Island Health And Rehabilitation Center

F-F814. As

a result of the repeat deficiencies, it was identified there was insufficient auditing and oversight to correct the deficiencies.

On 1/17/25 at 3:54 PM, the Administrator stated the QAPI committee met monthly and included staff from various departments. He explained the committee reviewed and discussed the previous month's data gathered by departments. The committee determined what Performance Improvement Plans (PIPs) to put in place to address the identified areas. The Administrator clarified audits were a part of PIP monitoring and were brought to QAPI to evaluate the effectives of the plan. He explained PIPs continued to be addressed until the committee determined the facility had reached a level of substantial compliance. The Administrator verified PIPs were developed and implemented based on survey outcomes.

He explained the goal of QAPI activities was to make and sustain improvements in identified areas. The Administrator acknowledged repeat citations were identified during the current survey. He stated there was no excuse and acknowledged there was obvious system breakdown which needed to be addressed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 105325 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105325 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrock Rehabilitation and Nursing Center at Islan 125 Alma Blvd Merritt Island, FL 32953

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 32131 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure correct signage was posted Residents Affected - Some for Enhance Barrier Precaution (EBP), failed to ensure Personal Protective equipment (PPE) was readily available for residents on EBP, and failed to ensure proper infection control measures were practiced, by failing to store residents' equipment in a sanitary manner on 1 of 2 Wings, (A wing).

Findings:

On 1/14/25 at 9:23 AM, observation showed signage on resident #5's room door for contact Isolation, a container with the appropriate PPE was not noted. Certified Nursing Assistant (CNA) D was sitting in the resident's room, and stated the contact isolation was for resident #5 due to wounds and explained she was providing one-on-one observation to the resident for safety. The CNA stated that gloves were in the room, but no other PPE was in place.

On 1/14/25 at 9:27 AM, Licensed Practical Nurse (LPN) A stated resident #5 was on contact isolation due to

a wound.

On 1/14/25 at 9:30 AM, the Infection Preventionist (IP) who explained she was also the Assistant Director of Nursing. She stated resident #5 was on EBP due to a wound. The signage posted on the resident's door was observed with the IP. She acknowledged the signage was incorrect, and should have been for EBP, not contact isolation, and acknowledged that the appropriate PPE was not in place. The IP stated EBP was initiated for residents with wounds, gastrostomy tubes (GT), and indwelling catheters. However, resident #31 was currently receiving GT feed, and had no signage in place regarding EBP, and PPE was not readily available. This was acknowledged by the IP. She verbalized that a total of thirty (30) residents were currently

on EBP but was unable to say if signage was posted for them. She shared that prior to 1/01/25 signage was posted, and caddies with PPE were outside of the resident doors in the hallways, but the caddies were removed from the hallways due to pillage'. The IP stated PPE were available in the CNA's supply room at the nurses' station.

On 1/16/25 at 8:52 AM, CNA B stated that when providing care for residents on EBP, she had to retrieve PPE from the CNA supply room by the nurses' station, prior to going into the resident's room. She said it was

a lengthy process.

On 1/16/25 at 9:00 AM, Licensed Practical Nurse (LPN) E stated signage for EBP was posted on the walls in

the resident's room, and PPE would be in a container at the resident's door. LPN E stated she had some residents on EBP, and signage was posted on the wall in the resident's room, but PPE was not available at

the doors, or in the residents' rooms. The LPN stated if she had to do catheter care she would need PPE and would have to go to the CNAs supply room at the nurses' station instead of having it readily available at the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 105325 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105325 B. Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrock Rehabilitation and Nursing Center at Islan 125 Alma Blvd Merritt Island, FL 32953

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/16/25 at 9:29 AM, the IP stated that a Quality Assurance and Performance Improvement (QAPI) meeting was held on 1/15/25 for implementing that EBP signs would be placed above the residents' bed in a Level of Harm - Minimal harm or sleeve. PPE would be made available in the supply room at the nurses' station, and she considered that as potential for actual harm being readily available. She shared that prior to the QAPI, Transmission Based Precaution signage was posted on the residents' doors, and caddies with the appropriate PPE were outside the rooms. However, Residents Affected - Some since 1/01/25, the caddies were removed from the hallways, gloves were available in each room, and gowns and other PPE had to be retrieved from the supply closet at the nurses' station.

The policy Enhanced Barrier Precautions with effective date of 4/01/24, and revision date of 4/03/24 read, Make gown and gloves available inside of the resident's room .Signage indicating enhanced barrier precautions to be placed inside of resident room. PPE to be kept inside resident room and easily accessible for use.

2. On 1/13/25 at 10:48 AM, and on 1/16/25 at 1:20 PM, observations showed two basins on the floor in the bathroom of room #A-17. The basins were not labeled with the individual resident's name and were not stored in a plastic bag.

On 1/16/25 at 1:23 PM, Registered Nurse (RN) F stated that in a perfect world resident's equipment/ basin should be labeled, placed in a plastic bag, and stored in the resident's closet, not stored on the floor.

On 1/16/25 at 1:25 PM, an observation of the basins on the bathroom floor was conducted with the IP. She acknowledged the findings, and stated for proper infection control practices, the basins should not be stored

on the floor, they should be labeled and placed in the individual residents' closet/drawer to prevent cross contamination.

On 1/16/25 at 1:38 PM, CNA M stated bed pans, and basins for residents should be placed in a plastic bag, labeled, and stored in the resident's closet or empty drawer.

The facility's policy Nursing-Infection Control Prevention and Control Program with effective date 2/21/23 did not address storage of resident equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 105325