Health inspection·March 21, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure showers were provided per resident preference and as scheduled for 1 of 3 sampled residents reviewed for choices (Resident #13). The findings included: During an interview on 03/18/24 at 10:07 AM, Resident #13 explained that staff keep her clean and dry as far as her incontinence, but they don't give her a full bed bath daily as she would like. The resident also stated she would like a shower. When asked how many showers she would like each week, the resident stated two. Resident #13 confirmed she does not get two showers weekly. Review of the record revealed Resident #13 was admitted to the facility on [DATE]. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating intact cognition. This MDS also documented the resident needed substantial assistance from staff for bathing. Review of the Significant Change MDS dated [DATE] documented it was very important for the resident to choose between a bath and a shower. Review of the current care plan initiated on 11/25/20, and revised on 03/18/24, documented the resident was at risk for decreased ability to perform ADLs (activities of daily living) in bathing, related to activity intolerance, and related to comorbidities that included quadriplegia, contractures, and traumatic brain injury. This care plan documented Resident #13 preferred showers and was dependent upon staff for showers and baths. Review of the shower schedule revealed Resident #13 was scheduled for a shower on Mondays and Thursdays during the 3 PM to 11 PM shift. Review of the tasks section of the electronic medical record for 02/19/24 through 03/19/24 documented the provision of 3 showers in 30 days, instead of the scheduled 9 showers for that same time period. The most recent shower was documented on Monday 03/18/24 by Staff A, Certified Nursing Assistant (CNA). A bed bath was also documented by the same CNA for the same day. During an interview on 03/21/24 at 9:22 AM, when asked if she provided a shower to Resident #13 on Monday, Staff A stated she had not given her a shower, but did a full bed bath instead. When shown that both a shower and bed bath were documented by her for Monday, the CNA stated it was a mistake. During a supplemental interview on 03/21/24 at 9:27 AM, when asked if she received a shower Page 1 of 9 106075 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

F 0561 Level of Harm - Minimal harm or potential for actual harm yesterday or any day this week, Resident #13 stated No. When asked if she still wanted a shower, the resident stated she did. When told she would have to get up out of bed, as the surveyor had only seen the resident up out of bed on one day that week, Resident #13 stated, I know! Residents Affected - Few 106075 Page 2 of 9 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure of an accurate Minimum Data Set (MDS) assessment related to medications for 1 of 5 sampled residents reviewed for unnecessary medications, (Resident #62). Residents Affected - Few The findings included: Review of Resident #62's electronic records revealed the resident was admitted to the facility on [DATE] with diagnoses to include Sequelae of Cerebral Infarction, Depression, Left Femur Fracture, Anxiety Disorder, Atrial Fibrillation, Muscle Weakness, and Acute Respiratory Failure. Review of the Minimum Data Set (MDS) Medicare 5-day assessment dated [DATE] documented the resident has a BIMS (Brief Interview for Mental Status) score of 12, indicating the resident's cognition is moderately intact. Review of the MDS section N, (Medications) documented the resident had 4 days of insulin injection and high-risk drugs antidepressant and anticoagulant. Review of Resident #62's diagnoses and physician orders revealed the resident did not have a diagnosis of Diabetes and did not have or had a physician's order for insulin while a resident in the facility. Further record review revealed a physician's order for Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML, inject 40 mg subcutaneously in the afternoon for DVT (Deep Vein Thrombosis) prevention; Start date 02/27/24 through 03/11/24 and 03/11/24-04/01/24 Enoxaparin Sodium is an anticoagulant medication (blood thinner). During an interview on 03/20/24 at 2:05 PM with Resident #62 and her daughter, she was asked about being on Insulin. She stated that she is not a Diabetic and has never been on Insulin. Her daughter confirmed this. She stated she is taking a medication that the staff injects in her stomach, which is a blood thinner. During an interview on 03/20/24 at 2:34 PM with the MDS Director, she was asked to review Resident #62's MDS record. She reviewed Section N (Medications) and was asked if the resident was a diabetic and taking Insulin, and stated, she is not a diabetic and coded it looking at the Enoxaparin as a diabetic medication. She stated, I know it is not a diabetes medication and acknowledged it was an error on her part. 106075 Page 3 of 9 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess