Health inspection·July 17, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation and interview the facility failed to ensure maintenance and housekeeping provided the services necessary to maintain a sanitary and orderly environment for the 200-hall shower room. Residents Affected - Few Findings include: During an observation on 7/14/24 at 10:00 AM during the initial tour of the 200-hall shower room it was observed that the ceiling, walls, and tiles surrounding the shower area were cracked and/or have holes. The walls of the shower room have streaks of a darkened green and brown substance running down the walls. It was also observed to have dirty linen and personal items that were left in the shower room. During this observation the shower floor was dry as were the walls. (Photographic evidence obtained) During observations on 7/15/24 staff were observed wheeling residents into the shower room on the 200-hall for showers. During an observation on 7/15/24 at approximately 10:00 AM the shower room walls in the shower room on the 200-hall were observed to have streaks of a darkened green and brown substance running down the wall. During observations on 7/16/24 staff were observed wheeling residents into the shower room on the 200-hall for showers. During an observation on 7/17/24 at approximately 9:45 AM the shower room walls in the shower room of the 200-hall were observed to have streaks of a darkened green and brown substance running down the wall. During an interview on 7/17/24 at 10:00 AM, while in the 200-hall shower room, the Maintenance Director stated, This is an area that is a concern. I am aware that it needs to be fixed, it is on my list. The housekeeping lead tells me that they clean the shower room daily. During an interview on 7/17/24 at 10:10 AM the Housekeeping Lead stated, I get a ticket that shows me that the cleaning is completed daily. I do not make a habit of checking after the staff. I can say they [the shower room walls] need to be cleaned. During an interview on 7/17/24 at 10:30 AM the Director of Nursing stated, Staff should not leave personal items, or linens in the shower room. My expectation is that staff are supposed to leave the Page 1 of 12 106003 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0584 shower room ready for the next person to use. Level of Harm - Minimal harm or potential for actual harm Review of policy and procedure titled P&P Environmental Services Cleaning Guidelines Issued 4/1/2022, last reviewed 1/25/24 read, Policy: It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule and documentation based on the area of the facility, type of surface to be cleaned, type of soil present and task being performed in the area. Purpose: It is important that a clean, safe and sanitary environment is maintained for our residents. Residents Affected - Few 106003 Page 2 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care services, Residents #591 and #80. (Photographic evidence obtained) Residents Affected - Few Findings include: 1. During an observation on 7/14/24 at 10:00 AM Resident #591 was observed resting in bed wearing a nasal cannula and the oxygen (O2) concentrator was administering oxygen at 5 liters with a humidifier bottle attached. During an observation on 7/14/24 at 1:04 PM Resident #591 was observed sitting at the edge of the bed wearing a nasal cannula and the O2 concentrator was administering oxygen at 5 liters with a humidifier bottle attached. During an interview on 7/14/24 at 1:04 PM Resident #591stated, I don't touch or adjust the settings on the oxygen concentrator. The staff is the one who touches the settings. During an observation on 7/15/24 at 8:09 AM Resident #591 was observed resting in bed eyes closed wearing a nasal cannula and the oxygen concentrator was observed administering oxygen at 3 liters. During an observation on 7/16/24 at 7:45 AM Resident #591 was observed resting in bed eyes closed wearing a nasal cannula and the oxygen concentrator was observed administering oxygen at 3.5 liters. During an interview on 7/16/24 at 7:51 AM Staff F, Licensed Practical Nurse (LPN) stated, I check the O2 setting every day. I know the O2 is supposed to be on 2 liters, I think he changes the setting himself. Review of the physician order dated 6/30/24 at 12:48 PM read, 02 2 L NC [oxygen at 2 liters via nasal canula]. 