Guardian Care Nursing & Rehabilitation Center

F-F689 for failing to provide a secure environment and adequate supervision when a cognitively impaired resident exited the facility through an unsecured/unalarmed door. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the repeat citation.

On 3/12/25 at 5:11 PM, the Executive Director reported the QAPI committee met monthly as well as held Ad HOC meetings when issues arose. She stated the committee used monthly reports and audits submitted by each department to identify areas of concern. She explained areas of concern were prioritized with areas affecting patient care with safety taking precedence. The Executive Director stated the committee always looked to identify a root cause to prevent the event from recurring. She stated that some type of auditing had to be put in place and documentation would be placed on the Performance Improvement Plan (PIP). The Executive Director explained she felt the previous situation was a result of a door malfunction and the current situation was different as resident #87 exited the building in an attempt to locate his wife. She did not explain how resident #87 was able to open the door without knowledge of staff if the door had been alarmed. The Executive Director acknowledged all exit doors were not alarmed after the previous elopement to ensure other residents could not exit through exterior doors that were designated as emergency exit only.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 105797 Department of Health & Human Services Printed: 09/04/2025 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 105797 B. Wing 03/12/2025

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

Guardian Care Nursing & Rehabilitation Center 350 South John Young Parkway Orlando, FL 32805

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 50401 potential for actual harm Based on observation, and interview, the facility failed to provide a sanitary environment to help prevent the Residents Affected - Few transmission of communicable diseases by failing to perform hand hygiene between delivering meals to 3 of 15 resident rooms in the East wing.

Findings:

On 3/12/25 at 8:55 AM, Certified Nursing Assistant (CNA) F, along with trainee CNA G, was observed as

they entered a resident's room on the East wing that had a Contact Precautions sign at the door. The sign indicated that anyone who entered must perform hand hygiene. CNA F and CNA G were observed as they brought a breakfast tray without performing hand hygiene before they entered the room or after they left. CNA F was observed as she then entered the next resident room without performing hand hygiene. CNA F without hand hygiene, then went to the food cart, got a tray of food and brought it into a resident in another nearby room. The Director of Nursing (DON) who was in the area and observed CNAs F and G, got up from

the unit nursing station and was overheard telling the trainee, CNA G to perform hand hygiene, which she then did. CNA F only nodded and stated, OK, when the observation of her and CNA G not performing hand hygiene between resident rooms was mentioned to her.

At 3/12/25 at 9:34 AM, the DON acknowledged CNA G did not perform hand hygiene when she served meals to residents, but should have. She confirmed she reminded the trainee CNA to disinfect her hands between residents when she served meals.

The facility's undated policy entitled Hand Hygiene and Resident Cleanliness Policy During Meal Times, indicated staff must wash hands or use hand sanitizer between residents when they delivered meal trays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 105797 Department of Health & Human Services Printed: 09/04/2025 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 105797 B. Wing 03/12/2025

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

Guardian Care Nursing & Rehabilitation Center 350 South John Young Parkway Orlando, FL 32805

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51023 potential for actual harm Based on interview, and record review, the facility failed to provide proof of consent, refusal, or medical Residents Affected - Some contraindication for pneumococcal vaccine for 3 of 5 residents reviewed for immunizations, of a total sample of 34 residents, (#20, #9, and #59).

Findings:

1. Resident #20 was admitted to the facility on [DATE REDACTED]. Review of her medical record revealed no documentation of consents, refusals, or medical contraindications for the pneumococcal vaccine.

2. Resident #9 was admitted to the facility on [DATE REDACTED]. Review of her medical record revealed no documentation of consents, refusals, or medical contraindications for the pneumococcal vaccine.

3. Resident #59 was admitted to the facility on [DATE REDACTED]. Review of his medical record revealed no documentation of consents, refusals, or medical contraindications for the pneumococcal vaccine.

On 3/12/25 at approximately 6:00 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed they were unable to provide a record of documentation of consent, refusal, or contraindication for administration of the pneumococcal vaccine for residents #20, #9, and #59. The DON acknowledged they could not find documentation to show if the residents had previously received the vaccination, refused it or if the vaccination was even offered. The DON explained that the previous ADON was responsible for obtaining consents from the residents or their representatives and it seemed she only documented for the Influenza vaccinations.

The facility's policy titled Pneumococcal Polysaccharide Vaccine (PPV) states that all residents will be offered a Pneumococcal Polysaccharide Vaccine (PPV) upon admission and every five years thereafter or according to local health department guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 105797