Health inspection·September 8, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure code status (type of emergent treatment a person would or would not want to receive if their heart or breathing were to stop) was identified and confirmed upon admission for two residents (#146, #144) out of four sampled residents. Findings included: Review of the medical record for Resident #144 was conducted on 09/06/22. The Resident Face Sheet revealed she was admitted to the facility on [DATE] at 2:27 p.m. There were no orders entered in the medical record for code status and no advance directive documentation was found identifying code status. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 09/06/22 at 3:35 p.m. She confirmed she was the assigned nurse for Resident #144. She reviewed the resident's electronic medical record (EMR) and confirmed no code status had been identified and no orders for code status had been entered in the record. She confirmed there should be a physician order entered for code status when a resident was admitted and said typically there would be an order and it would populate to the banner at the top of the record view in the EMR. She said the process for determining code status for a resident in an emergency was to consult the DNR (do not resuscitate) book and if a resident wasn't in the book, they were considered a full code (full resuscitation). Staff A said the facility process was that the admitting nurse was supposed to ensure code status was entered and ordered. She revealed a history and physical document from the resident's hospital record prior to admission where full code was documented and stated based on that she would immediately make an entry and order for full code in Resident #144's medical record. Follow up on 09/06/22 revealed full code was ordered and entered in Resident #144's record by Staff A. An interview was conducted on 09/6/22 at 3:50 p.m. with the Director of Nursing (DON). Findings related to Resident #144 were brought to her attention. Regarding facility process for identifying code status she said, What happens is everyone is full code until we have specific documentation otherwise. She confirmed it was the expectation that orders for code status should be entered by the admitting nurse during a resident's admitting process and said, Tomorrow we're having a class with the nurses on putting in new residents, things like code status and allergies, everything that needs to be done on admission. The DON identified that typically the facility social worker was responsible for confirming advance directives with residents at admission but stated the facility had not had a social worker for about a month. She stated Staff D, Marketing Director had been assisting with the social worker role including confirming code status. Page 1 of 15 105292 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/06/22 at 5:00 p.m. the DON provided the audit results for all residents of the facility related to advance directives and code status. She provided a copy of the audit dated 9/6/22 at 4:20 p.m. The review identified Resident #146 as having No Directives. Review of Resident #146's medical record revealed he was admitted to the facility on [DATE] at 9:43 p.m. Active physician orders for September 2022 revealed a general order dated 8/7/22 for Code Status: FULL FYI (for your information) Only and a general order dated 09/06/22 for Code Status: Full. There were no other advance directive documents or documentation found in the record. An interview was conducted with Staff D, Marketing Director on 09/07/22 at 4:05 p.m. He confirmed he was the person in the facility responsible for confirming code status with residents when they were admitted . He revealed a consent form document titled Code Status and explained it was used with each resident and the process was for the resident to sign confirming their code status as either DNR (Do Not Resuscitate) or full code. He revealed a signed document for Resident #144 dated 09/07/22 and said the resident had admitted to the facility on a holiday weekend which is why it had not been completed when she was admitted . He said, I'm here Monday through Friday and said the form was completed with Resident #144 on 09/07/22 because it wasn't done. He said, I'm the only one right now that does this document. Staff D confirmed the document was not provided or completed for Resident #146 upon admission either and revealed he had completed, and resident had signed it that day (09/07/22). Staff D stated he had explained to Resident #146 the facility had missed doing it when he was admitted . Review of the consent forms for both residents revealed they had each signed the form and elected code status of full code. An interview was conducted on 09/07/22 at 1:29 p.m. with the Nursing Home Administrator (NHA), the DON, and the corporate Director of Clinical Reimbursement (DCR). Findings related to advance directives and code status were discussed. All agreed that a physician order for code status was required for every resident upon admission to the facility. The NHA stated the admissions staff completed an admission packet that included code status. Regarding facility process for ensuring code status and advance directives were not missed, the NHA stated there was a 72-hour post-admission meeting where