for a voiced change in condition for 1 of 23 sampled residents (Resident #118), and the nursing staff held blood pressure medications without ordered parameters and failed to notify the physician of the low blood pressure readings for 1 of 5 sampled residents (Resident #21). Residents Affected - Few The findings included: During an interview on 03/20/24 at 1:11 PM, Resident #118 was asked if she still had her indwelling urinary catheter. Resident #118 stated she did not as it was taken out a few days ago, but volunteered she had a difficult time with a night nurse before the catheter was placed. Resident #118 explained she had a history of urinary tract infections, had had issues with voiding (urinating), and could tell when she was having difficulties. The resident stated the night before the catheter was placed, at about 3 AM, she was having horrible abdominal pain and she thought she needed a catheter because of the pressure she was feeling. Resident #118 stated the night nurse told her, Do you expect me to call the physician at this time of night. The resident explained she had told the nurse she hadn't urinated and had asked for a catheter. Resident #118 stated the night nurse told her she could not place a catheter because she was having spasms and she would continue to spasm. Resident #118 explained she then asked for some pain medication hoping for relief, but it did not help. During this description, Resident #118 demonstrated how she was having abdominal pain, grimacing, and rolling back and forth holding her abdomen. Resident #118 explained Staff D, Licensed Practical Nurse (LPN) and her day nurse, arrived and was her angel. Resident #118 stated she explained to the day nurse that she had been in horrible pain since 3 AM, and the day nurse told her that was unacceptable. The resident explained that Staff D returned, placed a catheter, and she immediately drained over 700 milliliters of urine, followed by 200 more. Resident #118 stated when that urine drained out, I felt such relief, I felt like I was just floating. During an interview on 03/20/24 at 1:14 PM, Staff D, day LPN, confirmed she had placed the urinary catheter for Resident #118 one morning, and had obtained a large amount of urine upon placement. During a supplemental interview on 03/20/24 at 3:02 PM, Resident #118 stated, Maybe that night nurse was having a bad night or something, but it wasn't like I had a headache and asking her to call the doctor for that. It could have been solved so quickly if she would have just called the physician and got an ok to cath me. I've had this before. Review of the record revealed Resident #118 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #118 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale. This MDS documented the resident had an indwelling urinary catheter. The physician orders revealed the indwelling urinary catheter was placed on 03/07/24. During a phone interview on 03/20/24 at 4:26 PM, when asked about Resident #118 and the night prior to the placement of the indwelling urinary catheter, Staff B, night LPN, explained she was told the resident wanted to see the nurse. Staff B stated the resident was in pain and pointed to her abdomen. Staff B stated she assessed the resident's abdomen and it was soft. Staff B stated Resident #118 asked about a catheter, but when she asked if she was voiding or needed to go to the bathroom, the 106075 Page 4 of 9 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident stated she was voiding and had just been to the bathroom. Staff B stated she gave Resident #118 pain medication, the resident went back to sleep, and she did not complain of pain through the rest of the night. Staff B stated she obtained her blood sugar level about 5 AM and still didn't voice any further complaints. Staff B stated Resident #118 had often complained of pain and took pain medication. Review of the March 2024 Medication Administration Record (MAR) documented Resident #118 had taken pain medication three times prior to the 3 AM pain medication for her abdominal pain. This MAR and associated progress notes revealed the following: On 03/02/24 at 1:33 AM the resident took Tylenol for complaint of bone pain in her legs rated at a 6, on a 0 to 10 scale. Follow-up rating at 2:29 AM was a 2. On 03/05/24 at 8:05 AM the resident took Oxycodone for documented chronic pain. The follow-up documented the intervention was ineffective, although the pain rating for the shift was documented as 0. On 03/06/24 at 10:03 AM the resident took Oxycodone for complaint of left hip pain rated at a 7, with a follow-up rating of 0. Staff B, the night LPN, documented she provided Oxycodone on 03/07/24 at 3:19 AM for severe pain in back rated at an 8. A follow-up note at 4:44 AM documented the resident then rated her pain at a 3. The progress notes lacked any documented assessment for the abdominal pain as voiced by Resident #118. 