Health inspection·October 4, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 of 4 residents reviewed for skin conditions, Resident #3. Residents Affected - Few Findings include: During an observation on 10/1/2024 at 9:09 AM, Resident #3 was lying in bed. Resident #3's left arm had bruising and scabbed skin tears. During an interview on 10/1/2024 at 1:20 PM, Staff B, Wound Care Licensed Practical Nurse (LPN), stated, [Resident #3's name] will get skin tears once a week. If she bumps against something her skin will open up and she will have a skin tear. Review of Resident #3's Weekly Skin Check/Nurse dated 9/2/2024 read, Description: Wound to left upper arm. Wound to left knee. Bruising to BUE [Bilateral Upper Extremities] and to BLE [Bilateral Lower Extremities]. Dry scabs to left hand and to bilateral feet/toes. Review of Resident #3's Wound Evaluation dated 9/17/2024 read, Site: Lt [Left] forearm. Type: Skin Tear . Describe Percentage of tissue type present in each wound: epithelial, granulation, slough, eschar. 3a. Wound #1: Epithelialized and resolved. Review of Resident #3's Wound Evaluation dated 9/23/2024 read, Site: Rt [Right] lateral knee. Type: Skin Tear . Describe Percentage of tissue type present in each wound: epithelial, granulation, slough, eschar. 3a. Wound #1: 15% granulation, 85% intact normal skin. Review of Resident #3's care plan did not document a focus for skin integrity. During an interview on 10/2/2024 at 1:50 PM, Staff C, MDS and Care Plan Coordinator, stated, [Resident #3's name] is not care planned for skin integrity and she needs it for potential skin integrity. Review of the facility policy and procedure titled Comprehensive Assessment and Care Plans with the last review date of 8/7/2024 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS [Centers for Medicare and Medicaid Services] . Guidelines . 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c) (2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, Page 1 of 7 106046 106046 10/04/2024 Terrace Healthcare & Rehabilitation Center 7207 SW 24th Ave Gainesville, FL 32608

F 0656 nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106046 Page 2 of 7 106046 10/04/2024 Terrace Healthcare & Rehabilitation Center 7207 SW 24th Ave Gainesville, FL 32608

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 Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care according to standard of practice for 1 of 4 residents reviewed for skin condition, Resident #374, and for 1 of 3 residents reviewed for pain management, Resident #116. Residents Affected - Few Findings include: 1) During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/1/2024 at 9:46 AM, Resident #374 stated, I do not know what happened to my leg. It probably happened while I was sleeping. During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room. There was a bandage dated 9/27 on his left shin. The DON removed the bandage and observed a small open area on the resident's left shin. Review of Resident #374's physician order dated 9/27/2024 read, Clean area, apply Xeroform and Zinc to skin tear on left shin one time a day for skin tear. During an interview on 10/2/2024 at 1:31 PM, the DON stated, I expect nursing staff to follow the physician orders and do wound care according to those orders. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Procedure . 6. Wound care procedures and treatment should be performed according to physician orders. 2) Review of Resident #116's physician order dated 9/19/2024 read, Oxycodone HCl oral tablet 5 mg [milligram] (oxycodone HCl), Give 2 tablets by mouth every 4 hours as needed for severe 7-10/10) pain, non acute. Review of Resident #116's Medication Administration Record (MAR) for September 2024 for Oxycodone 5 mg showed the resident received the medication on 9/23/2024 at 6:57 AM for pain level of 5, on 9/24/2024 at 2:32 AM and at 6:38 AM for pain level of 5, and on 9/25/2024 at 9:26 AM for pain level of 6. During an interview on 10/2/2024 at 1:33 PM, the DON stated, It was a new nurse, and she was not following physician orders. The medication was given out of parameters. I expect nurses to look at the orders and follow them. Review of the facility policy and procedure titled Medication Administration with the last review 106046 Page 3 of 7 106046 10/04/2024 Terrace Healthcare & Rehabilitation Center 7207 SW 24th Ave Gainesville, FL 32608

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few date of 8/7/2024 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 medication or refusals of medications by the resident. Review of the facility policy and procedure titled Pain Screening and Management with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to screen residents and attempt to provide effective pain and comfort management. Procedure . 4. Administer pain medications according to physician's orders and resident request for PRN [as needed] medications. 106046 Page 4 of 7 106046 10/04/2024 Terrace Healthcare & Rehabilitation Center 7207 SW 24th Ave Gainesville, FL 32608

