Health inspection·October 24, 2024

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 record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 5 residents reviewed for unnecessary medications, Resident #38. Residents Affected - Few Findings include: Review of Resident #38's Medicare admission 5-day MDS dated [DATE] showed the resident was receiving anticoagulant medication under Section N- Medications. Review of Resident #38's physician orders revealed no current or previous orders for anticoagulant medication. During an interview on 10/24/2024 at 8:15 AM regarding Resident #38's MDS dated [DATE], the MDS Coordinator stated, I reviewed it and it is inaccurate. During an interview on 10/24/2024 at 8:30 AM regarding MDS accuracy, the Administrator stated, I expect them to be accurate. Review of the facility policy and procedure titled Conducting an Accurate Resident Assessment revised on 1/4/2024 showed it read, Policy Explanation and Compliance Guidelines . 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. Page 1 of 7 105963 105963 10/24/2024 Lafayette Nursing and Rehabilitation Center 512 W Main St Mayo, FL 32066

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents received intravenous therapy (IV) in accordance with professional standards of practice for 1 of 1 resident, who was receiving intravenous medications, Resident #55. Residents Affected - Few Findings include: Review of Resident #55's admission record showed the resident was most recently admitted on [DATE] with the diagnoses to include encounter for surgical aftercare following surgery on the nervous system, disruption of internal operation (surgical) wound, and infection and inflammatory reaction due to internal fixation device. Review of Resident #55's physician order dated 10/21/2024 read, Cefepime HCl Injection Solution Reconstituted 1 GM [gram], Use 1 gram intravenously one time a day for Toxic Metabolic Encephalopathy until 10/24/2024 23:59 [11:59 PM]. Review of Resident #55's care plan dated 9/20/2024 read, [Resident #55's name] is on IV medications r/t [related to] toxic metabolic encephalopathy . Interventions . Administer medications as ordered. During an observation on 10/22/2024 at 8:24 AM, Staff A, Licensed Practical Nurse (LPN), was preparing Peripherally Inserted Central Catheter (PICC) in Resident #55's upper right arm for administration of Cefepime 1 gram in 100 milliliters (ml) Normal Saline. Staff A, LPN, sanitized and flushed the PICC line with 10 ml of normal saline and initiated antibiotic infusion via pump. Staff A did not check the patency of the line by aspiration for blood return to determine patency prior to flushing or administering the medication. During an interview on 10/22/2024 at 8:30 AM, Staff A, LPN, stated, We do not have to aspirate prior to flushing or providing intravenous medication. We just have to flush with saline first. During an interview on 10/22/2024 at 12:18 PM, the Director of Nursing stated, The PICC line must be checked for patency by aspiration of blood prior to flushing with normal saline and before administering medication via the line. That's our policy and process. Review of the facility policy and procedure titled Administration of IV Fluids and Medications, Setting Up a Primary Infusion (Hydration or Medication) dated 12/29/2023 read, Purpose: To correctly and aseptically set up the primary IV bag and tubing . Procedure . 7. Attach flush syringe, aspirate for a blood return to determine patency and then flush resident's IV catheter with appropriate flush solution as ordered. Review of the facility policy and procedure titled Intravenous Therapy dated 12/29/2023 read, Procedures. Continuous Infusion . 10. Confirm patency of vascular device (peripheral IV or CVAD) as per flush protocols . Intermittent Medication Infusion . 13. Attach 10 mL syringe normal saline and confirm patency of vascular access device as per protocol. 105963 Page 2 of 7 105963 10/24/2024 Lafayette Nursing and Rehabilitation Center 512 W Main St Mayo, FL 32066

