Health inspection·June 29, 2023

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, medical record review, and policy and procedure review, the facility failed to assist with making podiatry appointments and ensuring appropriate foot care was provided for one (Resident #36) of 27 sampled residents. Failure to provide appropriate foot care can result in ingrown toenails, fungal infections, skin infections, and can potentially impact the resident's dignity and sense of self-worth. Residents Affected - Few The findings include: During an interview with Resident #36 on 06/26/2023 at 1:20 PM, his toenails were observed to be untrimmed with dark matter growing under the nail on both large toes. He stated, They used to cut them, but it hasn't been done in a while. He stated he would like to have them cut. He explained that he had suffered a stroke and could not walk anymore. He had muscle wasting in his legs, and his feet were turned inward toward one another. During an interview with Resident #36 on 06/27/2023 at 5:20 PM, his toenails were not trimmed as was observed on 06/26/2023 at 1:20 PM. He again stated they needed to be trimmed. During an interview with Resident #36 on 06/28/2023 at 2:20 PM his toenails were not trimmed was was observed on 06/26/2023 and 06/27/2023 at 1:20 PM and 5:20 PM respectively. He again stated they need to be trimmed. During an interview with Resident #36 on 06/29/2023 at 12:33 PM he stated he still needed his toenails trimmed. He cut his own fingernails and could still do that. I can't reach my toenails or else I could probably do it myself. During an interview with Resident #36 on 06/29/2023 at 3:08 PM, he was asked how long it had been since his toenails were trimmed. He stated he could not remember exactly when he last had them trimmed. A man used to come and cut my toenails, but then he started using a sanding machine to file them down and my legs would shake all over. It was painful. He again stated he needed to have his toenails trimmed but did not know why the man stopped coming. (Photographic evidence obtained) A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 04/29/2023, revealed the resident was assessed as having diagnoses including type II diabetes mellitus, hemiplegia or hemiparesis, rash and other nonspecific skin eruption, localized edema, muscle weakness, and cerebrovascular disease. He was usually understood by others, usually understood others, had clear speech, adequate hearing and vision. His Brief Interview for Mental Status (BIMS) score was 15 out of a possible 15 points, indicating no cognitive impairment. The resident did not walk during the assessment period and required extensive assistance of one staff member for personal hygiene. (Copy obtained) Page 1 of 4 106065 106065 06/29/2023 Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the resident's care plan, dated 11/30/2021, revealed a focus area for Assistance with Activities of Daily Living (ADL)/Self-Care Performance Deficit related to cerebrovascular accident (CVA - stroke) with right-sided hemiplegia (Severe or complete loss of strength or paralysis on one side of the body). Resident currently requires assistance with activities of daily living. (Copy obtained) A review of the resident's physician's orders revealed an active order for ophthalmology, podiatry, and dental services as needed with a start date of 10/21/2020. (Photographic evidence obtained) A review of the contracted podiatry provider evaluation note, dated 04/03/2023, revealed that the resident was seen on 04/03/2023. The note read: Without debridement and treatment of mycotic nails, further complication and marked limitation of ambulation/or a secondary infection is likely to occur. Patient to be seen: 2 months. (Copy obtained) During an interview with the Director of Nursing (DON) on 06/29/2023 at 11:00 AM, he stated he was unaware that Resident #36 needed to be on the list for the contracted podiatry provider to have his toenails trimmed. He explained that the staff member who was responsible for scheduling appointments for the contracted podiatry provider was recently terminated from employment. The DON assumed that role in the interim until the facility could get someone hired to fill that position permanently. He stated he would look to see when the resident was last seen. During a second interview with the DON on 06/29/2023 at 2:33 PM, he provided the documentation from the contracted podiatry provider and stated the last time Resident #36 was seen by the provider was on 04/03/2023. He confirmed that Resident #36 was a diabetic and foot care was important. He confirmed that the facility nursing staff did not trim the toenails of the diabetic residents. That was why they contracted with the podiatry provider. He confirmed that Resident #36 needed to have his toenails trimmed and he should have been seen by June 3, 2023, which was two months after his last appointment. A review of the facility's policy and procedure for Foot Care (dated 01/15/2021), revealed: Standard: It will be the standard of this facility to ensure that residents receive proper treatment and care to maintain mobility and good foot health. 2. Provide foot care and treatments as needed/ordered by the physician. 3. Staff will monitor the resident for changes in foot condition and notify the nurse and/or physician as is appropriate. 5. If necessary, staff will assist the resident in making appointments with a qualified person, such as the podiatrist, and arrange for transportation to and from such appointments. (Copy obtained) . 