Health inspection·November 2, 2023

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a safe and effective discharge planning process for three (#8, #3, and #1) of five residents sampled for discharge. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for dialysis or home health services. Resident #3 had severe cognitive impairment and was discharged in a taxi cab to live with a family member who was not present or prepared to care for the resident in the home. Resident #3 had no way to access the home upon his arrival and the taxi cab driver contacted law enforcement for assistance. Resident #1, who was dependent on oxygen, was discharged home without medical equipment to maintain her respiratory status. Residents Affected - Some The facility's system failure placed Resident #8, Resident #3, and Resident #1 at serious risk of injury or death and resulted in the determination of Immediate Jeopardy on 09/23/2023. The findings of Immediate Jeopardy were determined to be removed on 11/02/2023 and the severity and scope was reduced to an E after verification of removal of immediacy of harm. Findings included: 1) Resident #8 was admitted to the facility on [DATE] with diagnoses to include unspecified sequelae of cerebral infarction, chronic pain, abnormalities of gait and mobility, muscle weakness, End Stage Renal Disease (ESRD) requiring dialysis, temporary catheter in upper right chest for dialysis, altered mental status and adult failure to thrive. A review of the MDS (Minimum Data Set) admission assessment dated [DATE] revealed the resident was able to make himself understood and he was able to understand others. The resident's BIMS (Brief Interview for Mental Status) score was 11, indicating moderately impaired cognition. In Section G: Functional Abilities, the resident was assessed as requiring extensive assistance with one staff for toileting, personal hygiene, and dressing; supervision with one staff for walking in his room or for short distances, with his balance described as unsteady. A review of the resident's care plan, dated 09/26/2023, revealed the following: Problem: discharge: Resident has D/C (discharge) plan, is uncertain at this time as he lost his home in the community. (start date 09/26/2023) Goal: Resident will receive assistance with discharge planning should preferences change through the review date. (Long term goal target date: 12/26/2023) Page 1 of 38 105292 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Approaches included: Ask about returning to the community with each assessment. Level of Harm - Immediate jeopardy to resident health or safety Re-evaluate preferences regarding discharge planning regularly and PRN (as necessary). (Start date: 09/26/2023) Residents Affected - Some Problem: Nutritional Status: Resident is at nutritional risk r/t (related to ): ESRD, new dialysis, hx (history) CVA (Cerebral Vascular Accident). (Start date: 09/27/2023) Goal: Resident's weight will remain less than +/- 5% weight change within a 30 day time period through next review. (Long term goal target date: 12/27/2023) Approaches included: Monitor lab values per dialysis record Albumin >60 yr: 3.4 - 4.8 g/dl (grams per deciliter); plasma transferrin> 60 yr: 180-380 g/dl; HGB (hemoglobin) - Males: 14-17 g/dl - Females: 12 15 g/dl; HCT (hematocrit) - Males 41-53 - Females 36-46; Potassium: 3.5 5.0 mEq/L (milli-Equivalents/Liter); Magnesium: 1.3 - 2.0 mEq/L). Resident will attend dialysis as scheduled T, Th, Sat (Tuesday, Thursday, Saturday). Resident will receive a NAS (no added salt diet), avoid potatoes, tomatoes, bananas, oranges r/t high K (potassium) content. Weigh and monitor results upon admission daily times 3 days, weekly x 4 weeks, then monthly if stable. (Start Date: 09/27/2023). A review of the Transition of Care/Discharge summary, dated [DATE], revealed Resident #8 would be returning to his home. The document showed the resident was responsible for himself. The Discharge Summary did not include a contact phone number for either the resident or an emergency contact. The summary did not include the ESRD facility address and his schedule to receive dialysis. Under the heading of Care Plan Goals, as a discharge goal, the facility had documented, PT (Physical Therapy), OT (Occupational Therapy) , RN (Registered Nurse) Eval (Evaluation). There was no reference to the referral for a Home Health Agency or who would be conducting the evaluations. The summary did not contain a Post Discharge Plan of Care which would include: arrangements that have been made for follow up care and services; how the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed in accordance with the facility's undated policy titled Discharge Summary and Plan. Review of the Social Services Director (SSD) progress note dated 10/05/2023 revealed a referral had been made to a Home Health Agency. A telephone interview was conducted with the Home Health Agency on 10/19/2023 at 11:08 a.m. to ask about services ordered for Resident #8. The Referral Intake Associate at the Home Health Agency reported they did not have Resident #8 in their system to provide home health services following his discharge on [DATE]. The Referral Intake Associate confirmed they made no visits to Resident #8 after he was discharged from the facility on 10/06/2023 and no PT, OT, or RN services had been rendered. 