Health inspection·September 23, 2021

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policies and procedures, resident and staff interviews, the facility failed to provide the necessary care and services to maintain grooming and hygiene for 2 (Resident #3 and Resident #180) of 3 dependent residents reviewed for assistance with activities of daily living. This has the potential to cause psychological harm to the resident. Residents Affected - Few The findings included: A review of the facility policy Activities of Daily Living (ADLs), Supporting (revised 11/28/16), specified, Residents who are unable to carry out ADLs independently, will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming and oral care). 1. A review of Resident #3' s clinical record revealed a care plan specifying Resident #3 required extensive to total assistance with ADLs including nail care, secondary to stroke and bilateral hand contractures (permanent tightening of joint). The care plan instructed staff to perform oral care daily and as needed and nail care as needed. Resident #3 had diagnoses including dementia and hemiparesis and hemiplegia (paralysis of one side of the body). The clinical record showed Resident #3 was on Hospice services. On 9/20/21 at 12:36 p.m., Resident #3's fingernails were observed extending over 1/2 inch from the fingertips with a large amount of brown substance under the nail beds. Resident #3's hands were contracted, curled inward in a fist with several fingers pressed into the palm of the hands. Resident #3 was observed to have greasy, uncombed hair. The same observation was made on 9/21/21 at 11:08 a.m. Resident #3's had caked food between the teeth. Resident #3's mouth and lips were dry. Resident #3 asked for something to eat several times and said, I'm hungry. On 9/21/21 at 11:11 a.m., Licensed Practical Nurse (LPN) Staff I was notified of Resident #3's request for something to eat. Staff I replied Resident #3 was demented, confused, and had eaten breakfast. On 9/21/21 at 11:30 a.m., LPN Staff I had not offered Resident #3 food or fluids. Page 1 of 7 106104 106104 09/23/2021 Renaissance at the Terraces 26475 South Tamiami Trail Bonita Springs, FL 34135

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/22/21 at 11:05 a.m., during an observation Registered Nurse (RN) Staff K and LPN Staff I were at Resident #3's bedside and confirmed the resident's fingernails were long and had a brown substance under nail beds. In an interview on 9/22/21 at 11:10 a.m., RN Staff K said she did not know who was responsible to trim the resident's fingernails. On 9/22/21 at 11:11 a.m., in an interview LPN Staff I said the Hospice aide was responsible to clean and cut Resident #3's fingernails but did not know when the Hospice aide would visit the resident. LPN Staff I said Resident #3 was bedbound and received bed baths from facility staff. LPN Staff I said she did not know when Resident #3 received bed baths or nail care. On 9/22/21 at 12:21 p.m., in an interview, Certified Nursing Assistant (CNA) Staff J said CNAs were not permitted to cut fingernails and the podiatrist would do it. The CNA said she could clean and file the residents' nails but not cut them. On 9/22/21 at 12:30 p.m., in a telephone interview, the Hospice aide said she visited Resident #3 on Mondays and Thursdays and would provide a bed bath and nail care. The aide said she would cut Resident #3's nails because she was worried, they would grow into the skin because of the hand contractures. The Hospice aide said she had not visited Resident #3 in three weeks. A review of the daily charting from 9/1/21 through 9/22/21 noted documentation the CNAs provided oral care. On 9/22/21 at 4:00 p.m., in an interview the Director of Nursing (DON) said the staff were responsible for nail care, but the Hospice aide would usually cut Resident #3 nails. The DON said staff were to observe resident for needs during care and if nails were long, they should take care of it. The DON said, the expectation was the staff provide ADL care to the residents each shift. 2. On 9/20/21 at 12:10 p.m., Resident #180, was observed in his bed, his fingernails were long, extending approximately 1/2 inch past the fingertips, with a large accumulation of brown and black substance under the nailbeds. Resident # 80 was unshaven, approximately two days growth, and unkempt. Crumbs of food were on his shirt and on the bed linen. Resident #180 said he had not received a shower or bath in several days and did not like for his nails to be so long. Resident # 180 said no one had cut or cleaned his nails. On 9/21/21 at 10:43 a.m., in an interview, Resident #180 said he had told the nurse he would like to have his nails cut. 9/22/21 at 12:35 p.m., in an interview CNA Staff J said CNAs followed the shower schedule, and it did not change. The CNA said the showers were assigned by room assignments and by shift, so it was always the same. The CNA said Resident #180 was scheduled to receive a shower on the 2:00 p.m. to 10:00 p.m., shift on Sundays, Tuesdays, and Thursdays. A review of the clinical record showed Resident #180 was admitted on [DATE]. The care plan documented the resident had a deficit in ability to self-perform ADLs. The clinical record lacked documentation Resident #180 received a shower on Sunday 9/19/21. 106104 Page 2 of 7 106104 09/23/2021 Renaissance at the Terraces 26475 South Tamiami Trail Bonita Springs, FL 34135