the resident's care needs were reviewed and said, That 72-hour meeting is not happening. Review of facility policy titled, Advance Directives, revised December 2016 revealed: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 22. The Staff Development Coordinator will be responsible for scheduling advance directive training 105292 Page 2 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0578 Level of Harm - Minimal harm or potential for actual harm classes for newly hired staff members as well as scheduling annual Advance Directive In-Service Training Programs to ensure that our staff remains informed about the residents' rights to formulate advance directives and facility policy governing such rights. Residents Affected - Few 105292 Page 3 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure baseline care plans with the instructions needed to provide effective and person-centered care according to professional standards of quality care were developed for two newly admitted residents (#147 and #144) out of four sampled residents. Findings included: A review of the medical record conducted on 09/06/22 for Resident #144 revealed she was admitted to the facility on [DATE] at 2:27 p.m. There was no baseline care plan in her record. Review of the medical record for Resident #147 revealed he was admitted to the facility on [DATE] at 5:00 p.m. There was no baseline care plan in his record. An interview was conducted with the Director of Nursing (DON) on 09/06/22 at 3:50 p.m. She reviewed the medical record for Resident #144 and confirmed there was no baseline care plan. She said, What is supposed to happen there, is I do the observations and I do the 48-hour care plan .this one I am negligent on that, I'll admit that I did not get to it. An interview was conducted on 09/07/22 at 1:29 p.m. with the Nursing Home Administrator (NHA), the DON, and the corporate Director of Clinical Reimbursement (DCR). All parties confirmed it was a facility requirement that a baseline care plan be developed for all residents within 48 hours of admission to the facility. The medical record for Resident #147 was reviewed and all parties agreed there was no baseline care plan for the resident. The DON said it hadn't been done because it had been due while she was away on vacation. The DON said she was the primary responsible party in the facility for baseline care plan development and said, I'm doing 98.5 percent of them. Regarding any backup for the DON, attendees reported there was a unit manager, but they had been out sick, just returned recently, and weren't fully trained on how to do a care plan. Review of the facility policy titled, Care Plans and Care Plan Meetings, revised 10/4/18, revealed: Baseline Care Plan - A preliminary plan of care that includes the minimum healthcare information necessary and instructions will be started and the facility will enable the resident to be informed of and participate in the development and implementation of the care and treatment regimen which will provide effective and person-centered care to properly care for the resident that meets professional standards of quality care and meets the resident's immediate needs shall be developed for each resident. The baseline car plan summary must be provided to the resident and/or their representative (RR) between the 48th hour and completion of the comprehensive care plan, which can be no more that 21-days after admission. 1. The nursing staff will review the Attending Physician's orders (e.g., dietary needs, medications, and routine treatments, etc.) with the resident and representative, if applicable and collectively implement a care plan to meet the resident's immediate care needs. The nursing staff will ask that the resident sign the Baseline Care Plan to indicate that a summary of contents was shared with him/her and will share the collaborative plan with the Attending Physician. 2. The Baseline Care plan will be referred to and updated while the staff can conduct the 105292 Page 4 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0655 comprehensive assessment and develop an interdisciplinary, comprehensive, resident-centered care plan. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105292 Page 5 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, facility policy and record review the facility failed to ensure a resident centered care plan was developed and implemented related to behavior monitoring for use of a psychotropic medication for one (Resident #39) of five residents sampled. Findings included: On 09/6/2022 at 9:41a.m., an observation was conducted of Resident #39 lying in bed, with Staff E, Certified Nursing Assistant (CNA) sitting in a chair next to Resident #39's bed performing a one on one (1:1). Staff E, CNA was interviewed and she revealed Resident #39 did not have any behaviors at the time. A review of Resident #39's Face Sheet indicated he was originally admitted on [DATE] and re-admitted [DATE] with multiple diagnoses to include vascular dementia with behavioral disturbance, alcohol abuse, anxiety disorder and Wernicke's Encephalopathy (degenerative brain disorder). A review of the Physician Order Report, dated 7/01/2022 - 09/08/2022, indicated Seroquel (Quetiapine) Tablet 50 Milligram (MG), One tablet given twice a day for Vascular Dementia with behavioral