105292 Page 2 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Level of Harm - Immediate jeopardy to resident health or safety A review of the Therapy Discharge Summary for Physical Therapy services provided from 9/20/2023 10/05/2023 for Resident #8 revealed the patient was unable to make significant functional gains due to being dialysis dependent and fatigued post dialysis. The discharge instructions included the resident's need for assistance with all ADLs. A review of Resident #8's progress notes revealed: Residents Affected - Some -admission note, dated 09/19/2023: The resident was alert, verbalizing appropriately, tearful at times and stated he was unsure of dialysis. -Social Services Director (SSD) note, dated 09/20/2023: The resident appeared alert and oriented x 3, with a plan of discharge to remain in the facility long term care for now. The note included the resident's statement of feeling depressed with the SSD noting she would refer the resident to the psychologist. -An IDT (Interdisciplinary team) note, on 09/26/2023, documented a continued need for a skilled level of care and continued work with therapy. The note indicated the discharge plan was uncertain at this time as he lost his home in the community. -10/02/2023 a note by the SSD indicated the plan for discharge was to go out of state to Indiana. -10/04/2023 the resident was presented with a Notice of Medicare Non-Coverage (NOMNC) showing the LCD (last covered day) of Medicare coverage to the facility was 10/05/23 and the resident chose not to appeal this decision. - SSD note, dated 10/05/2023: The resident would be going home to the address noted on his face sheet from admission and a name and address for the Home Health Agency was listed. -10/06/2023 a nurse's note confirmed the resident had been discharged to home by taxi. - Progress note, dated 10/09/2023 at 1:00 p.m., revealed the Administrator received a call from the Social Worker at the Dialysis center where Resident #8 had been receiving services. The Social Worker asked the Administrator why they discharged the resident to a condemned trailer and apprised the Administrator the resident had missed his last dialysis treatment, on 10/07/2023. The Administrator told the Dialysis Social Worker the facility was not aware the resident's home was condemned and didn't know he had skipped dialysis the day after he was discharged home. The Administrator explained to the Dialysis Social Worker, as documented in her progress note written on 10/09/2023, she had met with the resident with the facility SSD to explain to the resident he was welcome to remain at the facility during the Medicaid pending process. The Administrator documented the resident informing her and the SSD he wanted to return home and showed both of them he had his keys to his home to let himself back in. After the phone call, the Administrator and the facility SSD drove over to the resident's home and saw the home was a trailer that generally was in good repair, but had two windows broken out. The resident was sitting outside of the trailer and told the facility staff his neighbors were working on fixing up the trailer for him. After receiving permission, the SSD looked inside of Resident #8's trailer and documented garbage, filth, a horrible odor, and a piece of orange paper in the doorway. The orange paper was a condemned notice. When the facility staff told Resident #8, he could not remain 105292 Page 3 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Level of Harm - Immediate jeopardy to resident health or safety living in a condemned trailer he became verbally abusive. The facility staff phoned 911 and the police officer who responded told the resident he could not remain in a condemned trailer and if he did, he was trespassing. When the officer offered the resident three choices --going to the hospital, jail, or returning with the facility staff to the facility, he chose to return to the facility. Upon returning to the facility the resident was evaluated by Psychiatric services who determined the resident was a danger to himself and he was involuntarily admitted to the hospital. Residents Affected - Some An interview was conducted with the NHA (Nursing Home Administrator) and the SSD on 10/17/2023 at 5:00 p.m. The NHA reported they were not aware the trailer had been condemned and didn't know why the Home Health Agency hadn't called them to let them know the resident's trailer was condemned. The NHA said the resident told