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of policies and procedures, resident and staff interview, the facility failed to provide reasonable interventions and adequate monitoring to meet the needs of 1 (Resident #180) of 1 sampled resident requiring continuous use of oxygen. Residents Affected - Few The findings included: The facility policy Oxygen Administration (revised 10/2010) documented, The purpose of this procedure is to provide guidelines for safe oxygen administration . Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (blue tone to the skin and mucous membranes). 2. Signs or symptoms of hypoxia (rapid breathing, rapid pulse, restlessness, confusion). 3. Signs or symptoms of oxygen toxicity (difficulty breathing, slow or shallow rate of breathing). Review of the clinical record showed Resident #180 was admitted on [DATE] with diagnoses including, chronic obstructive pulmonary disease and dependence on supplemental oxygen. The admission orders dated 9/18/21 included oxygen therapy at 2 liters per minute per nasal cannula continuous. The clinical record revealed a care plan dated 9/20/21 specifying Resident #180 was at risk for respiratory complications due to a diagnosis of Congestive Obstructive Pulmonary Disease (COPD). The interventions listed on the care plan included to administer oxygen per order and monitor the resident for signs and symptoms of hypoxemia (low concentration of oxygen in the blood) such as restlessness, forgetfulness, anxiety, cyanosis (bluish discoloration of the skin from inadequate oxygenation), and lethargy. The staff was to assess the resident's respiratory status as needed and notify the physician of any abnormalities. On 9/20/21 at 12:14 p.m., Resident #180 was observed in bed, moving about in bed, restless and breathing fast. Resident #180 said he was short of breath and wanted a nebulizer (a machine that turns liquid medication into a mist inhaled into the lungs) treatment. Resident #180 said the nurse gave him an inhaler and said she would have to contact the physician to order the nebulizer. Resident #180 said, I keep telling her I can't breathe. The oxygen concentrator was observed plugged to the wall outlet, turned on and set at three liters. The oxygen tubing prongs were correctly placed in the resident's nostrils. The other end of the 106104 Page 3 of 7 106104 09/23/2021 Renaissance at the Terraces 26475 South Tamiami Trail Bonita Springs, FL 34135

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tubing was on the floor and not connected to the oxygen concentrator. Resident #180 was not receiving any oxygen. *Photographic Evidence Obtained* Registered Nurse (RN) Staff H was notified of Resident #180's complaint of difficulty breathing and request for assistance. RN Staff H walked in the room, checked the concentrator, said it was functioning properly. Upon further conversation with RN Staff H she noted the oxygen tubing was not connected to the concentrator. RN Staff H replaced the oxygen tubing, connected it to the concentrator and Resident #180. RN Staff H did not complete a respiratory assessment to determine the need for further intervention. On 9/21/21 at 5:10 p.m., a review of the clinical record showed no documentation RN Staff H completed a respiratory assessment for Resident #180 on 9/20/21. On 9/22/21 at 5:05 p.m., in an interview the Director of Nursing, said it was the nurse's responsibility to ensure a resident's oxygen was set on the physician ordered flow rate and functioning properly. 106104 Page 4 of 7 106104 09/23/2021 Renaissance at the Terraces 26475 South Tamiami Trail Bonita Springs, FL 34135

