Health inspection·October 19, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the comprehensive care plan for 2 (#99 and #107) of 29 residents reviewed for Advance Directives. Advance Directives includes code status, whether the resident wants Cardiopulmonary Resuscitation (CPR) or does not, Do Not Resuscitate (DNR). The findings included: The facility's policy and procedure titled, Comprehensive Care Plans and Revisions with a reviewed date of [DATE] noted the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery. The facility's policy and procedure titled, Advance Directives and Advance Care Planning with a reviewed date of [DATE] noted the DNR order is incorporated into the resident's care plan and is periodically reviewed, at least quarterly. 1. Clinical record review for Resident #99 revealed an admission date of [DATE]. The clinical record included a physician's determination of incapacity statement dated [DATE] which noted Resident #99 no longer had the capacity to make knowing health care decisions for herself or provide consent after sufficient explanation without coercion or undue influence. The clinical record included a yellow State of Florida Do Not Resuscitate order form signed and dated by the physician on [DATE] directing the withholding or withdrawing of cardiopulmonary resuscitation from the resident in the event of cardiac or respiratory arrest. The physician's order summary report noted a Do Not Resuscitate Order dated [DATE]. Review of the Social Services assessment dated [DATE] revealed Resident #99 was a DNR. The care plan initiated on [DATE] with a revised goal of [DATE] was not updated to reflect the resident's Do Not Resuscitate status. The care plan noted the resident chose to receive CPR (Cardiopulmonary resuscitation) if her heart should stop or if she should stop breathing and remain a full code. On [DATE] at 9:45 a.m., during an interview Resident #99's daughter said she has the power of attorney and confirmed Resident #99 was a DNR. Page 1 of 10 106057 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0657 2. Review of the clinical record for Resident #107 revealed an admission date to the facility of [DATE]. Level of Harm - Minimal harm or potential for actual harm The clinical record included a physician's determination of incapacity statement dated [DATE] which noted Resident #107 no longer had the capacity to make knowing health care decisions for herself or provide consent after sufficient explanation without coercion or undue influence. Residents Affected - Few Review of the Social Services assessment dated [DATE] revealed Resident #107 was a full code. Review of the physician's orders revealed an order for DNR on [DATE]. Review of the medical record revealed a State of Florida DNR order dated [DATE]. Review of the care plans last revised on [DATE] noted due to Resident #107's cognitive deficit, education was provided to her spouse, and he requested for the resident to remain full code. On [DATE] at 4:16 p.m., Resident #107's spouse said the resident was a DNR. On [DATE] at 10:28 a.m., the Social Services Director (SSD) said she was responsible to revise the care plan whenever there is a code status change. She said the care plan should reflect the wishes of the resident and/or responsible person and should match the physician's orders and the State of Florida DNR form. The SSD provided documentation of an audit completed on [DATE] which noted Resident #99 and #107's code status as DNR. The SSD verified the care plan for Residents #99 and #107 were not updated to reflect the change in code status. 106057 Page 2 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility policy Indwelling Urinary Catheter (Foley) Management (revised 6/37/23) documented Based on comprehensive assessment of a resident the facility must ensure that residents receive treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices. Maintain unobstructed urine flow. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. On 10/16/23 at 3:17 p.m., a male staff member was observed assisting Resident #336 to her room in in a wheelchair. The bottom of the urinary catheter drainage bag was dragging on the floor. Registered Nurse (RN) Unit Manager Staff I observed the drainage bag dragging on the floor and called out to the other staff member, the bag is on the floor. The staff escorting the resident stopped, looked at the catheter drainage bag for a second and continued to push the resident in the wheelchair. On 10/16/23 at 3:46 p.m., Resident #336 was observed sitting in her wheelchair in her room. The catheter drainage bag and tubing were observed touching the floor. Photographic evidence obtained. On 10/17/23 at 8:47 a.m., Resident #336 was out of bed sitting in her wheelchair. The catheter drainage bag was on the floor. Resident #336 said she did not know why she had the catheter, they put it in when I was in the hospital. I really don't know why. Photographic evidence obtained. On 10/17/23 at 9:00 a.m., RN Staff J was observed in the hallway of the unit at the medication cart. RN Staff J was notified Resident #336's catheter drainage bag was on the floor. Staff J said ok and did not go to the room to address the concern. On 10/18/23 at 9:38 a.m., Resident #336 was observed in her room, sitting in her wheelchair. The catheter drainage bag was on the floor. RN Staff I was notified and