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2) During an observation on 10/21/2024 at 10:30 AM, Resident #5 was lying in bed, receiving oxygen via nasal cannula at 2 L/M (Photographic evidence obtained). Residents Affected - Few During an interview on 10/21/2024 at 10:30 AM, Resident #5 stated, I wear oxygen all the time. During an observation on 10/22/2024 at 8:39 AM, Resident #5 was lying in bed, receiving oxygen via nasal canula at 2 L/M. Review of Resident #5's physician order dated 8/1/2024 showed it read, O2 @ [at] 4 lpm [liter per minute] via N/C [nasal cannula] to keep O2 Sat above 90% as tolerated every shift for COPD/CHF [Congestive Heart Failure]. Review of Resident #5's care plan dated 9/29/2023 showed it read, Focus: [Resident #5's name] has COPD . Interventions . Administer oxygen as ordered. During an interview on 10/22/2024 at 12:20 PM, Staff A, Licensed Practical Nurse (LPN), stated the resident should be at 4 liters per minute. During an interview on 10/22/2024 at 1:05 PM, the Director of Nursing (DON) stated, The expectation is that we follow orders for oxygen, even if it is prn. 3) During an observation on 10/21/2024 at 9:45 AM, Resident #44 was lying in bed, receiving oxygen via nasal cannula at 3 L/M. During an observation on 10/22/2024 at 9:00 AM, Resident #44 was lying in bed, receiving oxygen via nasal cannula at 3 L/M. During an interview on 10/22/2024 at 9:00 AM, Resident #44 stated, I only wear it when I'm laying down. I don't usually have problems otherwise. Review of Resident #44's physician orders showed an order dated 3/25/2023 for administration of oxygen at 2 L/M via nasal cannula as needed to keep oxygen saturation above 92%. During an interview on 10/23/2024 at 10:55 AM, Staff C, Certified Nursing Assistant (CNA), stated, He [Resident #44] lets us know when he needs it and then I let the nurse know. I can't make sure it's on the correct setting, so I have the nurses do it. During an interview on 10/22/2024 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN), stated, I would document if his [Resident #44's] sats were down under 92%. I would hook him up. During an interview on 10/22/2024 at 12:10 PM, the Director of Nursing (DON) stated, It is my expectation that they follow doctor's order to a tee. Only nurses should be adjusting the oxygen settings in accordance with physician orders. Review of the facility policy and procedure titled Oxygen Administration last reviewed on 12/29/2023, showed it read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals 105963 Page 3 of 7 105963 10/24/2024 Lafayette Nursing and Rehabilitation Center 512 W Main St Mayo, FL 32066

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and preferences . Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. Review of the facility policy and procedure titled Physician Medication/Treatment Orders last reviewed on 12/29/2023, showed it read, Policy: This facility shall use uniform guidelines for the ordering of medications and treatments by practitioners. Policy Explanation and Compliance Guidelines: 1. Medications/Treatment should be administered only upon the signed order of a person lawfully authorized to prescribe . 3. Elements of the Medication/Treatment Order . d. Dosage-strength of medication is included. Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as prescribed by physician for 3 of 8 residents reviewed for oxygen therapy, Residents #5, #31, and #44. Findings include: 1) During an observation on 10/21/2024 at 9:59 AM, Resident #31 was receiving oxygen via nasal cannula at 5 L/M [liters per minute]. During an observation on 10/21/2024 at 1:58 PM, Resident #31 was receiving oxygen via nasal cannula at 5 liters per minute. During an observation on 10/22/2024 at 7:40 AM, Resident #31 was receiving oxygen via nasal cannula at 5 liters per minute. Review of Resident #31's physician order dated 4/10/2023 read, Oxygen PRN [as needed]- O2 [oxygen] at 2 L/M via nasal cannula as needed for O2 sats [saturation] < [less than] 90%. Review of Resident #31's care plan dated 3/14/20244 read, Focus: [Resident #31's name] has COPD [Chronic Obstructive Pulmonary Disease] . Interventions/Tasks . Give oxygen therapy as ordered by the physician. During an interview on 10/22/2024 at 11:20 AM, Resident #31 stated, My oxygen is supposed to be set at 2 liters. I don't know what it is. I cannot and do not adjust it myself. During an observation on 10/22/2024 at 12:18 PM with Staff B, Registered Nurse (RN), she confirmed that oxygen was delivered to Resident #31 at 5 liters per minute, and stated, The oxygen should be set and delivered per physician orders at 2 liters via nasal cannula. 105963 Page 4 of 7 105963 10/24/2024 Lafayette Nursing and Rehabilitation Center 512 W Main St Mayo, FL 32066