2. During an observation on 7/14/2024 at 09:40 AM of Resident #80 it showed oxygen was being administered at 2.5 liters via nasal cannula. The humidified water bottle was empty. During an observation on 7/15/2024 at 2:45 PM of Resident #80 it showed oxygen was being administered at 2.5 liter via nasal cannula. The humidified water bottle was empty, and the humidified water bottle and tubing were dated 7/7/2024. Record review of Resident #80's physician order dated 6/14/2024 read, Change oxygen tubing and humidified H2O [water] weekly and PRN [as needed]. During an interview on 7/15/2024 at 2:55 PM Staff A, License Practical Nurse (LPN) stated, That oxygen tubing and humidification tubing is changed weekly, normally on night shift. The humidification bottle is empty, and the humidification bottle and tubing are dated 7/7/2024. This tubing should have been changed when there was no more water or weekly. During an interview on 7/15/2024 at 3:10 PM Staff C, LPN stated, I am assigned to the resident today and did not assess the oxygen delivery system for the oxygen delivery rate, the humidification 106003 Page 3 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0695 bottle or the tubing and the dates on the humidification bottle and tubing. Level of Harm - Minimal harm or potential for actual harm During an observation on 7/15/2024 at 3:11 PM with the Director of Nursing (DON) the DON confirmed the humidified water container was empty and the humidification bottle and tubing was dated 7/7/2024. Residents Affected - Few During an interview on 7/15/2024 at 3:11 PM the DON stated, Humidified water is to be changed when it is empty, and tubing is to be changed weekly. Review of the policy and procedure titled Oxygen Administration Issued 4/1/2022, last reviewed 1/25/24 read, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: .4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident. 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed to maintain infection control standards. 106003 Page 4 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

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 accurate nurse staffing information was posted on a daily basis for 3 of 6 days. Residents Affected - Many Findings include: Observation of the displayed nurse staffing information on Sunday, July 14, 2024 at 9:05 AM showed nurse staffing information for Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024 was posted in the front lobby area of the facility. A comparison review of the actual staff working hours on Friday, July 12, 2024, Saturday, July 13, 2024, and Sunday, July 14, 2024 with the Staffing Coordinator revealed the posted nurse staffing information did not accurately reflect the total number and actual hours worked by registered nurses, licensed practical nurses and certified nurses aides on Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024. During an interview on 7/16/2024 at 10:49 AM, the Staffing Coordinator stated the displayed nurse staffing information were projections and did not accurately reflect the total number and actual hours worked by registered nurses, licensed practical nurses and certified nurses aides on Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024. She stated she posted the projected nurse staffing sheets on Thursday evenings for Fridays, Saturdays, Sundays and Monday. Review of the facility policy titled Staff Postings, last reviewed 1/25/2024, read, Policy: It will be the policy of this facility to display staff posting information for visitors, families, residents and staff to be able to see. (1) Data requirements. The facility will post the following information on a daily basis: .(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. 2. Posting requirements. (i) The facility will post the nurse staffing data specified data on a daily basis at the beginning of each shift. 106003 Page 5 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. Twenty-eight medication administration opportunities were observed, and two medication errors were identified for 1 of 6 residents. The medication errors resulted in a medication error rate of 7.14%. Residents Affected - Few Findings include: During an observation on 7/16/2024 at 9:50 AM of Staff C, Registered Nurse (RN) during the medication pass for Resident #62 it showed Staff C administered one Midodrine HCL (hydrochloride) oral tablet 5 mg (milligrams), and one Vitamin D3 tablet 215 mg/equivalent to 5000 IU (international units). Resident #62's blood pressure results were documented as 140/88. Review of Resident #62's physician orders dated 5/6/2024 read, Vitamin D3 oral tablet give 3000 units by mouth in the morning for supplement. Midodrine HCL oral tablet 5 mg give 1 tablet by mouth three times a day for hypotension [low blood pressure] hold if systolic is greater than 110. During an interview on 7/16/2024 at 11:50 AM Staff D, RN stated, Midodrine should not have been given because his [Resident #62] blood pressure was not within the parameters as written, a systolic blood pressure less than110, and the Vitamin D should have been 3000 units not 5000 units. During an interview on 7/16/2024 at 4:15 PM the Director of Nursing stated, Midodrine is to be administered as ordered when the blood pressure falls within the parameters written and all medications are to be given as ordered. Review of the policy and procedure titled Medication Administration revised on 01/25/2024, read, It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by the resident. 