2) Review of the record revealed Resident #21 was admitted to the facility on [DATE]. Review of the current care plan initiated on 11/10/23 and revised on 02/16/24 documented Resident #21 had altered cardiovascular status related to hypertension. This care plan documented for staff to administer medication as per order, and to monitor for effectiveness and possible side effects. This care plan also documented for staff to monitor vital signs and to notify the physician of significant abnormalities. Review of the current orders revealed Resident #21 was taking Exforge (a medication to lower blood pressure) once daily. Review of the March 2024 Medication Administration Record (MAR) revealed the Exforge was not provided on 03/07/24 with a blood pressure of 117/57, on 03/12/24 with a blood pressure of 96/66, and on 03/13/24 with a blood pressure of 129/57. All three days the direct care nurse was Staff C, LPN. The documented reason for not administering the medication was that the blood pressure was outside of parameters for administration. Further review of the orders lacked any parameters for holding the medication. During an interview on 03/21/24 at 10:47 AM, when asked about the holding of the Exforge blood pressure medication for Resident #21 on the above three dates, Staff C stated she held it because the blood pressure was low. When asked if she asked or notified the physician, the LPN stated she did not. 106075 Page 5 of 9 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation, interview, record review, and policy review, the facility failed to ensure proper catheter care and services for 2 of 5 sampled residents with indwelling urinary catheters (Residents #32 and #4), and failed to ensure proper peri-care (personal care provided after an incontinent episode of urination) for 1 of 1 sampled resident observed (Resident #16). The findings included: 1) Review of the policy Catheter Care revised 01/06/23 documented after having cleaned the peri-area, 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Review of the record revealed Resident #32 was admitted to the facility on [DATE]. Review of the orders revealed an indwelling urinary catheter was placed on 02/20/24. Review of the current care plan initiated on 02/21/24, and revised on 03/11/24 documented, Resident #32 had an indwelling urinary catheter. Care plan interventions included catheter care with soap and water each shift and as needed. During an observation on 03/20/24 at 11:00 AM, Staff E, Certified Nursing Assistant (CNA) provided appropriate peri-care to the resident's front and back sides, but failed to wipe the urinary catheter tubing in any way. The CNA then placed an adult pull-up (adult incontinence brief) on Resident #32. Upon completion of care, when asked about cleaning the catheter tubing, the CNA stated, I thought I did. When asked if she had worked this week with Resident #32, the CNA stated she had. When asked if the resident had had any type of anchor or thigh strap to secure the catheter tubing that week, the CNA stated she had not. When asked if they use them at the facility, the CNA stated they do. When asked why the anchor or thigh strap would be used with the urinary catheter tubing, the CNA stated, So it won't come out. The CNA was unaware the anchor or thigh strap helped secure the urinary catheter tubing, to assist with the prevention of infection. 2) Review of the record revealed Resident #4 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0, on a 0 to 15 scale. This MDS also indicated the resident was dependent upon staff for all activities of daily living (ADLs) and had an indwelling urinary catheter. Review of the current care plan initiated on 02/24/22 and revised on 06/29/22 documented the resident required the indwelling catheter due to urinary retention. One of the interventions was to maintain the catheter off of the floor. Observations on 02/19/24 at 8:23 AM and on 03/21/24 at 8:59 AM revealed the indwelling urinary catheter bag lying directly on the floor. On 03/21/24 the catheter bag was not hooked or secured to the bed frame in any way (Photographic Evidence Obtained). During the observation on 03/21/24, the Unit Manager was passing by the room. The Unit Manager agreed the catheter bag should not be on the floor and noted it was not hooked to the bed frame. The Unit Manager properly secured the catheter bag to the bed frame and off of the floor. 