Health inspection·August 22, 2024

F 0692 Provide enough food/fluids to maintain a resident's health. 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 2 of 5 residents reviewed for weight loss, Residents #12 and #14, received nutritional supplements. Residents Affected - Some Findings include: 1) During an observation on 8/20/2024 at 12:18 PM, Resident #12 was sitting in a recliner, eating independently in her room. The resident's tray contained two cups of soup, apple juice, and coffee. There was no magic cup on the tray. During an observation on 8/21/2024 at 12:10 PM, Resident #12 was sitting in a recliner, eating independently in her room. The resident's tray contained tuna salad, curly fries, pie, and vanilla ice cream. There was no magic cup on the tray. Review of Resident #12's physician order dated 7/29/2024 read, Magic Cup (Formulary) two times a day for weight loss lunch and dinner. Review of Resident #12's weight record showed the weight of 136 lbs (pounds) on 7/21/2024, and 122.6 lbs on 8/18/2024, which is a -9.85% loss. Review of Resident #12's progress note dated 8/19/2024 read, Has orders for compression stockings to be worn daily d/t [due to] edema. Resident has order to be up daily for meals. Hx [history] of weight loss. Has intervention of magic cup offered at lunch and dinner (600 calories). accepts some of time. History of refusing oral supplements (Ensure, Boost). continue to follow. Review of Resident #12's Dietary/Nutrition Profile dated 7/19/2024 showed the resident was at risk for unintentional weight loss due to fair appetite and refusal of supplements under Section K. Nutritional Risk. During an interview on 8/21/2024 at 12:36 PM, the Registered Dietician stated, [Resident #12's name] has been a challenge for me. The first time I went to see her, she did not want to talk about her preferences and refused any supplements. She has been an ongoing challenge. [Resident #12's name] takes the magic cups some of the times. Her BMI [Body Mass Index] is 22.4 at this time. Anything above 21, I like. Ice cream does not have the same nutritional value as the magic cup. The ice cream has 200 to 250 calories and magic cup has more than 300 calories. Not having the magic cup can affect the weight but she will sometimes have half of it or sometimes will not. Resident #12 will rarely eat over 75%. It has been a challenge. Ensure would make her sick, so we decided to do the magic cups so if she eats at least 50% of her food plus the magic cup, she would have the minimum calories she Page 1 of 8 106083 106083 08/22/2024 Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159

F 0692 needed. Level of Harm - Minimal harm or potential for actual harm 2) During an observation on 8/20/2024 at 12:21 PM, Resident #14 was sitting up in the bed, eating independently. The resident's lunch tray had soup, coffee, sandwich, and beets. There was no magic cup on the tray. Residents Affected - Some During an observation on 8/21/2024 at 12:11 PM, Resident #14 was sitting up in the bed, eating independently. The resident's lunch tray had curly fries, sandwich, and strawberry ice cream. There was no magic cup on the tray. Review of Resident #14's physician order dated 8/19/2024 read, Magic Cup (Formulary) two times a day for give [Sic.] at lunch and dinner. Review of Resident #14's weight record showed the weight of 127 lbs on 8/1/2024, and 117.4 lbs on 8/18/2024, which is a -7.56% loss. Review of Resident #14's Dietary/Nutrition Profile dated 8/5/2024 showed the resident was at risk for unintentional weight loss due to eating fair, over [AGE] years of age under Section K. Nutritional Risk, with discharge goal of weight remaining more than 120 under Section L. Comments. During an interview on 8/21/2024 at 12:43 PM, the Registered Dietician stated, [Resident #14's name] came in on Ensure twice a day and her weight had decreased, so we boosted it to 3 times a day. On August 18, 2024, I saw she came down almost another pound and the nurses noted she hated the taste of ensure, so we recently changed her to the magic cup, which was ordered on the 19th [8/19/2024]. This was a recent change. During an interview on 8/21/2024 at 12:21 PM, the Certified Dietary Manager (CDM) stated, Ice cream and magic cups do not have the same nutritional value. We have magic cups at hand in the facility. The server makes sure they are on the tray when they are sent out to the resident. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing stated, Nursing staff should be checking the trays and if they are missing a magic cup, they are able to get it from the dinning area. Review of the facility policy and procedure titled Nutrition Risk-Weight Loss Management with the last review date of 1/23/2024 read, Policy: Goal: To implement a nutritional risk-weight loss management program that will emphasize implementation of services that minimize episodes of preventable weight loss and promote nutrition. 106083 Page 2 of 8 106083 08/22/2024 Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as per physician order for 1 of 2 residents reviewed for respiratory services, Resident #33. Residents Affected - Few Findings include: During an observation on 8/19/2024 at 9:58 AM, Resident #33 was lying in bed, receiving oxygen at 2 liters per minute via nasal cannula. During an observation on 8/20/2024 at 8:14 AM, Resident #33 was lying in bed, receiving oxygen at 2 liters per minute via nasal cannula. Review of Resident #33's physician orders revealed no order for oxygen administration. Review of Resident #33's Weights and Vitals Summary for oxygen saturation showed 94% (oxygen via nasal cannula) on 8/19/2024 at 10:12 AM and 99% (oxygen via nasal cannula) on 8/20/2024 at 8:52 AM. Review of Resident #33's care plan with an initiated date of 8/2/2024 read, Focus: The resident has altered respiratory status due to COPD [Chronic Obstructive Pulmonary Disease], acute respiratory failure with hypoxia and O2 [oxygen] use. During an interview on 8/21/2024 at 1:15 