3.Medication should be administered in a timely manner and in accordance with the physician's orders. 5. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director for further instructions. 8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time and right method of administration are verified. 106003 Page 6 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and policy and procedure review the facility failed to ensure medications were secure allowing access by unauthorized personnel, residents, and visitors when medications were left unattended on a resident's bed. Findings include: During an observation on 07/14/24 at 1:00 PM, there was a medication cup on Resident #491's bed containing seven pills, one green/white capsule, two white tablets, two pink tablets and two yellow tablets. The resident's bed was made, and the resident was not in the room. The resident's roommate was in the room in bed, with two family members visiting. The unsecured medication was in plain sight of the open doorway, where staff, residents and visitors were observed in the hallway. During an observation on 7/14/24 at 1:19 PM, the unsecured medications continued to be observed on Residents #491's bed. Resident #491 was not in the room. During an observation on 7/14/24 at approximately 1:45 PM of Resident 491's room with Staff E, LPN, she confirmed the medications in the medication cup were on Resident #491's bed and were unattended. During an interview on 7/14/24 at 1:45 PM Staff E, LPN stated, These were from 10:30 AM this morning. I brought them into [Resident 491's room] and she [Resident #491] wasn't here, but then I got distracted by the roommate and the roommate's family, and then I forgot the medications in the room. Staff E identified the medications as lisinopril [for elevated blood pressure], diltiazem [for elevated blood pressure], apixaban [a blood thinner], fluoxetine [for depression], memantine [for dementia], pantoprazole [for gastroesophageal reflux disease], and nitrofurantoin [an antibiotic to treat infection]. During an interview on 07/16/24 at 11:44 AM, the Director of Nursing stated, My expectation is that the nurse must find that resident and give those medications to the resident, stay and watch the resident take those medications. Staff should never have left those medications behind in the room unsecured and unattended. Review of the policy and procedure titled Medication/Biological Storage issued 4/1/2022, last reviewed 1/25/2024 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure: 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. 106003 Page 7 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure foods were prepared under sanitary conditions and failed to ensure food temperatures were documented to be at safe levels prior to meal service to residents. Findings include: An initial tour of the facility kitchen was completed on 7/14/2024 beginning at 9:16 AM. There was a black discoloration on the ceiling surrounding the large air conditioning vent above a food preparation area. There was a black discoloration on the large ceiling vent above the same food preparation area. There were uncovered peeled bananas on the counter underneath the discolored ceiling and ceiling vent. During a follow-up tour of the kitchen on 7/17/2024 beginning at 8:36 AM, there was a black discoloration on the ceiling surrounding the large air conditioning vent above a food preparation area. There was black discoloration on the large ceiling vent above the same food preparation area. There were two large baking sheets of uncovered raw chicken pieces on the counter underneath the discolored ceiling and ceiling vent. During an interview on 7/17/2024 beginning at 8:29 AM, the Dietary Manager acknowledged the ceiling area surrounding the ceiling and the ceiling vent above the food preparation area was dirty and needed to be cleaned. Review of the facility policy and procedure titled Kitchen Sanitation, last reviewed 1/25/2024, read, It is the policy of the facility that the food service area and equipment shall be maintained in a clean and sanitary manner. During a follow-up tour of the kitchen on 7/17/2024 beginning at 8:36 AM, kitchen staff were observed placing breakfast foods on plates for service to residents. Review of the food temperature log dated 7/17/2024 for the morning meal on 7/17/2024 at 8:36 AM, failed to reveal documentation food temperatures had been taken of the morning meal menu items before the meal was served to residents. During an interview on 7/17/2024 beginning at 8:29 AM, the Dietary Manager acknowledged there was no documentation that temperatures of the morning meal menu items had been taken before serving the meal to residents. She stated morning meal service had started at 7:30 AM. Review of the policy and procedure titled Final Cooking Temperatures, last reviewed 1/25/2024, read, Food is to be cooked to specified temperatures and times to mitigate the presence of dangerous microorganisms. Review of the policy and procedures titled Food Temperatures, last reviewed 1/25/2024, read, Foods will be maintained at proper temperature to insure food safety. 