disturbance, dated 05/08/2022, with no end date. Resident #39 did not have a physician order to have behavior monitored with the administration of the medication daily and on each shift. A continued record review revealed no documentation of behavioral monitoring for the medication Seroquel (Quetiapine) Tablet 50 Milligram (MG) twice daily 09:00 a.m. and 09:00 p.m., on the Medical Administration Record dated 09/01/2022 - 09/08/2022. The review of the Quarterly Minimum Data Set (MDS), dated [DATE], identified in Section C, Cognitive Patterns that Resident # 39's Brief Interview for Mental Status (BIMS) score was 00, indicating severe cognitive impairment, and Section N Medications indicated the resident was receiving antipsychotic therapy on a routine basis. A review of the care plan dated 06/30/2022, revealed the facility did not have a care plan focus area developed with goals an interventions related to psychotropic medication behaviors and side effectiveness monitoring for the medication Seroquel. On 09/08/2022 at 12:53 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed Resident #39 was not care-planned for the psychotropic medication. The DON indicated the facility uses an interdisciplinary approach to creating and updating care plans. The DON further indicated a remote person does MDS. The DON stated the MDS tells us what we need to do, and put in the care plan, but we all have the job of keeping it updated. A review of facility policy titled, Care Plans and Care Plan Meetings, revised 10/4/18, read as follows under Policy Statement: It is the responsibility of the Interdisciplinary team (IDT) to ensure the rights of the resident and/or resident representative (RR) to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, duration of care, and any other factors related to the effectiveness of the plan of care are honored. 105292 Page 6 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0656 Subsequent Comprehensive Care Plan Meeting Level of Harm - Minimal harm or potential for actual harm The Comprehensive Care Plan will be reviewed by the Interdisciplinary Team with the resident and if appropriate resident's representative including when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay and at least quarterly throughout the stay. Residents Affected - Few 11. Nursing Representative will inform the Attending Physician of any updates to the plan of care and obtain a signature on the care conference report (form Matrix Care) from the meeting to indicate that information was shared and add the signed report to the resident's medical record. Comprehensive Care Plan iii. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 105292 Page 7 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure comprehensive care plans were developed by the interdisciplinary team within required timeframes for two newly admitted residents (#145, #146) out of four residents sampled. Findings included: 1. Review of the medical record for Resident #145 revealed she was admitted to the facility on [DATE]. The resident face sheet revealed diagnoses upon admission included pneumonia due to SARS-associated coronavirus, COVID-19 acute respiratory disease, vascular dementia with behavioral disturbance, type 2 diabetes mellitus with diabetic chronic kidney disease, need for assistance with personal care, dysphagia following cerebral infarction, urinary tract infection, congestive heart failure, atrial fibrillation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Active physician orders for September 2022 revealed the resident was receiving the following treatments: physical, occupational, and speech therapy; a mechanical soft diet; oxygen as needed; blood sugar monitoring; blood thinner medication; psychotropic medications. The Brief Interview for Mental Status (BIMS) assessment completed on 8/17/22 revealed a score of 3 which meant the resident had severe cognitive impairment. The comprehensive care plan included only three care areas: nutrition related to swallowing problems (start date 08/24/22); infection related to COVID-19 infection (start date 08/17/22); participation in activities and leisure (start date 08/15/22). 2. Review of the medical record for Resident #146 revealed he was admitted to the facility on [DATE]. The resident face sheet revealed diagnoses upon admission included recent cardiac surgery, bacterial infection, repeated falls, presence of cardiac pacemaker, urinary tract infection, low blood pressure, major depressive disorder, seizures. Active physician orders for September 2022 revealed the resident was receiving the following treatments: physical and occupational therapy; indwelling catheter care; medication for low blood pressure; medication for depression; antibiotic therapy. The BIMS assessment completed on 08/12/22 revealed a score of 12 which meant the resident had moderate cognitive impairment. The comprehensive care plan included only two care areas: urinary incontinence and indwelling urinary catheter (start date 08/17/22); participation in activities and leisure (start date 08/08/22). An interview was conducted on 09/07/22 at 1:29 p.m. with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the corporate Director of Clinical Reimbursement (DCR). Regarding facility policy and expectation for comprehensive care plan development they all