Health inspection·April 11, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, it was determined, the facility failed to appropriately assess 1 of 2 sampled residents experiencing changes in condition, Resident #1, as evidenced by the lack of monitoring signs and symptoms of a bowel obstruction, that included vomiting, diarrhea, bradycardia / tachycardia and fever. Residents Affected - Few The findings included: Clinical record review conducted on 04/10/25 revealed Resident #1 has been a long-term care resident at the facility since 08/29/22. Review of the Minimum Data Set (MDS) quarterly assessment, with reference date 01/16/25, documents Resident #1 was assessed as severely impaired for skills of daily decision making; is always incontinent of bladder and bowel; has active diagnoses of dementia; and is dependent on staff for activities of daily living (ADLs). Revie of the Care plan titled, At risk for constipation related to decrease self-mobility, last revised 01/22/25, documents interventions as: observe for and report to medical doctor complications related to constipation: change in mental status, new onset confusion, sleepiness, inability to maintain posture, agitation, bradycardia, abdominal, distension, vomiting, small loose stools, fecal smearing, decreased bowel sounds, diaphoresis, abdominal tenderness, guarding, rigidity and fecal compaction. The electronic record revealed a nurse's note communicating to the physician via fax dated 03/04/25. The nurse advised the physician that Resident #1 was vomiting, and the nurse requested antiemetic medication. The physician replied with an order for Zofran 4 milligrams every six hours as needed. Review of the Progress notes dated 03/05/25 documents, Resident remains in bed at this time and will not allow staff to get her up. Resident did not eat breakfast this morning and would not allow staff to feed her. Vital signs stable. Resident fought this nurse when the blood pressure cuff was applied but ultimately allowed vitals to be obtained. Afebrile. Resident continues to sleep but is responsive and easily roused. Review of the Advance Practitioner Registered Nurse (APRN) notes dated 03/05/25 documents, Seen in bed lethargy, vital signs stable. Patient not eating, won't get out of bed which is not her norm. Patient did vomit one episode yesterday. Review of the APRN notes dated 03/10/25 documents, the resident was seen in the hallway, lethargy has resolved, chest x-ray and urine tests were negative. The resident refused intravenous fluids and Page 1 of 3 105277 105277 04/11/2025 Stuart Rehabilitation and Healthcare 1500 SE Palm Beach Rd Stuart, FL 34994

F 0684 laboratory studies. Level of Harm - Minimal harm or potential for actual harm Review of the Progress notes dated 03/11/25 documents as follows: Residents Affected - Few Resident noted to be choking while swallowing thin liquids. APRN notified and new orders for speech consult. APRN notified of resident's abdomen is distended and causing her discomfort. New orders to give a rectal enema and a KUB (abdominal x-rays, kidney, ureter and bladder) stat. APRN was notified of resident produced a large stool post enema. APRN was notified of KUB results. Review of the Abdominal x-rays results dated 03/11/25 documents, mild to moderate ileus, follow up x-ray is needed. Review of the vital signs report and progress notes indicated the last documented vital signs for Resident #1 were dated 03/05/25. Review of the Progress notes dated 03/12/25 documents the resident noted with no bowel sounds in any quadrant. Emergency services were called to send the resident out. APRN aware. Family notified. The record failed to document Resident#1's condition or vital signs prior to transfer. Review of the Hospital records indicate Resident #1 arrived at the emergency department via ambulance, with complaints of diarrhea and abdominal distention for two days. Rescue states, as per nursing staff, the patient had ileus found two days ago. The patient has dementia and is oriented to person. The record indicates the resident arrived with unstable vital signs, blood pressure 77/45, pulse 100, and oxygen level 90 percent on room air. Laboratory studies indicate increased white blood cell count, decreased potassium levels, and abnormal kidney function. Ct scan of the abdomen revealed the following: 1. Constipation with severe fecal impaction that extends out through the sigmoid colon to the upper abdomen. The rectum measures 11 cm in diameter and the sigmoid colon measures 12 cm in diameter and is distended with dense appearing stool. Constipation extends through the splenic flexure. There is wall thickening of the descending colon, sigmoid colon and rectum likely reflecting stercoral colitis. 2. Bowel perforation. Large amount of pneumoperitoneum from bowel perforation, likely related to the severe fecal impaction/stercoral colitis. Recommend General Surgery consultation. The emergency department notes documents, Patient with peritoneal signs on exam. Lab studies consistent with leukocytosis. Discussed with general surgery. Awaiting imaging.After imaging patient with 105277 Page 2 of 3 105277 04/11/2025 Stuart Rehabilitation and Healthcare 1500 SE Palm Beach Rd Stuart, FL 34994

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pneumoperitoneum in the setting of severe constipation and would require colostomy. Plan for hospice care with [Name provided] hospice. Patient to be admitted . An interview was conducted with the Director of Nursing (DON) on 04/10/25 at 12:34 PM who revealed the facility reviewed the care provided to Resident #1 after she learned the resident had a bowel obstruction and the staff reviewed the bowel protocols, and no deviations of care were identified. A phone interview was conducted with Staff A, Licensed Practical Nurse (LPN), on 04/10/25 at approximately 1:40 PM who revealed the staff worked on 03/11/25, the resident told her she had pain and pointed to her belly, she reported it to the practitioner and x-rays were ordered. The staff recalls the resident was at baseline, wheeling self around the building, she had an enema with good results and ate dinner. The staff stated she does not recall getting prior reports that the resident was vomiting but recalls reports of diarrhea. The staff is not sure when the episodes of diarrhea occurred two or three days prior to her shift on 03/11/25 as she did not have her notes available and does not recall if vital signs were taken as the resident was at baseline. An interview was conducted with the DON on 04/10/25 at approximately 1:50 PM who confirmed the fax addressing complaints of vomiting and the physician response prescribing Zofran did not make it to the clinical record, there were no orders written, and she would complete an incident report. A follow-up interview with the DON on 04/11/25 at 2:16 PM confirmed there are no documented vital signs after 03/05/25, there is no evidence the staff re-approached and attempted to obtain the prescribed blood work after the resident refusal, and confirmed the nursing staff did not document the resident had vomiting or diarrhea. The investigation determined the nursing staff did not assess Resident #1 to monitor for continued changes in condition. There was no evidence that the staff monitored vital signs from 03/05/25 through 03/12/25. There is no documentation of Resident #1 refusing vital signs. The record validates the resident started to exhibit signs of gastrointestinal complaints on 03/04/25. The nurse failed to document the resident was vomiting and how often it occurred and failed to document and implement the physician's orders to treat the vomiting with Zofran. The nurse failed to document episodes of diarrhea and how often it occurred, as it was reported by Staff A during her interview. The nurse documented the blood work was completed on the Treatment Administration Record (TAR) dated 03/06/25. The investigation determined the resident refused it and there was no evidence that any further attempts were made to complete the laboratory studies or to initiate the intravenous fluids. Resident #1 had dementia and was well known to the staff. There was no evidence the staff tried to reapproach the resident at a later time to complete the testing and treatment. 105277 Page 3 of 3