3. The cook is responsible to see that all food is at the proper temperature. 4. The temperature will be taken and recorded for all items at all meals. Record temperatures on extended menus. 106003 Page 8 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review the facility failed to ensure the accuracy of medical records when errors were identified by licensed nursing staff for medication administration for 1 of 5 residents, Resident #491 and failed to ensure accurate and complete records for 1 of 2 residents, Resident #49, reviewed for hospitalizations. Findings include: 1. During an observation on 07/14/24 at 1:00 PM, there was a medication cup on Resident #491's bed containing seven pills, one green/white capsule, two white tablets, two pink tablets and two yellow tablets. The resident's bed was made, and the resident was not in the room. The resident's roommate was in the room in bed, with two family members visiting. The unsecured medication was in plain sight of the open doorway, where staff, residents and visitors were observed in the hallway. During an observation on 7/14/24 at 1:19 PM, the unsecured medications continued to be observed on Residents #491's bed. Resident #491 was not in the room. During an observation on 7/14/24 at approximately 1:45 PM of Resident 491's room with Staff E, LPN, she confirmed the medications in the medication cup were on Resident #491's bed and were unattended. During an interview on 7/14/24 at approximately 1:45 PM Staff E, LPN stated, These were from 10:30 AM this morning. I brought them into [Resident 491's room] and she [Resident #491] wasn't here, but then I got distracted by the roommate and the roommate's family, and then I forgot the medications in the room. Staff E identified the medications as lisinopril [for elevated blood pressure], diltiazem [for elevated blood pressure], apixaban [a blood thinner], fluoxetine [for depression], memantine [for dementia], pantoprazole [for gastroesophageal reflux disease], and nitrofurantoin [an antibiotic to treat infection]. Review of the Medication Administration Record (MAR) on 7/16/24 documented dated 7/14/24 at 9:00 AM lisinopril, diltiazem, apixaban, fluoxetine, memantine, pantoprazole, and nitrofuratoin were administered to Resident #491. Review of the nursing progress notes for 7/14/24 through 7/16/24 at 9:00 AM provided no documentation the medications for Resident #491 were destroyed, were administered late, were not administered, of notification to the physician that medications were not administered as ordered, and/or for orders to administer the medications or to hold the medications. During an interview on 07/16/24 at 03:14 PM, the Director of Nursing stated The nurse did not give the medications to the resident and did not call the doctor. During an interview on 07/17/24 at 09:41 AM the Director of Nursing stated, It is my expectation that the nurse should have called the doctor and family when the medications were not given. The nurses must follow physicians' orders. The nurse should have told the physician the names of the medications, how late it was, and if it can be given now. She then should have charted everything that she did and put in a nurse's note because you cannot reverse what was put on the MAR. This was not done. 106003 Page 9 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy and procedure titled Medication Administration, last reviewed on 1/25/24, read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medications or refusals of medication by the resident. Procedure: 7. Medications should be administered within one (1) hour before or after their prescribed time. 12. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication will document this in the clinical record. 16. Should a resident be away from his/her room or unavailable during the medication pass, it is permissible to return during the appropriate time frame to that resident at a later time to complete the administration. 2. Review of Resident #49's progress note dated 5/8/24 read, Type: Event Note. Effective Date: 5/8/2024 15:43 [3:43 PM]. Note Text: Resident was driving her motorized chair to her room when she lost control of her chair and drove it into her bedframe causing a large laceration to her left lower extremity. Bleeding was controlled and 911 called. EMS [emergency medical services] transported Resident to [name of hospital] at 1530 [3:30 PM]. Review of the medical record for Resident #49 did not provide documentation of the transfer form to a higher level of care or for the change in condition for the event dated 5/8/2024. Review of Resident #49's progress note dated 6/5/24 read, Type: Event Note. Effective Date: 6/5/2024 18:06 [6:06 PM]. Note Text: Resident presented with a change of condition by not