Health inspection·January 25, 2024

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 observations, resident and facility record reviews, and interviews with staff, the facility failed to provide appropriate assistance with nail care for one (Resident #60) of four residents (Resident #60) reviewed for activities of daily living (ADLs), from a total of 29 residents in the sample. Residents Affected - Few The findings include: An observation of Resident #60 was made on 01/23/24 at 9:34 AM. The fingernails on both of her hands were elongated and an unknown dark brown substance was observed under the nail tips. The tips of her nails were jagged and in need of filing. (Photographic evidence obtained) On 1/24/24 at 1:43 PM, Resident #60's fingernails on both hands were observed still in the same condition and with the unknown brown substance under the tips. (Photographic evidence obtained) An interview was conducted with Licensed Practical Nurse (LPN) A on 1/25/24 at 11:24 AM. When asked who was responsible for residents' nail care, LPN A replied that certified nursing assistants (CNAs) provided nail care and were permitted to trim nails unless the resident was diabetic; in that case, the nurses provided the nail care. When asked how staff removed debris from underneath the nails, LPN A said she was not sure if CNAs were using nail brushes or orange sticks. She stated residents' fingernails should be tended to as needed. CNA B was interviewed on 1/24/24 at 2:38 PM. She confirmed that the CNAs were responsible for assisting residents with keeping their fingernails clean. CNAs could file and clean fingernails but not clip them. The nurses were responsible for that. Resident #60 was observed in her room on 1/25/24 at 9:49 AM. She was in bed and had the remains of her breakfast on her overbed table. Upon request, she displayed her fingernails which now appeared neatly filed, but still with the same brown substance under the tips. Resident #60 reported that the nurse had just come in the other day to do them. She asked, They look better, don't they? When shown, she acknowledged the brown substance underneath but could not state what it was or how it got there. The Long Term Care Unit Manager (LTCUM) was interviewed on 1/25/24 at 11:33 AM. She stated CNAs should provide care when a resident's nails were long or in need of cleaning. Orange sticks were available for cleaning underneath the nails but nail brushes were not. CNAs provided hand hygiene before meals by using hand wipes. The LTCUM was accompanied to Resident #60's room to observe her fingernails; however, the resident was receiving personal care. When shown the photographs, the LTCUM confirmed the presence of the dark brown unknown substance under the tips. She was unsure of what the matter Page 1 of 5 105822 105822 01/25/2024 Gardens Healthcare & Rehabilitation Center 1704 Huntington Village Circle Daytona Beach, FL 32114

F 0677 was but confirmed Resident #60's need for nail care. Level of Harm - Minimal harm or potential for actual harm A record review for Resident #60 found she was admitted to the facility on [DATE]. She had a quarterly minimum data set (MDS) assessment with an assessment reference date of 11/8/23. Resident #60 had a brief interview for mental status (BIMS) score of 13 out of 15 points, reflecting that she was cognitively intact. Her diagnoses included cancer, Parkinson's disease and renal insufficiency. Residents Affected - Few Resident #60 was care planned on 8/22/23 for her ADL self-care performance deficit related to her activity intolerance, impaired balance, weakness and Parkinson's disease. The goal was to maintain her current level of function through the next review date. Interventions included, but were not limited to, requires extensive assistance of 1 person with personal hygiene. Resident #60 was also care planed on 11/13/23 for a rash to her vaginal area, with the goal to heal by the next review date. Interventions included avoid scratching and keep hands and body parts from excessive moisture and monitor skin rash for increased spread or signs of infection. (Photographic evidence obtained) A review of Resident #60's CNA tasks found that she required physical to total assistance daily with bathing and personal hygiene. The bathing task further asked if nail care was provided during bathing. The task was marked yes for January 5, 10, 17, 19 and 22, 2024, and noted that Resident #60 required physical help to total assistance with nail care. She was independent with eating. (Photographic evidence obtained) A review of the facility's Standards and Guidelines: Nail Care (implemented 1/15/21, revised/reviewed 1/15/2) found: Standard: It will be the standard of this facility to provide nail care to residents per resident preferences and to maintain dignity. Guidelines: .3. Nail care includes regular cleaning and regular trimming, unless contraindicated by resident condition, specific behaviors or resident refusal. .6. Trimmed and smooth nails can help prevent the resident from accidentally scratching and injuring his or her skin. 7. Watch for and report changes in general condition of resident's nails. (Photographic evidence obtained) . 105822 Page 2 of 5 105822 01/25/2024 Gardens Healthcare & Rehabilitation Center 1704 Huntington Village Circle Daytona Beach, FL 32114