PM, the Director of Nursing (DON) stated, [Resident #33's name] did not have a current order in the facility for oxygen administration. We must have a doctor's order for all medications and interventions in order to know what rate the oxygen should be running at. Review of the facility policy and procedure titled Oxygen Administration with the last review date of 1/23/2024 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/23/2024 read, Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 106083 Page 3 of 8 106083 08/22/2024 Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 1 of 4 units. Findings include: 1) During an observation on 8/19/22024 at 9:52 AM, Resident #14 was lying in bed. On top of the resident's bedside table, there was a bottle of Magnesium Glycinate (Photographic evidence obtained). During an observation on 8/19/2024 at 11:02 AM with Staff G, Licensed Practical Nurse (LPN) Unit Manager, Resident #14 was lying in bed and there was a bottle of Magnesium Glycinate on top of the resident's bedside table. During an interview on 8/19/2204 at 11:02 AM, Resident #14 stated, I brought this Magnesium from home and the nurse will give it to me because the facility does not carry this type. 2) During an observation on 8/19/2024 at 9:43 AM, Resident #36 was not in his room. There was a bottle of Hydrogen Peroxide on top of the resident's drawer (Photographic evidence obtained). During an observation on 8/19/2024 at 11:00 AM with Staff G, LPN Unit Manager, there was a bottle of Hydrogen Peroxide on top of Resident #36's drawer. During an interview on 8/19/2024 at 11:05 AM, Staff G, LPN Unit Manager, stated, Those medications should not be there. Residents should not have medication at bedside. [Resident #36's name] does not even have orders for Hydrogen Peroxide. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing (DON) stated, Resident medication should be locked in a lock box inside the resident's drawer. Review of the facility policy and procedure titled Medication Labeling and Storage with the last review date of 1/23/2024 read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 106083 Page 4 of 8 106083 08/22/2024 Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure staff sanitized the equipment while taking food temperatures in accordance with professional standards. Residents Affected - Few Findings include: During an observation on 8/20/2024 at 7:40 AM, Staff C, Cook, picked up a towel that was sitting on the prep table and used the towel to wipe the temperature probe between taking temperatures of pureed foods including oatmeal, eggs, and waffles. Staff C did not use alcohol wipes after testing the first pureed food. During an interview on 8/20/2024 at 8:32 AM, Staff C, Cook, confirmed he used the towel to clean off the temp probe. During an interview on 8/20/2024 at 8:25 AM, the Certified Dietary Manager (CDM) stated they need to use alcohol wipes to clean the temperature probe and if they have to clean off the probe with another source, they would use a clean paper towel. During an interview on 8/21/2024 on 11:35 AM, the Registered Dietician stated that she expected the dietary staff to use alcohol wipes in between foods when using the temp probe. Review of the facility policy and procedure titled Food Temperatures with the last review date of 1/23/24 showed it read, Policy: Foods should be served at proper temperature to insure food safety and palatability. Procedure: 1. Wash, rinse and sanitize a dial face, metal probe-type thermometer with alcohol wipe. A practical range of 0-220 F [Fahrenheit] is recommended. Re-sanitize the thermometer after each use. 106083 Page 5 of 8 106083 08/22/2024 Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4) During an observation on 8/20/2024 at 1:18 PM, Staff A, Registered Nurse (RN) Supervisor, and Staff B, Registered Nurse, were providing wound care to Resident #7. Staff B did not put down a protective barrier to protect the bed linen and other body sites before wound care. Staff B removed the dressing to the resident's right foot and then removed her gloves. Staff B did not perform hand hygiene before applying another set of gloves to clean the wound on the resident's right foot. Without performing hand hygiene, Staff B applied another set of gloves to dry the wound area. Staff B did not perform hand hygiene before applying dressing to the right foot. Staff B removed her gloves after completing the dressing change to the right foot and applied another set of gloves without performing hand hygiene and removed the dressing to the resident's left foot. Staff B applied a new set of gloves without performing hand hygiene to clean the left foot wound area. Staff B removed her gloves and applied another set of gloves for drying the left foot wound area without performing hand hygiene. Staff B removed her gloves and applied another set of gloves for applying dressing to the resident's right foot wound without performing hand hygiene. Residents Affected - Few During an interview on 8/20/2024 at 2:45 PM, Staff A, RN Supervisor, stated, [Staff B's name] should have washed her hands between each procedure and placed a barrier between the resident and the bed. During an interview on 8/20/2024 at 2:45 PM, Staff B, RN, stated, I did the wound care just like I always do it. I should have washed my hands and should have laid a barrier down between the wound care and the bed before starting the procedure. During an interview on 8/22/2024 at 10:00 AM, the Director of Nursing stated, After removing the old dressing and removing gloves, they should wash hands before applying new gloves again. Review of the facility policy and procedure titled Dressings, Dry/Clean with the last review date of 1/23/2024 showed it read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressing . Steps in the Procedure . 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time, and initials, place on clean field. 11. Using a clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area usually from the center outward. 16. Use dry gauge to pat the wound dry. Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment while providing high contact care for the residents on enhanced barrier precautions for 2 of 6 residents observed, Residents #50 and #310, failed to ensure staff performed hand hygiene during medication administration for 1 of 6 residents observed, Resident #164, and failed to ensure staff followed infection control standard of practice while providing wound care for 1 of 2 residents reviewed for pressure wounds, Resident #7, to prevent the possible spread of infection and communicable diseases. Findings include: 106083 Page 6 of 8 106083 08/22/2024 Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159

