Health inspection·June 9, 2022

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the services provided for gastrojejunostomy tube care met professional standards of quality to 1 of 5 residents with gastrostomy tube, Resident #26, in a total sample of 25 residents. Residents Affected - Few Findings include: During an observation on 6/7/2022 beginning at 9:50 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #26's room. Staff A explained that she would be giving his morning medications through his gastrojejunostomy tube (GJ tube). Staff A sanitized her hands and prepared to pull the resident's medications from the medication cart. Staff A placed the medications into the individual medication cup. Staff A crushed all the pills individually. Staff A entered the resident's room and placed all medications on a bedside table. Staff A donned a pair of gloves and opened a new feeding syringe. Staff A checked the resident's identification. Staff A exposed the resident's abdomen to visualize his GJ tube. Staff A immediately flushed the GJ tube with 15 milliliter (ml) water. Staff A did not check for tube placement, did not do visual check for tube placement, and did not check for gastric residual prior to flushing the GJ tube with 15 ml water. Staff A proceeded to administer all the medications separately with 10 ml of water. Staff A flushed the GJ tube after each medication administration. Staff A made a final flush with 60 ml of water. Staff A cleaned the bedside table, washed her hands in the bathroom sink, then exited the resident's room at 10:12 AM. During an interview with Staff A, LPN, on 6/7/2022 at 10:13 AM, when asked why she did not check for tube placement, Staff A stated, Our DON [Director of Nursing] told us that we no longer need to check for tube placement. We only check for residuals. DON stated that we are injecting too much air to the tube. Sorry, I forgot to check for residual. During an interview with the DON on 6/7/2022 at 3:10 PM, when asked what the policy on medication administration via GJ tube is, the DON stated, The latest best practice in literature is that we do not put in air any longer, but nurse is supposed to check for residual, do visual check of the tube for placement, and if suspicious, we get an order for x/ray. Review of the facility policy and procedure titled Medication Administration via Enteral Tube with a revision date of 1/25/2022 reads, Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . 9. Procedure: . h. Check that tube is in place. Check external tube and if suspected of dislodgement, notify doctor to get x/ray. I. Check residual per physicians' order. Page 1 of 3 106066 106066 06/09/2022 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN 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 maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during wound dressing change for Resident #33, and during medication administration for Resident #31, in a total sample of 25 residents. Residents Affected - Few Findings include: 1. During an observation on 6/8/2022 at 8:42 AM, Staff B, Licensed Practical Nurse (LPN), was preparing to administer the morning medications for Resident #31. Staff B entered Resident #31's room with his medications and a portable/ wrist blood pressure (BP) apparatus that was on top of her medication cart. Staff B did not sanitize the blood pressure apparatus before she entered the resident's room. Staff B immediately applied the BP apparatus on Resident #31's right wrist and obtained a blood pressure reading of 115/84. Staff B administered the scheduled medications, then exited the room at 8:51 AM. Staff B did not sanitize or disinfect the BP apparatus after use and placed the apparatus back on to the medication cart. During an interview with Staff B, LPN, on 6/9/2022 at 10:05 AM in the presence of the Director of Nursing (DON), when asked what the process was to care for equipment for multiple resident use, Staff B stated, Like a blood pressure cuff, we sanitize them before and after use with a sanitizer wipe, leave for 2 minutes to dry. I have sanitizer wipes in my medication cart. When asked why she failed to sanitize the Blood Pressure cuff, Staff B replied, I was so nervous. Review of the facility policy and procedures titled Cleaning and Disinfection of Residents-Care Equipment reviewed on 1/25/2022, reads, 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. Staff shall follow established infection control principles for cleaning and disinfecting reusable equipment. General guidelines include: . d. Multiple-resident use equipment shall be cleaned and disinfected after each use. e. Most equipment may be cleaned/ disinfected in the areas in which the equipment is used. 2. During an observation on 6/8/2022 at 11:25 AM, Staff C, LPN, accompanied with Staff D, Registered Nurse (RN), entered Resident #33's room to change wound dressing change. All wound dressing supplies were on a paper barrier over bedside table. Staff C washed her hands and donned a pair of gloves. Staff C exposed the resident's left foot, used a sanitized scissors to cut old dressing dated 6/6/2022. The left heel had an open wound approximately 10 centimeter in diameter. The wound was macerated, no drainage, surrounding tissue was pink. Staff C replaced gloves and washed hands in sink. Staff C cleansed the wound with normal saline. Staff C did not replace the gloves after cleansing the wound. Staff C immediately applied a dime size Bacitracin on the wound, then applied betadine in a 4 x 4 gauze, used a Kerlix roll and wrapped the left heel. Staff C dated the dressing. During an interview with Staff D, RN, on 6/9/2022 at 10:40 AM, confirmed that Staff C failed to wash her hands and change gloves before applying the ointment (Bacitracin). Staff D stated, She was very nervous. Review of the facility policy and procedures titled Wound Treatment with a revision date of 106066 Page 2 of 3 106066 06/09/2022 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/25/2022 reads, Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Review of the facility's Hand Hygiene Table showed hand hygiene with either soap and water or alcohol based hand rub before applying and after removing personal protective equipment (PPE), including gloves; before and after handling clean or soiled dressings, linen, etc.; and after handling items potentially contaminated with blood, body fluids, secretions, or excretions. 106066 Page 3 of 3