F 0842 Level of Harm - Minimal harm or potential for actual harm 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 resident records were complete and accurate for 1 of 4 residents reviewed for skin conditions, Resident #374. Residents Affected - Few Findings include: During an observation on 10/1/2024 at 9:46 AM, Resident #374 was sitting at the edge of his bed. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an observation on 10/2/2024 at 8:12 AM, Resident #374 was sitting at the edge of his bed with breakfast tray in front of him. There was a bandage dated 9/27 on his left shin (Photographic evidence obtained). During an interview on 10/2/2024 at 8:12 AM, Resident #374 stated, No one has come to change my bandage. During an observation on 10/2/2024 at 1:30 PM with the Director of Nursing (DON), Resident #374 was sitting in his wheelchair in his room. There was a bandage dated 9/27 on his left shin. The DON removed the bandage and observed a small open area on the resident's left shin. Review of Resident #374's physician order dated 9/27/2024 read, Clean area, apply Xeroform and Zinc to skin tear on left shin one time a day for skin tear. Review of Resident #374's Treatment Administration Record (TAR) for September 2024 showed the resident received wound care on his left shin on 9/28/2024, 9/29/2024, and 9/30/2024 at 6:00 PM. Review of Resident #374's TAR for October 2024 showed the resident received wound care on his left shin on 10/1/2024 at 6:00 PM. During an interview on 10/2/2024 at 1:31 PM, the Director of Nursing stated, Nursing were documenting as performing wound care when they had not done the wound care. The documentation was not accurate. Nurses are expected to only sign off on orders when they have done the wound care. I expect nurses to have accurate documentation. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Procedure . 6. Wound care procedures and treatment should be performed according to physician orders . 10. Document in the clinical record when treatments are performed. 106046 Page 5 of 7 106046 10/04/2024 Terrace Healthcare & Rehabilitation Center 7207 SW 24th Ave Gainesville, FL 32608

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 performed hand hygiene while providing wound care according to the practice standard for 1 of 4 residents reviewed for skin conditions, Resident #76, and failed to ensure staff used appropriate personal protective equipment (PPE) while providing high-contact care for 1 of 6 residents reviewed, Resident #274, to prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: 1) During an observation on 10/2/2024 at 1:20 PM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, was inside Resident #274's room adjusting the IV (intravenous) tubing and turning the IV pump off. Staff A did not have gloves or gown on. There was a signage on the resident's room that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. Review of Resident #274's physician order dated 10/2/2024 read, Enhanced barrier precautions related to L [left] arm picc [Peripherally Inserted Central Catheter]. During an interview on 10/3/2024 at 1:02 PM, the Infection Preventionist sated, Staff should have donned a gown when going into the resident room if she was going to be handling the IV tubing. Enhance barrier is a constant battle, we keep educating. During an interview on 10/3/2024 at 1:25 PM, Staff A, LPN, Unit Manager, stated, I should have donned a gown before entering [Resident #274' name] room but the IV pump had been beeping for some time and I went in quickly. 2) During an observation on 10/3/2024 at 11:30 AM, Staff B, Wound Care Licensed Practical Nurse (LPN), performed hand hygiene before entering Resident #76's room. Staff B donned a pair of gloves and removed dressing from Resident #76's buttock area. Without changing her gloves or performing hand hygiene, Staff B cleaned Resident #76's wound. Staff B removed her gloves and donned a glove on her right hand without performing hand hygiene. A therapy staff member knocked and stated she needed to take Resident #76's roommate to therapy and Staff B, with her left hand which did not have a glove, pulled Resident #76's curtain to provide privacy while the therapy staff member removed the roommate from the room. Staff B proceeded to apply hand sanitizer to her left hand and donned the other glove she was holding with her right hand. Staff B applied the treatment and applied the new wound care dressing. Staff B removed her gown and gloves and washed her hands. During an interview on 10/3/2024 at 11:40 AM, Staff B, Wound Care LPN, stated, I did hand hygiene outside by the cart when we were first coming in. I do not like using the hand sanitizer in the room. I like using my own. If I removed my gloves making sure not to touch anything and keep sterility, then I can don a new pair of gloves and do not need to hand sanitize. During an interview on 10/3/2024 at 1:20 PM, the Infection Preventionist sated, Staff should have performed hand hygiene after removing the old dressing and before cleaning the wound. After removing a pair of gloves, staff should preform hand hygiene before donning a new pair of gloves. 106046 Page 6 of 7 106046 10/04/2024 Terrace Healthcare & Rehabilitation Center 7207 SW 24th Ave Gainesville, FL 32608

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/4/2024 at 8:12 AM, the Director of Nursing (DON) stated, While the nurse is dirty, she does not have to remove her gloves. While she is dirty, she is dirty, and while she is clean, she is clean. The staff did not need to change her gloves after removing the old dressing before cleaning the wound because she is in her dirty filed. The staff should sanitize her hands after removing gloves and before donning new pair of gloves. The staff should don gloves and a gown if she will be in contact with the IV tubing of a resident. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 8/7/2024 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 5. Use an alcohol-based hand rub containing 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc. k. After handling used dressing, contaminated equipment, etc. m. After removing gloves. Review of the facility policy and procedure titled Wound Care with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure . 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 8/7/2024 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact care activities that have been found to increase risk for transmission of multidrug-resident organism. Procedure . 4. For residents for whom EBP are indicated, EBP is employed when performing the following High-contact resident care activities . g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. 106046 Page 7 of 7