confirmed a comprehensive resident-centered care plan must be developed for every resident within 21 days of admission to the facility. The medical record for Resident #145 was reviewed with the group and the DCR confirmed 105292 Page 8 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the comprehensive care plan was not fully developed. She said based on Resident #145's admission date she would expect the comprehensive care plan would have been developed by 08/30/22. She reviewed the three care areas that were developed and said, That is not complete. The medical record for Resident #146 was reviewed with the group and they confirmed only two care areas present and the care plan was missing components and not completed within the required timeframe. All parties confirmed the care plan should be comprehensive with a focus area for all of a resident's care needs. The DCR stated that development of the comprehensive care plan was an interdisciplinary team function. All parties confirmed they agreed with findings that comprehensive care plans were not being developed for facility residents and reported it was a problem that had been identified and that there had been a Quality Assurance Process Improvement action plan in place related to the problem for 15 months. Regarding facility process for identifying care planning needs or gaps, the NHA stated, we have a 72-hour meeting where we go over what their (residents) needs are, it's a review of the baseline care plan with the resident & representative. The NHA said, That 72-hour meeting is not happening, and said, We're not where we need to be with the care plans but we're working on it. Review of facility policy tiled, Care Plans and Care Plan Meetings, revised 10/4/18 revealed: 72-Hour Care Plan Meeting - An Initial Care Plan Meeting shall be scheduled with the resident and representative, if applicable preferably within the first seventy-two (72) hours after admission, to discuss billing, insurance coverage, co-pays, care plan development, physician's orders, diagnoses, dietary needs and preferences, choices, goals and discharge planning since summary was presented. 1. The Social Services Director or the Administrator's designee, will serve as the Meeting Coordinator and will be in charge of initiating the Initial Care Plan meeting with the resident and an individual if he/she has identified an individual or role to be included in the planning process and the right to request meetings if applicable preferably within seventy-two (72) hours of admission. Facility staff required participation at the 72-Hour Care Plan Meeting: (A) The Attending Physician (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Comprehensive Care Plan - A comprehensive care plan must be (i) Developed within seven (7)-days after completion of the comprehensive assessment. 105292 Page 9 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to monitor behaviors related to a psychotropic drug regime for one resident (#39) of five sampled residents. Residents Affected - Few Findings included: On 09/6/2022 at 9:41a.m., an observation was conducted of Resident #39 lying in bed, with Staff E, Certified Nursing Assistant (CNA) sitting in a chair next to Resident #39's bed performing a one on one (1:1). Staff E, CNA was interviewed and asked if the resident is having any behaviors. She revealed he did not have any behaviors, but her assignment is to watch the resident due to his aggressive behaviors in the hospital, and that he tried to elope from the hospital and leave. On 09/07/2022 at 3:17 p.m. Resident #39 was observed to be lying in bed, an unidentified CNA was in the room performing a 1:1. On 09/08/2022 at 9:41a.m. Resident #39 was observed to be walking with a CNA and a nurse by the nursing station. Resident #39 was observed to be dressed appropriately for the time of day, and pleasantly smiled at the staff member next to him. A review of Resident #39's Face Sheet indicated he was originally admitted on [DATE] and re-admitted [DATE] with multiple diagnoses to include vascular dementia with behavioral disturbance, alcohol abuse, anxiety disorder and Wernicke's Encephalopathy (degenerative brain disorder). A review of the Physician Order Report, dated 7/01/2022 - 09/08/2022, indicated Seroquel (Quetiapine) Tablet 50 Milligram (MG), One tablet given twice a day for Vascular Dementia with behavioral disturbance, dated 05/08/2022, with no end date. Resident #39 did not have a physician order to have behavior monitored with the administration of the medication daily and on each shift. A continued record review revealed no documentation of behavioral monitoring for the medication Seroquel (Quetiapine) Tablet 50 Milligram (MG) twice daily 09:00 a.m. and 09:00 p.m., on the Medical Administration Record dated 09/01/2022 - 09/08/2022. A review of the care plan dated 06/30/2022, revealed the facility did not have a care plan area developed with interventions related to psychotropic medication behaviors and side effectiveness monitoring. The review of the Quarterly Minimum Data Set (MDS), dated [DATE], identified in Section C, Cognitive Patterns that Resident # 39's Brief Interview for Mental Status (BIMS) score was 00, indicating severe cognitive impairment, and Section N Medications indicated the resident was receiving antipsychotic therapy on a routine basis. On 09/08/2022 at 12:53 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed Resident #39 was not being monitored for a psychotropic medication. The DON further verified Resident #39 had not been monitored for the medication since he was originally admitted into the facility (05/04/2022). 