F 0880 Level of Harm - Minimal harm or potential for actual harm 1) During an observation on 8/21/2024 at 5:38 AM, Staff F, Licensed Practical Nurse (LPN), entered Resident #50's room and donned gloves. Staff F did not don a gown. Resident #50's room door had an enhanced barrier precautions signage. Staff F administered IV (intravenous) medication and exited the room. While Staff F was standing outside of the room, Resident #50's IV pump started beeping and Staff F entered the resident's room and adjusted the IV pump. Staff F was wearing gloves and no gown. Residents Affected - Few During an interview on 8/21/2024 at 5:54 AM, Staff F, LPN, stated, Wearing a gown is not something we regularly do only when the resident is on isolation. Enhanced barrier is more for infection. 2) During an observation on 8/21/2024 at 8:12 AM, Staff D, LPN, entered Resident #310's room. Resident #310's room door had an enhanced barrier precaution signage posted. Staff D entered Resident #310's room after pouring medication and donned gloves without donning a gown. Staff D administered the medication via Resident #310's gastric tube. During an interview on 8/21/2024 at 9:42 AM, Staff D, LPN, stated, I should have put on a gown since he [Resident #310] has a gastric tube and is under enhanced barrier precautions. 3) During an observation on 8/21/2024 at 8:57 AM, Staff E, LPN, was pouring medication for Resident #164. One Flomax capsule fell on top of the medication cart. Staff E proceeded to grab the capsule with her hands without wearing gloves and placed the capsule back into the medication cup. Staff E entered Resident #164's room and administered the medication. During an interview on 8/21/2024 at 9:05 AM, Staff E, LPN, stated, I should have discarded the medication once it fell onto the medication cart and poured a new medication onto the medication cup. During an interview on 8/21/2024 at 1:45 PM, the Infection Preventionist stated, Staff should wear gloves and gown when providing direct care to residents who are under enhanced barrier precautions and if they are at risk for a splash, they should wear a face shield. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing (DON) stated, Staff should follow full personal protective equipment when resident is under enhanced barrier precautions. The staff should wear gloves and gown when coming into direct contact with resident. Staff should discard medication and pour a new one if they fall. Medication should not be touched without gloves. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/23/2024 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi0frug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high-contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) Review of the facility policy and procedure titled Administering Medications with the last review date of 1/23/2024 read, Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 106083 Page 7 of 8 106083 08/22/2024 Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 the residents' health record showed the residents either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 2 of 5 residents reviewed for immunization, Residents #3 and #7. Residents Affected - Few Findings include: Review of Resident #3's admission record showed the resident was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, insomnia and chronic pain syndrome. Review of Resident #3's vaccination records showed a flu vaccine consent signed on 11/6/2023. Further review of the records showed the resident received the last flu vaccine on 10/25/2022, with no documentation of a flu vaccine administered after 11/6/2023. Review of Resident #7's admission record showed the resident was admitted on [DATE] with diagnoses including heart failure, atrial fibrillation, dementia and chronic kidney disease. Review of Resident #7's vaccination records showed a flu vaccine consent signed on 11/6/2023. Further review of the records showed the resident received the last flu vaccine on 10/25/2022, with no documentation of a flu vaccine administered after 11/6/2023. During an interview on 8/21/2024 at 10:02 AM, the Infection Preventionist confirmed Residents #3 and #7 had consented to having a flu vaccine administered and there was no documentation of the vaccine being administered after 11/6/2023. She stated, We got the consent on the unit, and it was the previous Infection Preventionist who was responsible for the administration. I cannot find documentation of administration for either resident. During an interview on 8/21/2024 at 2:45 PM, the Director of Nursing stated, It is my expectation that when a resident signs a consent for a vaccine, the staff obtain an order if there is not a standing order, administer it and document it in the record. Review of the facility policy and procedure titled Influenza, Prevention and Control of Seasonal with the last review date of 1/23/2024 showed it read, Policy Statement: This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Policy Interpretation and Implementation . Vaccination: 1. The Infection Preventionist organizes and oversees an annual influenza vaccine campaign. 2. All residents and staff are offered the vaccine prior to the onset of the influenza season. 106083 Page 8 of 8