Health inspection·March 3, 2022

F 0908 Keep all essential equipment working safely. 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 resident equipment was maintained in a sanitary and safe operating condition for 1 of 5 residents observed with wheelchairs, Resident #6, in a total sample of 46 residents. Residents Affected - Few Findings include: Review of Resident #6's records revealed the resident was admitted on [DATE] with the diagnoses to include hemiplegia following cerebral infarction, hypertension, and history of falling. Review of Resident #6's care plan revealed the resident had self-care deficit and required extensive assistance in self-care abilities including dressing, toileting, bathing related to hemiparesis on left side. On 2/28/2022 at 2:02 PM, the surveyor observed Resident #6 in bed, awake, alert, and oriented to name and place. There was a wide wheelchair at bedside that was unclean with reddish colored stains and food debris on the brake handles, the tread on the wheelchair tires was almost completely worn off and in disrepair, and the left wheel was tilted outward. During an interview with Resident #6 on 2/28/2022 at 2:02 PM, when asked if her wheelchair had been cleaned or checked, Resident #6 stated, Not that I know of. On 3/2/2022 at 8:42 AM, the surveyor observed Resident #6 was up on her wheelchair. Wheelchair remained unclean, with dust buildup, food debris on break handle, and rust buildup. The tread on the wheelchair tires was almost completely worn off and the left wheel was tilted outward. During an interview on 3/2/2022 at 8:44 AM, Resident #6 stated she came in here over three months ago and stated, I came in here last November and had this same wheelchair and have not seen them clean my wheelchair. During an interview with the Director of Nursing (DON) on 3/2/2022 at 8:55 AM, when asked how often the wheelchairs were cleaned and maintained, the DON stated, I do not know. Let me ask housekeeping. The DON confirmed Resident #6's wheelchair was unclean and confirmed that the tires needed repair. During an interview with the Environmental Service Director (ESD) on 3/2/2022 at 9:26 AM, in the presence of the DON, stated that she was the Environmental Service Director (ESD) for the past 10 years. She stated the wheelchairs are pressured cleaned bi-annually, every 6 months by the housekeeping staff. The maintenance department does the preventive maintenance. We clean all the wheelchairs in the entire building, including shower chairs. We take them out court by court (Dogwood, Magnolia, and Camellia units) and pressure clean them. They were last cleaned on January 5, 2022 [Resident #6's name] wheelchair is unclean and has some rust, the wheels are tilted, and agreed that it [wheelchair] has not been pressure cleaned since last January. On 3/2/22 at 9:30 AM, the DON and ESD confirmed that Resident # 6's wheelchair was unclean and needed some repair or replacement. During an interview with the Maintenance Supervisor on 3/2/2022 at 10:49 AM, when asked about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105809 If continuation sheet Page 2 of 3 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Center 10676 Marvin Jones Blvd Live Oak, FL 32060 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility's preventive maintenance (PM) process on residents' wheelchairs, he stated, We do not have a PM for wheelchairs. It is done as needed. I will receive a work order from the courts [facility units], then I go and check the wheelchair and do what is needed. I have not seen [Resident #6' name] wheelchair until today when I received a work order. He confirmed that Resident #6's wheelchair wheel was bent outward, and he had to remove some parts. When asked if he does maintenance rounding to check on equipment/wheelchair condition, he stated, I do, but I did not see her wheelchair. The CNAs are probably using the old work order system, so I am not getting the work order sheet. They are aware to use the new work order system. Review of the work order log from December 2021 to March 2022 did not reveal Resident #6's name on the log. Review of the facility policy and procedure titled Resident Wheelchair Cleaning last reviewed on 12/29/2021, reads, Policy: The intent of this policy is to establish a procedure for the proper and safe technique to be used for cleaning manually operated wheelchairs. Review of the facility policy and procedure titled, Preventive Maintenance Program, last reviewed on 12/29/2021, reads, Policy: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for the residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director or designee is responsible for maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director or designee shall inspect aspects of the physical plant to determine if Preventive maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, rounding, life safety requirements, or experience. 3. If preventive maintenance is required, the Maintenance Director or designee shall decide what tasks need to be completed and how often to complete them. 4. The Maintenance Director or designee shall develop a schedule to assist with keeping track of all tasks. 5. Documentation shall be completed of all tasks and kept in Maintenance Directors' office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105809 If continuation sheet Page 3 of 3