Based on observation, record review, policy review, resident and staff interview the facility failed to have documentation of physician's orders for follow up care of surgical incision for 1(Resident #246) of 5 residents reviewed with wounds. The findings included: Facility policy #205, revised 12/20, titled, Wound and pressure Injury Assessment, Treatment and Prevention, defined surgical wound as a physical disruption of the skin caused by a cutting instrument. Policy stated, . Comprehensive assessments must be completed by the registered nurse and documented in the clinical record . Call physician for wound care/dressing change orders if none available on admission . Surgical wound . Dressing as per surgeon orders . Document daily on progress and healing . Alert MD [Physician] to any changes . On 11/1/21 at 10:53 a.m., Resident #246 was observed in wheelchair with left leg elevated. Surgical wound with visible staples to left knee observed. Resident #246 said he was concerned he had the staples for 16 days. The Resident said he knew they should come out in 10 days to 2 weeks. The Resident said, They haven't told me anything about when they will come out. I don't want to get an infection or something. On 11/2/21 at 12:10 p.m., Resident #246 was observed in bed, staples continued to left knee surgical site, resident remained unaware of when they would be removed. On 11/2/21 review of the clinical record revealed on 10/13/21 Resident #246 had a left knee arthroplasty (Surgical reconstruction or replacement of joint). The record had no physician orders for management of surgical incision, including the removal of the staples. On 11/2/21 at 3:50 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said the care of the staples are based on the individual physician's orders. Upon review of the clinical record, LPN Staff A said she was unable to find any information or physician orders addressing the resident's staples to left knee surgical site. On 11/2/21 at 4:00 p.m., Charge Nurse RN Staff B, reviewed Resident #246 electronic medical record and confirmed she was unable to find documentation of physician's orders for follow up care of the surgical incision and staples for Resident #246's left knee. On 11/2/21 at 4:30 p.m., in an interview, the Director of Nursing (DON) said the surgical staples can be removed at the facility or at the follow-up appointment. The DON confirmed the facility should have communicated with the surgeon to find out when he wanted the staples removed. The DON said, We missed it and I will add surgical wound site management to the performance improvement plan (PIP) I currently have for wounds. I recognize it is a problem that none of the staff confirmed what the treatment plan was for this resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and procedure, and staff interview the facility failed to have documentation of reasonable efforts to locate and involve appropriate individuals to assist in decision making for 1 (Resident #8) of 1 resident reviewed for advance directives. The findings included: Review of the facility's policy and procedure for advance directives approved on 9/2019 revealed If a physician has determined a patient lacks capacity to make informed health care decisions, Social Services shall make reasonable efforts to locate the appropriate individual(s) listed below in the following order of priority, if no individual in a prior class is reasonably available, willing, or competent to act: a) The judicially appointed guardian of the patient . b) The resident's spouse c) An adult child of the resident d) A parent of the resident e) The adult sibling of the resident f) An adult relative of the resident who exhibited special care and concern for the patient and has maintained regular contact with the patient . g) A close friend of the resident who exhibited special care and concern for the patient and has maintained regular contact with the patient and who is familiar with the resident's activities, health, and religious or moral beliefs. Review of the clinical record revealed Resident #8 was admitted to the facility on [DATE]. Review of the social service assessment dated [DATE] revealed [Resident #8] had a young woman at his bedside that he said was his daughter & [and] she only speaks Spanish. The Social Worker also documented Resident #8 was married and Pt [patient] has children & [and] a cousin who live in the US. His cousin [name] said that he has a wife in Haiti. On 5/24/18 the Social Worker documented Spoke to [name] in regards to discharge planning. She said that she spoke with her husband [name] & [and] pt. [patient] cannot discharge home w/them [with them] .Pt's [patient's] children live in other people's homes and there is no other family that can take pt [patient]. On 5/30/18 the Social Worker documented Cousin [name] and his wife [name] were supposed to be present for the meeting [care plan meeting] but got into a car accident on the way to the meeting. On 9/19/18 the Social Worker documented Family has been offered assistance in helping patient apply for Medicaid for LTC [Long Term Care]. On 7/4/19 the attending physician signed a physician's determination of patient's capacity form concluding Resident #8 lacked the capacity to communicate a willful and knowing health care decision for himself or herself or to provide informed consent. On 8/7/19 the facility sent a letter to a Licensed Clinical Social Worker that read Mr. [name] is currently a patient at Health Park Care and Rehabilitation Center. It has been determined that he does not have capacity to make his own medical decisions, and there is no family who will accept responsibility for him .I am requesting that you accept responsibility for this patient as his Health Care Proxy. On 8/29/19 the Licensed Clinical Social Worker who was contacted accepted the health care proxy designation. The clinical record lacked documentation of reasonable efforts to contact the resident's spouse, adult children or interested family members to be responsible for making health care decisions on behalf of Resident #8. On 2/3/20 at 4:53 p.m., the facility Social Worker said she could not locate documentation of efforts made to contact family members to act as a health care proxy for Resident #8. She said the resident's adult children recently visited but the facility did not realize they did not have a phone number for the children. She said she will try to contact the wife, and interested family members. The facility Social Worker verified during the interview the facility failed to reach out to the resident's family members in accordance with the facility's policy and procedure.

