Health inspection·November 30, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record view, the facility failed to develop a person-centered care plan for 1 of 3 residents reviewed for respiratory services, Resident #43. Findings include: Review of Resident #43's physician order dated 10/17/2023 reads, Apply Oxygen @ [at] 2 liters via nasal cannula for SOB [shortness of breath] or sats <90% [saturation less than 90 percent]. Review of Resident #43's Weights and Vital Summary reads, 11/21/2023 00:56 [12:56 AM] 93% (Oxygen via Nasal Cannula) . 11/17/2023 16:01 [4:01 PM] 98% (Oxygen via Nasal Cannula) . 11/06/2023 19:45 [7:45 PM] 96% (Oxygen via Nasal Cannula) . 11/04/2023 23:30 [1:30 PM] 95% (Oxygen via Nasal Cannula). Review of Resident #43's Minimum Data Set, dated [DATE] showed the resident uses oxygen while a resident. Review of Resident #43's care plan did not reveal a focus for shortness of breath or oxygen therapy. During an interview on 11/29/2023 at 2:00 PM, the Director of Nursing stated, Our practice is to develop care plans based on residents' needs. [Resident #43's name] had a physician order and there is documentation that oxygen was administered. There should have been a focus in her care plan regarding oxygen, but I do not see one. Review of the facility policy and procedures titled Comprehensive Care Plans with the last review date of 1/30/2023 reads, Policy: It is this policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Page 1 of 5 106066 106066 11/30/2023 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accepted professional standards of practice were followed for intravenous medication administration via midline catheter for 1 of 3 residents with midline catheters, Resident #52. Residents Affected - Few Findings include: Review of Resident #52's admission record showed the resident was admitted on [DATE] with the diagnoses including sepsis, tubo-ovarian abscess (a pocket of pus due to infection of the ovary and fallopian tube), pelvic inflammatory disease, peritoneal abscess, chronic obstructive pulmonary disease, essential primary hypertension, hyperlipidemia, iron deficiency anemia, primary osteoarthritis, and presence of artificial hip joint. Review of Resident #52's physician orders dated 11/4/2023 reads, Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM (grams), Use 3.375 gm intravenously four times a day for sepsis w/o [without] acute organ dysfunction/tubo ovarian abscess until 12/07/2023 06:59 [6:59 AM], Administer every 6 hours at 10am, 4 pm, 10pm, 4 am. Review of Resident #52's physician order dated 11/4/2023 reads, Flush midline using SASH method [Saline-ABT [Antibiotic]-Saline-Heparin) with each IV [Intravenous] ABT administration, four times a day for IV ABT. During an observation of medication administration on 11/27/2023 at 11:00 AM, Staff C, Licensed Practical Nurse (LPN), assembled all supplies for intravenous antibiotic administration for Resident # 52 without performing hand hygiene. Staff C, LPN, removed the end cap of the intravenous tubing and attached the antibiotic bag to the intravenous line. Staff C removed the end cap of the intravenous tubing and attached the antibiotic bag to the intravenous line. Staff C held the uncapped end of the intravenous tubing in her left hand and cleansed the needleless hub of the midline catheter with alcohol with right hand for less than 2 seconds. Staff C did not allow the needleless hub to dry before attaching a 10-milliliter normal saline flush. Without observing the insertion site or attempting to verify for blood return, Staff C administered the normal saline and the antibiotic. During an interview on 11/27/2023 at 11:07 AM, Staff C, LPN, stated, I did not verify for blood return prior to hanging the medicine. I should have cleaned the needleless connector longer and let it dry before giving the flush or antibiotic. During an interview on 11/29/2023 at 1:00 PM, the Director of Nursing (DON) stated, Staff should attempt to verify midline placement and clean the needleless connector before giving antibiotics. They should follow our procedures. Review of the facility policy and procedures titled Intermittent infusion device flushing and locking with the last revision date of 8/21/2023 reads, Introduction: An intermittent infusion device consists of an IV catheter with a needleless connector attached. This device helps maintain venous access in a patient who receives IV medications or solutions intermittently or in a patient who might need medications should an emergency arise. An intermittent flush device requires flushing before each infusion to assess vascular access device function, after each infusion to prevent mixing of incompatible medications and solutions, and after blood sampling to clear the device of blood and debris . 106066 Page 2 of 5 106066 11/30/2023 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hospital-acquired condition alert: Keep in mind that the Centers for Medicare and Medicaid Services considers vascular catheter-associated infection a hospital acquired condition because it can reasonably [be] prevented using a variety of best practices. Make sure to follow evidence-based infection prevention practices, such as performing hand hygiene, using sterile no-touch technique, and performing a vigorous mechanical scrub of needleless connectors to reduce the risk of vascular catheter-associated infections . Implementation . Assess the intermittent infusion device insertion site to ensure that it's free from signs of infection, infiltration, and phlebitis . Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely. While maintaining sterility of the syringe tip, attach a prefilled 10-ml [milliliter] syringe or a syringe designed to generate lower injection pressure containing preservative-free normal saline solution to the needleless connector. Unclamp the intermittent infusion device and aspirate slowly for a blood return that's the color and consistency of whole blood. Review of the facility policy and procedures titled Medication Administration with the last revision date of 2/27/2023 reads, Policy: Medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 4. Wash hands prior to administering medication per facility protocol and product. 106066 Page 3 of 5 106066 11/30/2023 Oak Hammock at the University of Florida Inc 2660 SW 53rd LN Gainesville, FL 32608