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Residents Affected - Many Findings include: During an observation on 10/21/2024 at 9:15 AM, Daily Nursing Staffing Form was posted in the main entry hall of the facility. The form read, Saturday. Today's Date: 10/19/2024. During an interview on 10/24/2024 at 9:10 AM, the Administrator stated, I would like the staffing sheet posted by 11:00 AM. Mondays can take a little longer because they are balancing 3 days of staffing. Review of the facility policy and procedure titled Nurse Staffing Posting Information last reviewed on 12/29/2023, showed it read, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information . 2. The facility will post the Nurse Staffing Sheet daily each morning. 105963 Page 5 of 7 105963 10/24/2024 Lafayette Nursing and Rehabilitation Center 512 W Main St Mayo, FL 32066

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received food at a safe and appetizing temperature. Residents Affected - Few Findings include: During an observation of the tray line for breakfast meal service on 10/23/2024 at 7:40 AM, after one hall's trays were prepared, sausage patty temperature was at 130 degrees Fahrenheit on the steamtable and 4-ounce strawberry yogurt was at 47.8 degrees Fahrenheit. During an interview on 10/23/2024 at 7:40 AM, the Dietary Manager confirmed the temperatures recorded and stated that the temperature for the sausage should have been above 135 degrees and the temperature of the yogurt should have been below 41 degrees. Review of the facility policy and procedure titled Food Holding and Service dated 10/1/2018 and last reviewed on 12/31/2023 showed it read, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP [Hazard Analysis Critical Control Point] guidelines. Procedure: 1. Serve all hot foods at a temperature of 135 F [Fahrenheit] or greater and all cold food at 41F or less. Adjust the temperature to account for the time the food will be held prior to service on the steam table and on the tray carts. 105963 Page 6 of 7 105963 10/24/2024 Lafayette Nursing and Rehabilitation Center 512 W Main St Mayo, FL 32066

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff sanitized resident-care equipment between resident use to prevent the possible development and transmission of communicable diseases and infections. Residents Affected - Few Findings include: During an observation on 10/22/2024 at 8:03 AM, Staff A, Licensed Practical Nurse (LPN), obtained blood pressure for Resident #261 and returned to the medication cart and placed the blood pressure cuff on top of the medication cart without sanitizing the blood pressure cuff. At 8:04 AM, Staff A proceeded to Resident #23's room and obtained blood pressure reading from right arm and administered the medications returning to the medication cart to prepare medication for Resident #55. Staff A did not sanitize the blood pressure cuff. During an interview on 10/22/2024 at 8:30 AM, Staff A, LPN, stated, They are cloth. How are we going to clean them? I didn't wipe it off and I should have wiped it down with a sanitizer cloth after each resident use. During an observation on 10/22/2024 at 10:35 AM, Staff B, Registered Nurse (RN), obtained oxygen saturation with finger probe for Resident #31. The portable oxygen finger probe monitor was placed back into the medication cart. Staff B did not sanitize the probe. During an interview on 10/22/2024 at 10:50 AM, Staff B, RN, stated, I forgot the probe has to be cleaned before and after resident use. During an interview on 10/22/2024 at 10:59 AM, the Registered Nurse Consultant stated, Durable medical equipment needs to be cleaned between each resident use. The blood pressure cuff and machine should be cleaned between each resident use. The finger oxygen monitor must be cleaned between each resident use. During an interview on 10/22/2024 at 12:18 PM, the Director of Nursing stated, Any re-useable equipment must be cleaned with purple wipes [sanitary wipes] and then the dwell time should be followed per the container. Blood pressure cuffs and oxygen finger probes must be cleaned before and after each resident use with sanitizer. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Equipment dated 1/4/2024 and last reviewed on 12/29/2023 showed it read, Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection . Policy Explanation and Compliance Guidelines: 1. Resident-care equipment is categorized based on the degree of risk for infection involved in the use of the equipment . c. Non-critical items come in contact with intact skin, but not mucous membranes. These items require cleaning followed by low/intermediate-level disinfection (i.e., use of EPA [Environmental Protection Agency]-registered disinfectants) following manufacturers' instructions . 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use. 105963 Page 7 of 7