106065 Page 2 of 4 106065 06/29/2023 Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain appropriate infection control practices during medication administration for two (Residents #51 and #15) of five residents observed during medication administration from a total of 27 residents in the sample. Failure to adhere to infection control and prevention protocol increases the risk of transmitting communicable diseases and infection. Residents Affected - Few The findings include: During a medication administration observation on 6/27/23 at 4:32 p.m., Licensed Practical Nurse (LPN) A was observed outside of room [ROOM NUMBER]. She reviewed the Medication Administration Record (MAR) for Resident #51. She performed hand hygiene with hand sanitizer. She then obtained a lancet and an alcohol wipe. She proceeded to the resident's room and obtained a glucometer and glucose monitoring test strips that were stored in the drawer inside the resident's room. She removed the glucometer and a container of test strips from the zip lock bag. She removed one test trip from the container and inserted it in the glucometer. She then placed the glucometer on the resident's bed. LPN A did not don gloves but proceeded to clean the resident's left middle finger with an alcohol wipe. She obtained a blood sample, holding the lancet with her bare hand. After obtaining the sample, she used the soiled alcohol wipe that was used for cleaning the resident's finger prior to the procedure, to clean the resident's finger after the procedure. LPN A then went to the medication cart, removed a sani-wipe (disinfectant wipe) from the bottom drawer and cleaned the glucometer. She placed it on the resident's bedside table, which had not been cleaned, and left it to air dry. She washed her hands in the resident's bathroom, reviewed the MAR for the insulin sliding scale, and obtained the insulin pen for Resident #51. She did not don gloves. She injected four units of Novolog insulin in Resident #51's left lower abdomen. She performed hand hygiene with hand sanitizer. She did not don gloves. She obtained artificial tears for Resident #51 and instilled one drop on each eye. She documented both medications as given, then performed hand hygiene. During another observation on 6/27/23 at 4:32 p.m., LPN A was observed preparing medication for Resident #15. She crushed the medication and mixed it with apple sauce. Upon entering the resident's room, she donned gloves then called another staff member to help her adjust the resident in the bed. After adjusting the resident in bed, she used the same gloved hand to administer the medication in the resident's mouth. In an interview on 6/27/30 at 4:58 p.m., LPN A was asked to evaluate herself. She said, I think I did good and followed all the steps I was taught in school. She was asked to explain the process for using the Accucheck device (blood glucose monitor). She explained the process the same way she had performed the task. When asked if she was supposed to use a barrier or don gloves during the process, she hesitated, then said, but I performed hand hygiene. LPN A could not correctly state the proper way to use the Accucheck device, and could not identify that she should have donned gloves for the task. She was asked if she was familiar with the facility's policy and procedure for this task, and she stated she was not sure, then added that she would consult the Director of Nursing (DON). On 6/28/23 at 11:30 a.m., the DON was asked to describe the facility's process for medication administration competencies. He stated the competencies were conducted upon hire and annually. He was informed of the observation made during medication administration. He confirmed that there was a breach in infection control standards and added that education and competencies had already been initiated 106065 Page 3 of 4 106065 06/29/2023 Isle Healthcare & Rehabilitation Center 1125 Fleming Plantation Blvd Orange Park, FL 32003

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and they would be provided to all nurses. When he was asked about the glucose monitoring/Accucheck policy and procedure, he stated the facility did not have a specific procedure for glucose monitoring. The facility utilized the medication administration and infection control policies. A review of the facility's policy and procedure titled Medication Administration (Revised on 1/01/2021), revealed guidelines that must be followed during medication administration. The guidelines included, but were not limited to the following: Follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.). The facility's Infection Prevention and Control Program policy (revised 01/01/2021) read, The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infection. Guidelines indicated that standards and transmission based precautions were to be followed to prevent the spread of infections (selection and use of PPE). Hand hygiene guidelines were to be followed by staff involved in direct resident contact. According to the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html. (Accessed on 07/05/2023): Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings include but is not limited to: Wearing gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids; Changing gloves between patient contacts. Changing gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other persons (CDC, 2011). . 106065 Page 4 of 4