said, I know. I told therapy when I saw it dragging the other day that it has to be off the floor. All the staff know that. I went over it with them. RN Staff I entered the resident's room with the certified nursing assistant and said, the bag needs to be off the floor, we will take care of it. Based on observations, interviews, and record review, the facility failed to ensure infection control practices were followed for 2 (Residents #107 and #336) of 2 residents reviewed with urinary catheters. The findings included: Review of the facility's Indwelling Urinary Catheter Management Policy reviewed on 8/24/23 indicated the facility will ensure residents admitted with a urinary catheter or determined to need a urinary catheter for a medical indication, will have the following areas addressed: 106057 Page 3 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ongoing care (will) adhere to professional standards of practice and infection prevention and control procedures . Do not rest the bag on the floor. 1. Review of Resident #107's clinical record revealed an admission date of 7/19/21, with diagnoses including urine retention. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed use of an indwelling catheter (Catheter inserted in the bladder to drain urine). Review of the care plans revealed Resident #107 had a history of and is at risk for Urinary Tract Infections (UTIs) due to indwelling catheter: readmitted on [DATE] with sepsis/UTI; on 4/17/23 on antibiotic for 10 days; on 6/17/23 on antibiotic for 7 days; on 9/19/23 on antibiotic for 10 days for UTI. On 10/16/23 at 11:26 a.m., observed Resident #107 in her room, sitting in the wheelchair, eyes closed. The resident's urinary catheter drainage bag was hanging from the wheelchair and resting on the floor. On 10/16/23 at 2:56 p.m., Resident #107's urinary catheter drainage bag was hanging from the wheelchair and resting on the floor. On 10/18/23 at 9:09 a.m., Certified Nursing Assistant (CNA) Staff Q said the urinary catheter drainage bag should never touch the floor. Staff Q said bacteria on the floor can travel up the tubing and give the resident a urinary tract infection (UTI). On 10/18/23 at 3:55 p.m., observed catheter care for Resident #107 with CNA staff P. The Staff Developer, the person responsible for ensuring all CNAs meet criteria for skill competency, was present to hold the resident's legs. Staff P wiped the catheter tubing from an area farther away from the resident back up towards the resident's urinary meatus four times. Staff P then applied a clean incontinent brief for the resident. She did not remove her gloves or wash her hands after catheter care, before, or after applying the clean incontinent brief. Staff P fixed the resident's blanket and handled the call bell. Staff P picked up the wash basin, went to the bathroom to discard the dirty water. Staff P stored the wash basin directly on the floor under the sink. Staff P exited the bathroom, removed gloves and gown. Staff P did not sanitize or wash her hands after removing the gloves. Staff P went back to the resident's bathroom, picked up the resident's body wash, squirted the body wash into her hand, and washed her hands. On 10/18/23 at 4:20 p.m., the Staff Developer acknowledged the infection control breaches by Staff P during the observation which included, wiping the catheter tubing back up to the resident's meatus, not removing gloves and using hand sanitizer before applying the brief, placing the wash basin on the floor, and using the resident's body wash with dirty hands. On 10/19/23 at 8:45 a.m., during a telephone interview, staff P said the facility did not provide catheter care training. Review of Staff P's skills competency for indwelling urinary catheter care conducted by the Staff Developer on 8/16/23 revealed Staff P verbalized catheter care management but had no competency 106057 Page 4 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0690 Level of Harm - Minimal harm or potential for actual harm demonstrating urinary catheter care. There was no other documented catheter care training or competency from 8/16/23 through 10/19/23. On 10/19/23 at 9:27 a.m., the Staff Developer verified the lack of return demonstration to ensure competency in catheter care for Staff P. Residents Affected - Some 106057 Page 5 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. 2. Review of the clinical record for Resident #1 revealed and admission date of 6/8/21 with diagnoses including Alzheimer's disease, dementia, and muscle weakness. On 10/16/23 at 10:00 a.m., and on 10/18/23 at 11:00 a.m., Resident #1 was observed in bed with 1/2 bedrails up elevated on both sides of the bed. Resident #1 was not able to answer questions. The clinical record lacked documentation of appropriate alternatives attempted prior to installation of the bedrails. There was no documentation the risks and benefits of the bed rails were reviewed with the resident or representative, and informed consent obtained prior to installation of the bed rails. On 10/18/23 at approximately 11:05 a.m., the Unit Manager said Resident #1 received hospice services. Hospice provided the bed, and the mattress. She said she would look for documentation of appropriate alternatives used prior to installation of the bed rails, and the informed consent with documentation the risks and benefits were reviewed with the resident