them his home was ok, he showed them his keys indicating he would be able to get into the trailer, and he could discharge to his home. The SSD reported she just hadn't revised the care plan to indicate he had a home in the community. They confirmed they had not investigated the home and the condition of the home. They confirmed they discharged the resident as he requested and had not followed up on the resident's statement that he lost his home in the community as documented in the 09/26/2023 care plan and IDT progress note. A call was placed to the Dialysis Social Worker on 11/02/2023 at 3:10 p.m. She confirmed the dialysis facility had not been notified of the resident's discharge from the nursing home to his mobile home. She stated she would have questioned that discharge as she was aware the mobile home had been condemned. She stated she knew about the trailer from his initial hospitalization paperwork, which led to his transfer into the nursing home. She reported the resident had been receiving dialysis at her facility for a year or two and agreed the address and schedule should have been on his discharge paperwork for him due to his fluctuating cognition. Resident #8 was re-admitted to the facility on [DATE] from the hospital. On 11/02/2023 at 9:00 a.m. an interview was conducted with Resident #8. He stated he was found at his mobile home by the lady in charge (NHA), was taken back to the hospital (for an involuntary admission), and then came here (back to the facility). He confirmed he received dialysis services and touched the dressing on his catheter located in his upper right chest, then held up his right arm to expose his new permanent vascular access for dialysis. He wasn't sure if he had gone to dialysis. He said he felt ok and didn't think he needed to go. When asked if he went to dialysis when he was discharged home on [DATE], he stated he hadn't been told the address or the schedule for his dialysis treatments when he was sent home so he had not gone. 2) Resident #3 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization with diagnoses to include senile degeneration of brain, altered mental status, vascular dementia, severe with agitation, schizophrenia, and major depressive disorder. A review of the 08/01/2023 admission Minimum Data Set (MDS) Assessment, Section C: Cognitive Abilities, showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident's mental status was described as inattentive with disorganized thinking. In Section G: Functional Abilities, the resident was assessed as needing extensive assistance with two staff for bed mobility, transferring, and toileting; extensive assistance with one staff for locomotion around the facility in a wheelchair, dressing, eating, and personal hygiene; and his gait was not steady. A review of the care plan, dated 08/18/2023, revealed the following: 105292 Page 4 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Problem: discharge: Resident has chosen to discharge home with family. Plan to return to community or other care setting at this time. Level of Harm - Immediate jeopardy to resident health or safety (Start Date: 08/18/2023) Residents Affected - Some Goal: Resident will receive assistance with discharge planning should his preferences change through the review date. (Long Term Goal Target Date: 11/14/2023) Approaches included: Resident preferences regarding his discharge planning regularly and PRN (as necessary). (Start Date: 08/18/2023) A review of progress notes for Resident #3 revealed the following: -Nurses admission note, dated 07/27/2023, revealed the resident required total assistance for his Activities of Daily Living (ADL), but he was able to feed himself after staff set up the meal and provided cueing during the meal. The resident was described as alert and oriented to himself and able to answer simple yes and no questions. -On 07/28/2023 at 1:52 p.m., the SSD documented she attempted to contact the resident's next of kin several times but got no answer, so she left a voice mail. -Nurses notes from 07/28/2023 through to 08/08/2023 continued to document the resident as alert and oriented x 2, able to understand and follow simple commands, without any signs or symptoms of distress. -A note labeled IDT (Interdisciplinary Team) documented on 07/31/2023 staff had tried to contact the family but was unable to make contact and left a message. -On 08/08/2023 at 1:23 p.m., an IDT note documented the resident under skilled level of care, receiving physical and occupation therapy, making minimal progress as his cognition was a barrier to progress. There was to be a new review date by the insurance company on 08/15/2023 and the D/C (discharge) plan was to d/c home with a family member. -On 08/11/2023 the IDT note documented an attempt to make contact with the resident's family member to provide an update on the resident but was unable to make contact with the family and a