responding as her usual. Vitals within normal limits. O2 sat [oxygen saturation level] is 97%. Scant twitching noted systemically. Order obtained to send resident to E.R. [emergency room] for further evaluation. Called son to notify. Review of the medical record for Resident #49 did not provide documentation of the transfer form to a higher level of care or for the change in condition for the event dated 6/5/2024. During an interview on 7/16/24 at 2:50 PM the Director of Nursing stated, [Resident #49's name] went out to the hospital on 5/8/24 due to an accident in her wheelchair and came back that night, on 6/5/24 because she was septic. They have their notes [progress notes] in the chart, but there aren't any transfers or change in condition forms. The expectation is that they complete transfer and change in condition forms when they send patients out [to the hospital]. 106003 Page 10 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

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 prevent the possible spread of infection by not completing sanitization of blood pressure cuffs, hand hygiene during medication administration, and hand hygiene after the delivery of personal care. Residents Affected - Some Findings include: 1. During an observation on 7/16/2024 at 09:00 AM Staff B, License Practical Nurse (LPN) retrieved the blood pressure cuff from the top of the medication cart and obtained a blood pressure reading for Residents #55. Staff B, LPN returned to the medication cart and placed the blood pressure cuff inside the cart without cleaning/sanitizing the cuff. During an interview on 7/16/2024 at 09:17 AM Staff B, LPN stated, Blood pressure cuffs are to be wiped after each use with Clorox wipes. I should have cleaned the blood pressure cuff after using it. 2. During an observation on 7/16/2024 at 09:25 AM Staff D, Registered Nurse (RN) exited the nutrition room and initiated medication administration for Resident #103. Staff D pulled the wrong medication, then destroyed the wrong medication in a drug buster, opened the bottom drawer of the medication cart, and secured the drug buster. Staff D, RN did not perform hand hygiene and proceeded with preparing the correct medications for Resident #103. Staff D went to administer the medications to Resident #103, Staff D did not perform hand hygiene and attempted to administer the medications. Resident #103 refused to take the medications. Staff D did not perform hand hygiene, exited Resident #103's room, returned to the medication cart and destroyed the medications, did not perform hand hygiene, and proceeded to prepare medications for Resident #122. Staff D did not perform hand hygiene and administered the medications to Resident #122. Staff D did not perform hand hygiene, exited the resident's room, returned to the medication cart, did not perform hand hygiene, and proceeded to prepare medications for Resident #62. Staff D removed the medications from their containers, put them in a bag and crushed the medications for Resident #62. Staff D did not perform hand hygiene and administered the medications to Resident #62. Staff D did not perform hand hygiene, exited Resident #62's room and returned to the medication cart. During an interview on 7/16/2024 at 10:20 AM Staff D, RN stated I did not do hand hygiene and I should before and after medication preparation and administration. During an interview on 7/16/2024 at 12:50 PM the Director of Nursing (DON) stated, The expectation is for hand hygiene to be completed before and after contact with each patient and before and after medication preparation and administration for each resident. The blood pressure cuffs are to be cleaned before and after each resident use. 3. During an observation on 07/15/24 at 01:50 PM, Staff G, CNA (Certified Nursing Assistant) was observed coming into the doorway of a resident's room holding a soiled brief, with gloves on. She stood in the doorway and spoke with a visitor from another room, and then placed the brief in a trash bag. While wearing the same gloves, Staff G assisted Resident #48 into a wheelchair, she then picked up the resident's hairbrush, brushed the resident's hair and wheeled him out of the room. During an interview on 07/15/24 at 2:10 PM, Staff G, CNA stated, I didn't wash my hands after peri-care. I usually do, if I have time. 106003 Page 11 of 12 106003 07/17/2024 Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue Lady Lake, FL 32159

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 07/15/24 at 02:55 PM, the Director of Nursing stated, I expect my staff to remove their gloves and wash their hands after providing patient care. Review of the policy and procedure titled Hand Hygiene dated 1/25/2024 read, This facility considers hand hygiene the primary means to prevent the spread of infections. 5. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; i. After contact with resident's intact skin. 106003 Page 12 of 12