and/or representative. As of 10/19/23 the facility failed to provide documentation of appropriate alternatives used prior to the installation of the bed rails, the risks and benefits of the bed rails were reviewed with the resident or representative, and informed consent obtained prior to installation of the bed rails. Based on observation, record review, staff interviews and review of facility policy, the facility failed to ensure 2 (Residents #1, and #21) of 4 sampled residents with bedrails were assessed for alternative interventions prior to the use of bed rails and failed to accurately assess the continued need for the bed rails. The findings included: The facility policy, Bed Rails-Safe and Effective Use of Bed Rails, documented the facility must attempt to use appropriate alternatives prior to installing a side or bed rail . Residents will be assessed upon admission, readmission or upon initiation utilizing the Evaluation for Use of Bed Rails Assessment . If bed rails are determined to be appropriate for use with a resident a reassessment of bed rail(s) will be assessed at a minimum quarterly and potentially with a change of condition utilizing the Evaluation for Use of Bed Rails form . The facility will document alternatives to the use of bed rails and how these alternatives did not meet the resident's assessed needs prior to the utilization of bed rails . 1. Review of the clinical record revealed Resident #21 had an admission date of 12/27/21 with diagnoses including dementia, muscle weakness, cognitive communication deficit and lack of coordination. Review of the plan of care initiated 12/29/21 (revised 9/20/23) identified Resident #21 uses 1/4 bed rails to aid in mobility. The goal for the resident was bed rails will safely assist resident in repositioning and transfers. The plan of care interventions specified, Encourage resident to use bed rails to aid in repositioning and/or transfers. Provide continued patient teaching/reminders on safe use of bed rails as 106057 Page 6 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0700 Level of Harm - Minimal harm or potential for actual harm needed. Complete the Evaluation for use of Bed Rails, upon admission, readmission, quarterly, and change of condition. Review of the Quarterly Evaluation for Use of Bed rails dated 9/13/23, documented alternatives that were attempted since last review- practice with moving in bed. Residents Affected - Few Are bed rails still appropriate for resident- coded yes. The form documented Resident #21 had weakness, pain, and fear of falling out of bed. The form specified Bed rails will assist the resident in turning side to side, moving up and down in bed, pulling self from lying to sitting, improving balance, supporting self, entering/exiting the bed more safely, and transferring more safely. On 10/17/23 at 9:40 a.m., Resident #21 was observed in bed with 1/4 bed rails in the raised position on both sides of the bed. There was a long-padded device on both sides of the inner rails. The Resident was lying on a scoop mattress (a mattress with inflatable raised sides). On 10/17/23 at 3:30 p.m., in an interview the Risk Manager said the pads placed in front of the bed rails were for resident safety. If a resident was moving their extremities, they would not get hurt. On 10/18/23 at 12:09 p.m., Certified Nursing Assistant (CNA) Staff M said Resident #21 had no use of the left arm because she could not move it. Staff M said Resident #21 required total care and was not able to turn herself in bed. Staff M said the resident was not able to grab the bed rail on cue. We turn her, she can't do it. She does not walk. On 10/18/23 at 11:40 a.m., the Director of Nursing (DON) said the process for bed rails was at admission the nurse puts the bed rails down and the bed is in low position. The nurse completing the admission asks if the resident wants the bed rails to assist them with turning and positioning. Some residents have a fear of falling. If the resident wants the bed rails, then the rails are raised. If the resident does not want the rails, then maintenance comes and removes them, or the staff just leave them down. The evaluations for the bed rails are done quarterly, on admission and if a significant change had occurred. On 10/19/23 at 9:09 a.m., in an interview CNA Staff O said Resident #21 used to move around but not now, she is total care. I got her up today, she does not use the bed rail to turn, she can't. Staff O said Resident #21 rarely speaks and she does not understand. Staff O said she had to do everything for the resident. If you told her to turn or grab the bed rail, she can't. On 10/19/23 at 9:33 a.m., Registered Nurse Unit Manager Staff I, said the nurse doing an admission was responsible to do the admission bed rail evaluation but he did not know who was responsible to complete the quarterly and annual bed rail evaluation. Staff I said Resident #21 was able to move in bed and uses the bed rail to move around in bed. On 10/19/23 at 10:11 a.m., the DON said the assigned nurse does the admission, the quarterly and annual bed rail evaluations. The nurse is to assess the resident and evaluate for use of bed rails. The DON said she was unaware Resident #21 had both a scoop mattress and bed rails. On 10/19/23 at 12:10 p.m., the DON confirmed Resident #21 was not able to use the bed rails for mobility and said they