Health inspection·February 27, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to timely report to the State Agency allegations of resident-to-resident abuse for 4 of 6 sampled residents, Resident #1 and Resident #2 involved in an incident; and Resident #5 and Resident #6 involved in another incident. The findings included: Review of the Policy titled Abuse-Reporting and Response - No Crime Suspected, issued on 10/04/22 and reviewed on 06/17/24 documented, in part, . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance to State law through established procedures. 1. Record review revealed Resident #1 was admitted to the facility 01/02/25 with diagnoses including recurrent Major Depressive Disorder, Paranoid Schizophrenia, Anxiety Disorder, unspecified Intellectual Disabilities, Impulsiveness, and Emotional Lability. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. This same MDS documented mood and behavior symptoms that occurred frequently. Record review revealed Resident #2 was admitted to the facility 07/22/22 with diagnosis including Moderate Vascular Dementia with Mood Disturbance, generalized Anxiety Disorder, unspecified Dementia with unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Major Depressive Disorder. Resident #2 did not have a BIMS score, indicating the resident was unable to answer any of the interview questions. Review of the abuse incident that happened on 02/11/25 documented an incident that had occurred between Resident #1 (the perpetrator) and Resident #2 (the victim.) The incident was reported by the Social Services Director (SSD) as followed: Incident time: 11:00 AM . Staff became aware of the incident .11:10 AM . Allegations: Physical Abuse .Time reported to the Abuse Registry: 12:43 PM. This report was not submitted to the State Agency until 4:26 PM, approximately 5 and a 1/2 hours after the incident occurred. Page 1 of 2 105268 105268 02/27/2025 Lakeside Health Center 2501 N Australian Avenue West Palm Beach, FL 33407

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of an incident that happened on 02/10/25 documented an incident had occurred between Resident #5 (the perpetrator) and Resident #6 (the victim.) The incident was reported by the SSD as followed: Incident time: 6:00 PM . Staff became aware of the incident .6:01 PM . Allegations: Physical Abuse .Time reported to the Abuse Registry: 10:39 AM on 02/11/25. This report was submitted to the Abuse Registry approximately 16 and a 1/2 hours later and to the State Agency at 11:49 AM on 02/11/25, approximately 18 hours after the incident occurred. During an interview on 02/27/25 at 1:45 PM, when asked what the timeframes were involved with abuse allegation reporting, the SSD stated it must be reported within two hours to Adult Protective Services. When asked if that was the only agency that needed to know of the incident, she stated, Just Adult Protective Services within 2 hours and the State agency right after, but I have not been instructed on a specific timeframe for the State Agency. She stated that there was no way she could submit a timely report without doing her own observations and interview, checking on both residents' safety and compiling a list of witnesses to the incident. The SSD explained if she had to report it within 2 hours to the State Agency, her report would not be detailed. During a side-by-side review of the regulation, the SSD agreed she should have completed the immediate report to the State Agency within 2 hours. During an interview on 02/27/25 at 3:22 PM, when asked why the abuse report between Resident #5 and Resident #6 was not submitted timely, the Director of Nursing (DON) stated that the reason that staff (the evening supervisor) was not working for the facility any longer. The DON stated the incident between Resident #5 and Resident #6 happened during the evening, and the evening supervisor did not report the incident to anyone. The DON stated she found out about the incident the next morning. When asked what the timeframes were for reporting abuse allegations, the DON stated it is within 2 hours for both Adult Protective Services and the State Agency. When asked why the SSD did not know the reporting time for the State Agency, the DON stated she should have known it was 2 hours. 105268 Page 2 of 2