Health inspection·April 9, 2025

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to maintain posting of the daily staffing requirements at the beginning of the shift in a prominent place visible to residents and visitors for 2 of 4 days observed. Residents Affected - Few The findings include: Upon tour of the facility on 4/6/25 and 4/7/25, there was no daily posting of the staff names in a prominent place for visitors and residents. On 4/7/25 at approximately 9:15 AM, an interview was conducted with the Staffing Coordinator, who indicated that she prints the staffing data to post daily on the counter behind the receptionist desk in the front lobby. The Staffing Coordinator further indicated that she lays it face up on the counter. When asked if the placement of the staffing posting is visible to residents and visitors, the staffing coordinator confirmed that placement would not be visible. She also stated that they used to keep it in a stand but they had stopped doing that for an unknown reason, but going forward it will be placed in the stand at the desk and will also place them at the nursing stations. On 4/7/25 at approximately 9:30 AM, an interview was conducted with the Administrator, who indicated that it was his expectation that the daily staffing requirement be placed in a stand up at the receptionist desk so that it would be visible to residents and visitors. Page 1 of 3 106117 106117 04/09/2025 Olive Branch Health and Rehabilitation Center 8325 University Parkway Pensacola, FL 32514

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and policy review, the facility failed to ensure safe injection practices of intravenous medications by swabbing the rubber septum of the vial prior to accessing the medication for 1 of 12 residents sampled for medication administration. (Resident #71) Residents Affected - Few The findings include: During a medication administration observation on 04/06/2025 at 1:03 pm, Staff A, a Registered Nurse (RN), administered Ertapenem (an antibiotic), 1 gram in 100 milliliters of normal saline, to Resident #71. The Ertapenam was contained in a glass vial with a rubber septum covered by a plastic cap. Staff A performed hand hygiene and popped the plastic cap off the vial using her bare hand. She then attached the vial to the 100 milliliter bag of normal saline without swabbing the rubber septum of the vial first. Staff A then administered the medication to Resident #71. In an interview afterwards, she acknowledged did not swab the top of the medication vial with alcohol before mixing with the bag of normal saline. In an interview on 4/06/25 at 3:16 PM, the Director of Nursing said the facility does not use multi-dose vials. During this interview, she was unable to recall if there was a policy which specifically included swabbing the rubber septum of the vial of medication with alcohol prior to accessing the medication and administering the medication. Review of the facility policy titled Parenterals/Intravenous Solutions dated October 2019 did not include language about wiping the rubber septum of a vial with alcohol swab prior to piercing the septum. The Centers for Disease Control and Prevention (CDC) Injection Safety Checklist dated February 7, 2024 and accessed on 04/06/2025 at 3:43PM included in the checklist The rubber septum on a medication vial is disinfected with alcohol prior to piercing. 106117 Page 2 of 3 106117 04/09/2025 Olive Branch Health and Rehabilitation Center 8325 University Parkway Pensacola, FL 32514

F 0920 Level of Harm - Minimal harm or potential for actual harm Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observation, resident interviews, and staff interview, the facility failed to provide a dining room to dine in for 1 out of 4 days observed. Residents Affected - Few The findings include: A tour of the facility's dining area was conducted on Sunday, 4/06/25 at approximately 10:40AM. During this tour, the dining area was observed clean with dim lighting, and the tables were not set up to accommodate residents for lunch. An interview was conducted on 4/6/25 at approximately 12:15 PM, with the Certified Dietary Manager (CDM) concerning the fact that no one was eating in the dining room on Sunday during lunch. She stated that they were waiting for the facility to increase staffing for the weekend and that a plan is in the works. On 04/08/25 at approximately 11:25 AM, an interview was performed with Resident # 227 who was sitting at a dining room table reviewing the lunch menu to place an order. The resident stated, I have more options available here in the dining room then I do in my room. On Tuesday 04/08/25 at approximately 11:45AM, the dining area with was being used by about 15 residents throughout the dining area. Several dietary staff were tending to the resident's needs. On 04/09/25 at 11:00 AM, Dietician Tech C stated, I have been here since June 2022 and the dining room has not been open on the weekends as long as I have worked here. An interview was conducted on 4/09/25 at approximately 2:45PM, with the Administrator. The Administrator stated that the dining room was closed on the weekends due to short staffing, which was a result of the Center of Disease Control (CDC) COVID guidelines. However, it was shown that the CDC changed the guidelines 3 months ago. The Administrator stated that there was a meeting a couple of weeks ago to discuss the reopening of the dining room in two months. This would allow time to hire more staff, for the new food vendor to be in place, and new menus to be created. 106117 Page 3 of 3