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, staff interview, and policy review, the facility failed to ensure all medications were locked and secured when not in sight and failed to date opened medications to prevent expired medications from being administered to residents in 1 (3rd floor medication cart) of 2 medication carts. This had the potential for unsecured and expired medications to create hazardous health consequences for residents in the facility. The findings included: The facility policy Storage of Medications (revised 4/2007) specified, The facility shall store all drugs biologicals in a safe, secure and orderly manner . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . Compartments (including carts, drawers, and boxes) containing drugs and biologicals shall be locked when not in use. 1. On 9/20/21 at 9:35 a.m., during observation the 3rd floor medication cart with Registered Nurse (RN) Staff H the following was found: A Budes/Formot AER 80-4.5 inhaler (medication inhaled to treat respiratory symptoms) for Resident #180 with directions to discard the inhaler after 90 days from the date opened. The inhaler was open and there was no date on the label to identify when the inhaler was opened. Registered Nurse (RN) Staff H said when she used the inhaler today it was already opened. RN Staff H confirmed without the open date it was impossible to know when the inhaler would expire. *Photographic Evidence Obtained* An opened bottle of Refresh Tears 0.5%, without a date to indicate when the medication was first opened. The Manufacturer instructions specified to discard the medication 90 days after opening. RN Staff H confirmed without a date, it was impossible to know when the medication would expire. *Photographic Evidence Obtained* 2. On 9/20/21 at 4:44 p.m., during a medication observation, RN Staff H poured Milk of Magnesia (MOM) liquid into a medication cup for Resident #181. RN Staff H left the medication uncapped on top of the cart and did not lock the cart. RN Staff H walked down the hall to the resident's room, leaving the cart and medication unsecured, and out of her sight. Two Certified Nursing Assistants were observed standing next to the unsecured medication cart. RN Staff H returned to the cart and confirmed she had left the medication open on top of the cart and did not lock the medication cart when the cart was not in her sight. 106104 Page 5 of 7 106104 09/23/2021 Renaissance at the Terraces 26475 South Tamiami Trail Bonita Springs, FL 34135

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, policy review, and interview, the facility failed to store, label, food products in walk in refrigerator and freezer in a safe and sanitary manner to prevent potential cross contamination. The facility failed to discard expired food items in the walk-in refrigerator. The findings included: The Santa Fe Senior living Food Storage and Handling Policies and Procedures created March 2020 read, Policy It is the policy of the Dining services team (managers and associates) to cover, label, date, and store all foods in a safe storage area: refrigerator, freezer, or dry storage. Purpose The purpose is to prevent food borne illness(es). Procedures All cooked, pre-packaged open container, protein-based salads, desserts, and canned fruits are labeled, dated, and accurately covered. Dating System for Opened Foods Always securely cover the food item(s). Using a label, complete the following information using the referenced guide. Clearly write the item mane/contents, made on date, use by date, and initials of the person who prepared the label. On 9/20/21 at 9:20 a.m., during observation of the initial kitchen tour with the Consultant Dietitian in the walk-in freezer, there was an unwrapped, frozen pizza not covered or labeled. In the walk-in refrigerator there was: Salisbury steaks uncovered and unlabeled Crab mix with an expiration date of 9/17/21, not discarded. Pea soup uncovered and unlabeled. Cooked Asparagus uncovered and unlabeled. Raw pork uncovered and unlabeled. Raw fish uncovered and unlabeled. Raw chicken marinating unlabeled. 106104 Page 6 of 7 106104 09/23/2021 Renaissance at the Terraces 26475 South Tamiami Trail Bonita Springs, FL 34135

F 0812 *Photographic Evidence Obtained* Level of Harm - Minimal harm or potential for actual harm On 9/20/21 at approximately 9:30 a.m., in an interview the Consultant Dietician verified the crab mix was expired and should have been discarded. She also verified all food items stored in the freezer and refrigerator should be covered and labeled. Residents Affected - Few 106104 Page 7 of 7