105292 Page 10 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0757 Level of Harm - Minimal harm or potential for actual harm On 09/08/2022 at 1:04 p.m., an interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated, Yes, they (facility) should be monitoring for behaviors for Seroquel. It has been a work in progress, I have been working on it, and possibly this resident slipped thru the process. A facility policy titled, Antipsychotic Medication Use, with a revision date of December 2016, read: Residents Affected - Few Policy Interpretation and Implementation 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the residents and others. 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for appropriateness and indications for use. The interdisciplinary team will: b. Re-evaluate the use of the antipsychotic medication at the time of admission and or within two weeks (at the initial MDS assessment) to consider whether the medication can be reduced, tapered or discontinued. 16. The staff will observe, document and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. 105292 Page 11 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure implementation of an effective performance improvement action plan ongoing for 15 months related to care plans. Failures included not ensuring consistent audit process and not analyzing and tracking data from audits that were conducted to implement correction. This resulted in five residents (#144, #147, #39, #145, and #146) out of five residents sampled not having comprehensive care plans developed by the interdisciplinary team and within required timeframes. Findings included: 1. A review of the medical record conducted on 09/06/22 for Resident #144 revealed she was admitted to the facility on [DATE] at 2:27 p.m. There was no baseline care plan in her record. 2. Review of the medical record for Resident #147 revealed he was admitted to the facility on [DATE] at 5:00 p.m. There was no baseline care plan in his record. 3. A record review for Resident #39 indicated he was originally admitted on [DATE] and re-admitted [DATE] from the hospital, with multiple diagnoses of Vascular Dementia with behavioral disturbance, Alcohol Abuse, Anxiety Disorder and Wernicke's Encephalopathy. A review of physician orders indicated Seroquel (Quetiapine) Tablet 50 Milligram (MG), One tablet given twice a day for Vascular Dementia with behavioral disturbance dated 05/08/2022, with no end date. Resident #39 did not have a physician order to have behavior monitoring performed daily and on each shift. A continued record review revealed no documentation of behavioral monitoring for medication Seroquel (Quetiapine) Tablet 50 Milligram (MG) twice daily 09:00 a.m. and 09:00 p.m., on the Medical Administration Record, (MAR). The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 39's Brief Interview for Mental Status (BIMS) score was 00, (indicating severe cognitive impairment); and Section N indicated the resident was receiving antipsychotic therapy on a routine basis. A review of care plan dated 06/30/2022, Resident #39 did not have a care plan focus, goals area developed with interventions related to Psychotropic medication behaviors and side effectiveness monitoring for medication Seroquel. 4. Review of the medical record for Resident #145 revealed she was admitted to the facility on [DATE]. The resident face sheet revealed diagnoses upon admission included pneumonia due to SARS-associated coronavirus, COVID-19 acute respiratory disease, vascular dementia with behavioral disturbance, type 2 diabetes mellitus with diabetic chronic kidney disease, need for assistance with personal care, dysphagia following cerebral infarction, urinary tract infection, congestive heart failure, atrial fibrillation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. 105292 Page 12 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Active physician orders for September 2022 revealed the resident was receiving the following treatments: physical, occupational, and speech therapy; a mechanical soft diet; oxygen as needed; blood sugar monitoring; blood thinner medication; psychotropic medications. The Brief Interview for Mental Status (BIMS) assessment completed on 8/17/22 revealed a score of 3 which meant the resident had severe cognitive impairment. The comprehensive care plan included only three care areas: nutrition related to swallowing problems (start date 08/24/22); infection related to COVID-19 infection (start date 08/17/22); participation in activities and leisure (start date 08/15/22). 