #34 was admitted to the facility on [DATE] with diagnoses including joint replacement for left hip fracture. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. Review of the physician orders reflected a midline catheter was inserted on 9/15/21. Another order dated 9/17/21 read, Change IV dressing every week and as needed. A midline catheter is inserted into a vein near the elbow or upper arm and ends in a vein below the armpit. A midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments. (retrieved on 10/18/21 from www.drugs.com). A review of the Medication Administration Record showed the resident's midline IV dressing was marked with a check mark indicating the dressing was changed on 9/24/21 and 10/1/21. On 10/04/21 at 10:34 AM, during a joint observation of resident #34 with the 3rd floor Assistant Director of Nursing (ADON), he validated the resident had a midline IV catheter inserted in his right upper arm. The ADON confirmed the transparent dressing at the site was dated 9/24/21 and was loosely secured with surgical tape. He acknowledged the dressing at the IV site should have been changed weekly to minimize infection, according to facility policy. The ADON stated resident #34's dressing should have been changed on 10/01/21 but it was not. Review of nursing progress notes revealed no documentation to show the resident's IV dressing change was done after 9/24/21. On 10/07/21 at 11:20 AM, the Infection Preventionist stated the clinical ADONs were responsible for checking all residents with IVs on their units. She explained a contracted IV specialty nurse from an outside company came to the facility to insert midlines. The Infection Preventionist stated facility nurses were responsible for obtaining and entering physician orders for IV flushes and weekly dressing changes. She stated orders would be transcribed to the medication and/or treatment administration records with specific days and shifts identified for each task. Review of the policy and procedure for Intravenous Therapy dated July 2020 revealed,6) IV dressing changes will be done every 7 days and [as needed] per the doctors' orders.10) IV documentation is recorded in the nurses' notes and or Medication Administration Record. 105757 Page 7 of 7