message was left. -On 08/13/2023 a nurse's note revealed the resident was alert with noted confusion, not able to make his needs known to staff but understood simple commands. -On 08/15/2023 the IDT weekly review described the resident as making slow progress toward therapy goals, he remained a fall risk as he frequently attempted to get up from the wheelchair unassisted and was difficult to redirect due to impaired cognition. He remained at moderate nutritional risk and was followed by the RD (Registered Dietitian). He remained appropriate for skilled level of care. 105292 Page 5 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some -On 08/21/2023 a nurse documented the resident as alert and oriented x 3, with periods of confusion, but able to make his needs known. He required the assistance of one staff with ADLs, stand by assistance for transfers, and he was incontinent of bowel and bladder. -On 08/22/2023 the IDT documented the resident continued to require a skilled level of care and was receiving therapy. An insurance update had been sent with the outcome pending. His discharge plan remained to discharge home with family. -On 08/29/2023 the facility attempted to contact the family and left a voice mail with an update on the resident. -On 09/05/2023 an IDT note revealed the resident continued at a skilled level of care and was working with therapy. The note showed he was making progress toward his goals. His cognition remained a barrier to his safe discharge. His discharge plan was home with family when all of his goals were met. -On 09/12/2023, at the weekly IDT meeting, the note revealed the resident continued to require a skilled level of care with therapy. His impaired cognition remained a barrier to a higher level of safety. His discharge plan was to go home with family. A new review date for his insurance was 09/15/2023 with the insurance company asking the facility to prepare the resident and family for discharge. -On 09/12/2023 the SSD (Social Services Director) contacted the resident's family to inform them the resident would be discharged after 09/15/2023. She received no answer and left a voice mail. -On 09/14/2023 the SSD documented a note showing it was her third attempt to contact the resident's family about an insurance review and documented her desire to discuss a safe discharge with them. There was no answer, and she left a message, but received no response. -On 09/18/2023 the IDT documented the resident propelling up and down the hallways with attempts to transfer himself without assistance. The note documented the resident was not strong enough to do so and would remain at risk for falls. He continued to work with therapy services to increase his strength. -Later that day, on 09/18/2023, the nurse documented the patient remained severely confused to time and environment. He was not able to make his needs known. He was cooperative with taking medication. He continued to throw himself on the floor numerous times throughout the shift and was seen scooting across the floor several times during the shift. The physician had been made aware of the behaviors and Ativan (as needed) was given but not effective. -On 09/20/2023 the SSD documented the resident's Power of Attorney (POA) had been informed of the resident's NOMNC letter, but he refused to sign the letter. -On 09/20/2023 the SSD documented her visit, with the Maintenance Director to the resident's home to inform the family the resident's last covered day would be 09/22/2023 with a discharge home on [DATE]. Her note revealed several unsuccessful attempts at contacting the family by phone, therefore she felt an in-person visit was necessary. She documented the family had refused to sign the NOMNC letter so the resident would be discharged . -On 09/23/2023 at 8:20 a.m., the SSD documented the family had been informed of the resident's 105292 Page 6 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 discharge and transported home by a cab service. Level of Harm - Immediate jeopardy to resident health or safety In an interview with the Administrator and the SSD, on 10/17/2023 beginning at 3:30 p.m., the SSD stated due to the family member not responding to phone calls, she went to the home with the facility's Maintenance Director on 09/20/2023 to discuss the NOMNC document and the resident's potential discharge. She reported the family member answered the door and after the SSD explained the NOMNC and applying for Medicaid so Resident #3 could remain at the facility, the family member said no. The family member would not sign the NOMNC and was not interested in applying for Medicaid. The SSD reported during the visit, the family member opened the garage door to the home to show them that work was being done inside the garage to accommodate the resident upon his return. The family member said the work wasn't done yet so he wasn't ready for the resident to return to the home. The