5. Review of the medical record for Resident #146 revealed he was admitted to the facility on [DATE]. The resident face sheet revealed diagnoses upon admission included recent cardiac surgery, bacterial infection, repeated falls, presence of cardiac pacemaker, urinary tract infection, low blood pressure, major depressive disorder, seizures. Active physician orders for September 2022 revealed the resident was receiving the following treatments: physical and occupational therapy; indwelling catheter care; medication for low blood pressure; medication for depression; antibiotic therapy. The BIMS assessment completed on 08/12/22 revealed a score of 12 which meant the resident had moderate cognitive impairment. The comprehensive care plan included only two care areas: urinary incontinence and indwelling urinary catheter (start date 08/17/22); participation in activities and leisure (start date 08/08/22). An initial interview was conducted on 09/07/22 at 1:29 p.m. with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the corporate Director of Clinical Reimbursement (DCR) regarding findings. They confirmed findings and stated lack of care planning development and implementation was a problem that had been identified and there had been a Quality Assurance Process Improvement action plan in place for 15 months and was ongoing. The DCR stated the goal of the action plan was to ensure all facility residents had a comprehensive care plan developed. Regarding why after 15 months of an action plan the problem remained, the DCR stated turnover in staffing and staff being spread too thin was part of the problem. She said, We've tried a couple different things and they just haven't worked successfully . I know it's no excuse, staffing is crazy. The NHA confirmed the facility had been without a Social Worker since the end of July (2022). Regarding facility process for identifying care planning needs or gaps, the NHA stated, we have a 72-hour meeting where we go over what their (residents) needs are, it's a review of the baseline care plan with the resident and representative. The NHA said, That 72-hour meeting is not happening, and said, We're not where we need to be with the care plans but we're working on it. A follow up interview was conducted with the NHA, DON, and DCR on 09/08/22 at 12:55 p.m. The NHA confirmed the Quality Assurance and Performance Improvement (QAPI) Committee met every month. Regarding committee process for identifying problems she said, each leadership team has a section and they report on their area, we analyze any concern or problem areas to determine a need to investigate or establish a formal QA (quality assurance) or PIP (process improvement plan), we also look at common denominators/trends there, then we get to nursing which is the meat of it . catheters, falls, wound care, weights, care plans, etc. Regarding process for developing an action plan the NHA said, We first work to identify the cause and then figure out the next step, which is usually an audit, and then 105292 Page 13 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some we go to education and follow up. Regarding evaluating effectiveness of an action plan the NHA stated the team reviewed the process and progress of any action plan at each monthly meeting and adjusted as needed. She stated determination of effectiveness of an action plan was variable depending on the focus area. The NHA reported the only current active PIP at the facility was related to care planning and had been started 15 months ago. The DCR stated the breakdown in care plans not being developed was not having an MDS (minimum data set assessor) person and not having the staff to do the care plans. She said, [DON] can't do it with all the other things she has to do. The NHA confirmed that auditing was supposed to be a part of the PIP and correction process and said, The audit process is not happening as we intended it to. Regarding whom was responsible for ensuring audits were conducted the NHA said the DCR did them. The DCR confirmed this but would not confirm an established frequency of auditing. She said, I looked at it in February and April . [MDS Coordinator] was trained yesterday on doing the audit. The DCR provided copies of a full-house audit completed on 09/07/22 following the initial interview. The audit revealed 44 residents had been audited and 29 had incomplete care plans. The NHA stated the goal was for the auditing to happen on an ongoing basis so that any new admission got added into the audit when they were admitted . No other documentation or information was provided related to the committee's PIP for care planning. Review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, dated April 2014, revealed: The primary goals of the QAPI Committee are to: 1.Establish, maintain and oversee facility systems and processes to support the delivery of quality of care and services; 2. Promote the consistent use of facility systems and processes during provision of care and services; 3. Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; 4. Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems; 5. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care; 6. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and 7. Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members. Committee Audit Process 1. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. 105292 Page 14 of 15 105292 09/08/2022 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0867 Level of Harm - Minimal harm or potential for actual harm 2. The QAPI Committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up. 3. The committee shall track the progress of any active plans of correction. Residents Affected - Some 4. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented. 105292 Page 15 of 15