106075 Page 6 of 9 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3) Record review revealed that Resident #16 was admitted to the facility on [DATE] with a diagnosis to include: Urinary Tract Infection (UTI). Review of the admission Minimum Data Set (MDS) assessment, reference date 01/12/24, documented a Brief Interview for Mental Status (BIMS) score of 08, indicating Resident #16 was moderately cognitively impaired. Laboratory test dated 03/10/24 for urinalysis, culture, and sensitivity (UA/ C&S) were reviewed. It indicated to straight catheterize the resident for a urine sample for symptom of urinary frequency, relating to strong smelling urine. It was revealed the lab was completed 03/10/24. The lab result was reported to the facility on [DATE]. The result was >100,000 CFU/ML [greater than 100,000 colony forming units per milliliter] Klebsiella pneumoniae, ESBL [Extended Spectrum Beta-Lactamase]. ESBL is an enzyme found in some strains of bacteria. ESBL bacteria can be spread from person to person on contaminated hands of both patients and healthcare workers. The risk of transmission is increased if the person has diarrhea or has a urinary catheter in place as these bacteria are often carried harmlessly in the bowel. Review of physician orders dated 03/13/24 revealed an order for Ciprofloxacin HCl [antibiotic] oral tablet, give 500 mg by mouth two times a day for UTI for 7 Days. Review of a care plan dated 03/14/24, documented, Resident #16 had a Urinary Tract Infection related to ESBL. Review of interdisciplinary progress note dated 03/14/24 recorded (Resident #16) 'was being skilled for right pelvic fracture, she was positive for ESBL as of 03/13/24, she was on an antibiotic by mouth until 03/21/24 with contact precautions.' On 03/21/24 at 9:23 AM, the surveyor met Staff G, Certified Nursing Assistant (CNA), in the hallway in front of the resident's room, to observe peri-care. The surveyor and Staff G donned gowns and gloves and entered the room. Once inside the room, Staff G and the surveyor introduced themselves to Resident #16. The resident was observed sitting in the wheelchair. Staff G removed Resident #16's shoes and assisted her to get into the bed. Staff G obtained the bed remote control and placed the bed in a high position. Staff G opened the resident's drawers, removed a basin, and went to the bathroom to collect water into the basin and left it in the bathroom. Staff G obtained a plastic bag which had towels and washcloths in it. She removed a large towel from the plastic bag, removed Resident #16's pants and adult brief and covered her private area with the large towel. At 9:27 AM, Staff G went to the bathroom and obtained the basin of water, placed the basin on the bedside table, put soap in the basin, and then placed a small washcloth in the water. At 9:29 AM, without changing her gloves, she began the peri care. She washed the peri area using one wash cloth at a time. After she completed the care, she removed her gloves, collected new gloves from her pocket and put them on without preforming hand hygiene in between glove changes. Staff G looked for cream in the drawers and applied the cream to Resident #16's groin and bottom area. After the peri care was completed, an interview was held with Staff G, who was asked why she didn't change her gloves before she began the peri care. She then acknowledged that she did not change her gloves. On 03/21/24 at approximately 9:50 AM, an interview was conducted with the Director of Nursing (DON) 106075 Page 7 of 9 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

F 0690 and the Regional Nurse Consultant. They were made aware of the concern, as the surveyor explained the whole procedure, and the matter of which the peri care was rendered. They acknowledged the findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106075 Page 8 of 9 106075 03/21/2024 Garden View Health and Rehabilitation Center 2180 10th Avenue Vero Beach, FL 32960

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review, interview, and policy review, the facility failed to ensure reconciliation of controlled medications for 4 of 4 sampled residents reviewed (Resident #22, #68, #37 and #6). Residents Affected - Some The findings included: Review of the policy Controlled Substance Administration & Accountability revised 10/2023 documented, 1. General Protocols: . i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed form the pharmacy. Review of the current Medication Monitoring/Control Records and the corresponding March 2024 Medication Administration Records (MARs) revealed the following discrepancies: 1). Resident #22, a 5 milligram (mg) tablet of oxycodone was signed out of the medication cart, as per the control record, on 03/12/24 at 12:30 PM, but not signed out on the corresponding MAR. 2). Resident #68, a 5 mg tablet of oxycodone was signed out as per the control record on 03/18/24 at 10:33 PM, but not signed out on the corresponding MAR. During this review on 03/21/24 at 12:22 PM, Staff D, Licensed Practical Nurse (LPN) agreed with the findings and confirmed the nurses were to sign out a controlled medication on both the control record and the MAR. Additional observations of the medication carts and controlled records revealed the following discrepancies: 3). Resident #37, one 50 mg tablet of Tramadol was signed out as per the control record on both 03/17/24 at 4:43 AM and on 03/19/24 at 4:36 AM, but not signed out on the corresponding MAR for either date. 4). Resident #6, one 50 mg tablet of Tramadol was signed out as per the control record on 03/14/24 at 3:13 AM, but not signed out on the corresponding MAR. During this review on 03/21/24 at 12:29 PM, Staff F, Registered Nurse (RN) agreed with the findings. 106075 Page 9 of 9