Based on observation, review of facility policy and procedure, resident and staff interview the facility failed to have a system to maintain continuous positive airway pressure (CPAP) machines in a sanitary manner for 4 (Residents #35, #50, #94 and #300) of 5 residents who use a CPAP machine (helps you breathe more easily when you sleep). The findings included: The facility policy, CPAP Cleaning Instructions specified Wash mask daily with a mild soap, wipe with a clean dry cloth. Air dry .empty chamber water daily and replace with distilled water. On 2/5/20 at 10:00 a.m., in an interview, the Unit Manager, Licensed Practical Nurse (LPN) Staff A, said the night shift nurse was responsible to clean the CPAP machines and add water if needed. Staff A said she did not know how the machines were being cleaned. On 2/5/20 at 2:15 p.m., in an interview the Registered Nurse (RN) Staff Educator said, we were told by the Respiratory Therapist to have the nurse clean the CPAP masks daily. She said, the nurse was responsible to change the water and clean the reservoir daily and then the masks were stored in a plastic bag. On 2/4/20 at 10:46 a.m., during an observation of Resident #35's CPAP machine, the machine was turned on and working, but the resident was not in the room. The CPAP mask was lying on top of the nightstand and was not covered. The mask was dirty with flakes of white grime. On 2/03/20 at 10:43 a.m., in an interview Resident #50 said he used a CPAP machine at night. Resident #50 said he brought his own machine with him when he was admitted to the facility in December 2019. Resident #50 said the staff gave him a bottle of water for the machine. Resident #50 said staff had never cleaned his mask or tubing for him. On 2/4/20 at 10:50 a.m., during an observation of the CPAP machine for Resident #50, the CPAP mask was lying in the cluttered, top drawer of the nightstand and was not covered. There were flakes of black dust on the mask and tubing. On 2/4/20 at 11:00 a.m., an observation was made of Resident #94's CPAP machine. The CPAP mask was lying on top of the machine and was not covered. The water reservoir had water condensation from use. On 2/4/20 at 11:16 a.m., during an observation, Resident # 300's CPAP mask, was on top of the nightstand, the mask was uncovered on top of the machine and the resident's jacket was lying on top of the mask. On 2/05/20 at 1:58 p.m., in an interview Staff A said there was no documentation of who was responsible to clean the CPAP machines. On 2/05/20 at 2:05 p.m., in an interview the RN Staff Educator confirmed there was no documentation staff had been cleaning the CPAP machines. Photographic evidence obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policies and procedures, and staff interview the facility failed to maintain a system to ensure accurate reconciliation of controlled substances prior to destruction. The findings included: Review of the facility's policy and procedure for narcotic medication administration approved on [DATE] revealed If controlled medication is discontinued and needs to be disposed, Medication Destruction will be completed in Omniview and destroyed in the presence of the Director of Nursing or licensed nurse designee and Pharmacy Consultant. Review of the pharmacy policy and procedure for disposal/destruction of expired or discontinued medications with an effective date of [DATE] revealed In Florida, Schedule II, III, IV and V controlled substances that have been dispensed and not used by the patient shall not be returned to the Pharmacy and shall be securely stored by the nursing home until destroyed. A document must be completed showing the name and quantity of the drug, strength and dosage form, patient's name, prescription number and name of the nursing home. This documentation, at the time of destruction, shall be witnessed and signed by the Consultant Pharmacist, Director of Nursing, and the nursing home Administrator or his/her designee excluding the above. On [DATE] at 11:50 a.m., the Director of Nursing (DON) said when a controlled substance was discontinued, two nurses verified the quantity of the medication to be destroyed and signed on the narcotic count sheet. The Unit Manager placed the controlled medications and the count sheet in a locked cabinet in the medication room on the unit. She said, once a month she collected all the discontinued controlled substances and the count sheets from the cabinet, created a log and prepared them for destruction. She said the log was created on the day the consultant pharmacist came for the destruction. The DON said no one kept track of the discontinued controlled substances once placed in the cabinet. She said the nurses and the unit managers have access to the cabinet. On [DATE] at 2:45 p.m., observation of the medication room with the Assistant Director of Nursing (ADON) revealed a locked cabinet with a large gap of approximately 7 inches between the cabinet and the door. The cabinet contained multiple blister cards of controlled substances. She acknowledged that anyone could easily pull medications from the cabinet through the gap. The ADON said they did not keep a log with a list of the medications in the cabinet. She said the unit manager also had a key to the medication room and the controlled substance cabinet. She verified that all the nurses have access to the medication room. On [DATE] at 4:00 p.m., during an interview with the Unit Manager she said she kept a key for the controlled substances cabinet. She said when she leaves the facility, she placed the key in the Social Worker's office in order for the night shift supervisor to have access to the controlled substances. She said a few people, including the DON and the supervisors had the master key that opens all the doors.