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards and included expirations dates when applicable in 2 of 4 medication carts reviewed. Findings include: During an observation of Medication Cart 1 on 11/27/2023 at 9:15 AM with Staff A, Licensed Practical Nurse (LPN), there were one 30-milliliter medication cup with chocolate pudding and crushed pieces of medications with no label identifying the medication or any resident identifier, one opened bottle of Brimonidine/ timolol ophthalmic solution with no opened or expiration dates, and one opened Basaglar insulin pen with no opened or expiration dates. During an interview on 11/27/2023 at 9:25 AM, Staff A, LPN, stated, That cup of medications with the pudding is for a resident who refused the medications earlier and I was going to go back and check before I threw it out. I should have labeled who it was for and what medications were in it. The eye drops and insulin should have a date they were opened. During an observation of Medication Cart 2 on 11/27/2023 at 9:30 AM with Staff B, LPN, there were one 30-milliliter medication cup with chocolate pudding with pieces of crushed medications with no label identifying the medications or any resident identifier, one medication cup that contained two medications (one red capsule and one white tablet) with no label identifying the medications and no resident identifier, one medication cup with three medications (2 white tablets and 1 yellow tablet) with no label identifying the medications and no resident identifier, one medication cup with four tablets brown in color with no label identifying the medication and no resident identifier, one opened bottle of Polymycin B and trimethoprim ophthalmic solution with no opened or expiration dates, one opened bottle of Brimonidine ophthalmic solution with no opened or expiration dates, one opened bottle of Systane eye drops with no opened or expiration dates, and one opened bottle of Bimatoprost ophthalmic solution with no opened or expiration dates. During an interview on 11/27/2023 at 9:40 AM, Staff B, LPN, stated, I was just called away to help a resident and didn't get to give these medicines. I should have given them. They should be labeled with what the medications are and who they are for. I didn't have Vitamin B Complex, so I borrowed these from another nurse. There is no label as what they are. All eye drops should be labeled with the date they are opened or when they expire. During an interview on 11/29/2023 at 1:00 PM, the Director of Nursing (DON) stated, The nurses should administer the medications when they get them ready. They should have gotten a new bottle of Vitamin B Complex and not borrowed from another cart and put them in her cart. All medications should have the date opened or expiration dates on them. Review of the facility policy and procedures dated 2/27/2023 reads, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moist control, segregation and security. 106066 Page 4 of 5 106066 11/30/2023 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 ensure staff performed hand hygiene during intravenous medication administration. Residents Affected - Some Findings include: During an observation of medication administration on 11/27/2023 at 10:45 AM, Staff C, Licensed Practical Nurse (LPN), prepared medications for Resident #167 without performing hand hygiene, entered the resident's room and administered the medications. Staff C exited the room and went to the medication cart to prepare medications for another resident. During an observation of medication administration on 11/27/2023 at 11:00 AM, Staff C, LPN, prepared medications for Resident #52 without performing hand hygiene, entered the resident's room and administered the oral medications without performing hand hygiene. Staff C donned gloves and placed gloved hands inside the rim of the trash can and moved the trash can closer. Staff C then picked up the bag of antibiotics and intravenous tubing, removed the end cap of the intravenous tubing and attached the antibiotic bag to the intravenous line. Staff C held the uncapped end of the intravenous tubing in her left hand and cleansed the hub of the midline catheter with alcohol with right hand for less than 2 seconds. The uncapped end of the intravenous tubing was touching the sheets on the bed and the resident's arm. Staff C attached the intravenous tubing to the midline catheter, removed gloves, and exited the room without performing hand hygiene. During an interview conducted on 11/27/2023 at 11:07 AM, Staff C, LPN, stated, I did not wash my hands before preparing the medications. I reached into the trash can with my gloved hands. I should have changed my gloves after that. I didn't realize that the end of the IV line touched the resident or the sheets. During an interview on 11/29/2023 at 1:00 PM, the Director of Nursing (DON) stated, All staff should practice infection control standards and wash their hands before and after administering medications. Review of the facility policy and procedures titled Medication Administration with the last revision date of 2/27/2023 reads, Policy: Medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 4. Wash hands prior to administering medication per facility protocol and product. Review of the facility policy and procedures titled Hand Hygiene with the approval date of 1/30/2023 reads, Purpose: To ensure that all staff perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 106066 Page 5 of 5