were removed from the bed. 106057 Page 7 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow the menu prepared in advance for residents on oral diets. Residents Affected - Some The facility policy titled Menus, Substitutions, and Alternatives, revised on 4/25/23 stated, Menus are planned in advance and followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Residents with known dislikes of food and beverage items, who express a refusal of the food served or requires a different meal choice are offered a substitute of similar nutritive value . The residents are informed of the alternates at each meal per facility guidelines. The findings included: Observation of the posted menu for 10/17/23 revealed the lunch meal consisted of barbecue chicken, potato salad, and seasoned green beans. On 10/17/23 at 11:45 a.m., observation of tray line revealed the lunch meal consisted of Barbeque Pork, Coleslaw, Baked Beans, Pureed Beans, Pureed Mashed Potatoes and Pured bread. The Kitchen Manager said the mashed potatoes were the fortified food item for the lunch meal. He verified all residents received fortified mashed potatoes, even those without an order for fortified food. The dietary manager said, this is a problem, and we will begin education. On 10/17/23 at 11:52 a.m., the cook said, So many people get fortified mashed potatoes, that's why I didn't make the regular. On 10/17/23 at 12:20 p.m., the tray line ran out of Barbeque pork. The staff verified there was no additional pork in the kitchen or freezer. The 13 remaining residents on the 100 hall were served the alternate of a cold chicken salad sandwich with potato chips. On 10/18/23 at 8:46 a.m., Resident #64's responsible party said there had been no menus for a long time. There are people in the dining room that do not eat anything, no one asks them if they want an alternate or substitution. On 10/18/23 at 1:01 p.m., observation of the lunch meal in the dining room revealed nine residents were not given fruit cups as was specified on their meal ticket and the menu. Facility dietary aide Staff ZZ said he didn't bring the fruit cups out to them. They were not offered any substitution. On 10/18/23 at 3:01 p.m., The Kitchen Director stated there had been delivery issues. She said, We give the resident as much information as possible regarding substitutions. Today they already have the menu for tomorrow. Sometimes the residents are notified of changes, sometimes not. We do our best. The dietary manager verified the Everyday Available Menu is provided to residents on admission but is not posted in the facility. 106057 Page 8 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0803 On 10/19/23 at 9:00 a.m., Resident #63 said, I've never seen the everyday menu, that would be very nice to have choices. Level of Harm - Minimal harm or potential for actual harm On 10/19/23 at 9:02 a.m., Resident #103 said she had never seen the everyday available menu before. Residents Affected - Some On 10/19/23 at 9:05 a.m., Resident #114 said she had never seen any everyday available menu. 106057 Page 9 of 10 106057 10/19/2023 Life Care Center of Estero 3850 Williams Road Estero, FL 33928

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, review of the policies and procedures, resident and staff interview, the facility failed to obtain food preferences and provide meals according to resident's choice for 4 residents, (#42, #51, #64, #111) of 4 residents who complained about not having food choices. The findings included: The facility policy titled Nutritional Assessment, revised 4/25/23 stated a representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences are obtained, and a nutritional assessment to determine nutritional needs on admission. The facility policy titled, menus, substitutions, and Alternatives revised on 4/25/23 included Residents preferences are followed to the extent possible in order to promote food acceptance. On 10/17/23 at 10:03 a.m., Resident #111 said, The food has no taste and texture. We never get what we ask for ever. The chicken is always dry, and you only get a small portion. On 10/17/23 during the Resident Council Meeting, Resident #51 said, we complain and nothing is done. I ask for a salad at night, and I never get it. You never get what you ask for. On 10/17/23 at 12:00 p.m., Resident #42 said, There are problems with the food, we do not get what we have ordered. On 10/17/23 at 1:41p.m., The Registered Dietitian said Today, we ran out of the barbeque pork. The chicken salad was the alternate and they had enough to make the alternate sandwiches. So far, we have not have any complaints from people that got the chicken sandwich versus the pulled pork. 10/18/23 8:46 a.m., Resident #64's responsible party said during a telephone interview that there were no menus for a long time. Resident #64 would taste the food and not like it. No one asks them if they want an alternate or substitution. No one has met with us regarding preferences. No one has ever offered something else. She would have preferred the pulled pork, but they ran out. I don't understand how they could have run out of food. They frequently run out of desert. On 10/18/23 12:15 p.m., The Kitchen Manager said, Preference meetings have not occurred in all situations. The Kitchen Manager stated she would meet with the residents to obtain their preferences. 106057 Page 10 of 10