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 observations, interviews with staff, and a review of the 2022 Food Code, the facility failed to store and distribute ice in accordance with professional standards for food service safety in two of three ice machines inspected. This had the potential to affect all 103 residents who ate and drank by mouth from a total of 104 residents in the facility. Failure to ensure ice machines are clean and draining properly poses a risk of contamination with mold or bacteria, which could lead to waterborne illness. The findings include: During an initial tour of the kitchen on 1/22/24 at 10:25 AM, the ice machine was inspected. Standing water was pooled at the base of the opening where the ice machine lid closed and came to rest. The location of the pooled water presented a likelihood of splashing into the ice when the lid was closed. (Photographic evidence obtained) The Certified Dietary Manager (CDM), who was present at the time of the tour, acknowledged the pooled water and it's proximity to the ice. She stated it had always been like that. The CDM retrieved some paper towels and began wiping up the water but it splashed back into the ice. The tile floor around the base of the machine was very wet and had shallow, pooled water around the legs of the machine. During a visit to the 500 hallway on 1/22/24 at 12:21 PM, the food pantry's ice machine was inspected. The white plastic face plate concealing the ice chute had what resembled reddish pink bio-slime along the base of the plate. (Photographic evidence obtained) During a revisit to the kitchen on 1/25/24 at 1:40 PM, the ice machine pooling water concern had been resolved. The CDM explained that maintenance assisted with the resolution. She was accompanied to inspect the ice machine on the 500 hall. Upon inspection, she confirmed the presence of the pink substance. The CDM put the machine out of commission by posting a sign. The Maintenance Director (MD) was interviewed on 1/25/24 at 2:01 PM. He was asked about the kitchen ice machine and reported it had been fixed. He explained he had to raise and level it to ensure condensation drained forward to the drain and not back into the ice. The MD was asked how often he monitored the buildup of condensation for that machine. He said daily since the discovery was made days ago. Prior to that, he deep cleaned the machines every three months and did a general cleaning monthly. The MD and the Administrator were accompanied to the 500 hall ice machine. The MD attempted to wipe the area but the substance was embedded in the plastic and would not come off. He confirmed the presence of the substance. A review of the 2022 United States Food and Drug Administration found under section 4-602.11 Equipment Food-Contact Surfaces and Utensils it states: Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. (Photographic evidence obtained) A review of the Internet website 105822 Page 3 of 5 105822 01/25/2024 Gardens Healthcare & Rehabilitation Center 1704 Huntington Village Circle Daytona Beach, FL 32114

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (https://www.mytwintiers.com/news-cat/national-news/what-is-that-pink-slime-in-the-ice-machine/) found the biofilm known as pink slime is a frequent sight on ice machines and as buildup anywhere near water. The substance is a bacteria colony that could lead to serious health problems if ingested or if left unattended. Biofilms are the result of microorganisms attaching to a surface and often is a result of mold or fungus that has accumulated from bacteria growth on a surface that is constantly exposed to clinging water droplets and warm temperatures. Once well-developed biofilms establish themselves on surfaces, cleaning and sanitation become much more difficult. Sanitizing might not be enough and the substance must be physically removed from a surface in addition to regular cleaning. (Photographic evidence obtained) . 105822 Page 4 of 5 105822 01/25/2024 Gardens Healthcare & Rehabilitation Center 1704 Huntington Village Circle Daytona Beach, FL 32114

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews with staff, the facility failed to ensure waste and refuse were disposed of properly into one of two dumpsters inspected. Failure to ensure refuse is contained presents unsanitary conditions and the risk of harboring and feeding pests. Residents Affected - Few The findings include: During the initial kitchen tour on 1/22/24 at 10:25 AM, the facility's two commercial garbage dumpsters were inspected. One of the two dumpsters was found with medical waste, food, cardboard boxes and trash strewn about the base of the dumpster. Some of the debris had migrated to the base of electrical equipment nearby. (Photographic evidence obtained) The Certified Dietary Manager (CDM), who was present for the tour, confirmed the condition of the area. She explained garbage pickup was two days a week and as requested. Maintenance was responsible for picking up the trash around the dumpsters. The CDM was asked if maintenance worked weekends but she did not respond. The dumpsters were revisited on 1/25/24 at 1:40 PM. The same one of two dumpsters was now overfilled and the lid was propped open approximately three feet. Cardboard boxes were holding the lid open and boxes and trash were exposed. The CDM recognized the concern and asked for assistance with redistributing the contents of the dumpster in order to get the lid to close. She again stated maintenance was responsible for maintaining the dumpsters. The Maintenance Director (MD) was interviewed on 1/25/24 at 2:01 PM. He was asked about his responsibility with maintaining the condition of the dumpsters and surrounding areas. The MD stated the dietary department was responsible, but he helped and picked up when he saw something. He had spoken to dietary about it. Trash pickup was daily except for Thursdays and Sundays. The MD looked at the photographic evidence and confirmed the unsanitary conditions. . 105822 Page 5 of 5