SSD reported that because she and the Maintenance Director had spoken with the family member on 09/20/2023 about the resident's plans to return home on [DATE], and the resident would have discharge documents for the family to reference upon his return, she sent the resident home alone in a taxi cab. The SSD reported the family member said they were expecting the resident back and they would provide the care. Residents Affected - Some A telephone interview with Resident #3's family member on 11/07/2023 at 10:30 a.m. revealed he called the facility on 09/22/2023 around 3:00 p.m. and spoke with an unknown staff member to request for the resident to remain in the facility for another week. He said he told the staff member he would come in on Monday, 09/25/2023, to pay privately for the extra time. The family member stated they must not have received his message because they sent Resident #3 out the next day. The family member confirmed he did not sign the NOMNC because he wasn't going to appeal the decision. He was told the resident had to leave the facility or pay privately and that was what he was going to do. The family member confirmed he was not ready for the resident to return on 09/23/2023 because the construction was not completed. A review of the Transition of Care/Discharge Summary report, dated 09/23/2023, revealed the resident was not identified as being responsible for himself. Under the heading of Special Instructions, therapy had documented: Pt (patient) has been receiving skilled PT/OT since admission at this facility. Pt reached max (maximum) potential and is unsafe to ambulate by himself. Pt is WC (wheelchair) bound and is independent with WC mobility within the facility. Pt recommended continued use of WC upon DC (discharge) for safe mobility. The Home Health Agency company was to provide the wheelchair. The summary did not contain a Post Discharge Plan of Care which would include: arrangements that have been made for follow up care and services; how the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed in accordance with the facility's undated policy titled Discharge Summary and Plan. A review of the Therapy Discharge Summary for Physical and Occupational Therapy services provided from 7/26/2023 - 9/22/2023 showed: The Physical Therapist documented the resident's inability to make significant functional gain which was limited by poor cognition and the inability to learn new information. The resident was able to transfer and ambulate with minimal assistance. The Discharge recommendations from the Physical Therapist was for 24 hour care. The Occupational Therapist documented the resident's progress was hindered by cognitive deficits. The recommendation stated the family should assist with personal and domestic tasks. 105292 Page 7 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some A review of a local law enforcement report, dated 09/23/2023, revealed the cab driver who took Resident #3 to his home from the facility notified the police of the resident's inability to enter his home. The police officer notified the facility the resident was sitting outside of his home without the ability to enter the home. The police officer had the resident taken to the local hospital where he was admitted . A review of the hospital records dated 09/23/23 at 1:31 p.m. described the resident as having a history of dementia and presenting to the emergency room due to homelessness. The resident's history was obtained from the paramedics as the resident presented with dementia. The note included the resident's recent stay at the facility where his insurance ran out. The facility, according to the hospital note, had tried to get in touch with the family but were unsuccessful and ultimately put the resident into a cab. The cab took the resident to an address listed on the resident's contact sheet. The note described the cab driver's reluctance to leave the resident at a home that did not appear to be lived in. Attempts by the hospital to contact the family were unsuccessful as well. Resident #3 remained at the hospital for a few days prior to being discharged to another long-term care facility. An interview was conducted with the Nursing Home Administrator (NHA) and the SSD on 10/17/23 at 3:30 p.m. The NHA stated the facility had not received return phone calls from the family about Resident #3's stay or his pending discharge. Neither facility staff could remember whether the family had ever visited the resident at the nursing home. They stated a family member had met with the Business Office staff (which is in a different building from the nursing home) to discuss the NOMNC and possibly apply for Medicare. The NHA stated she was not aware of the family member coming into the facility to visit with the resident after being at the Business Office. The Administrator and the SSD stated looking back, this was not a safe discharge. An interview was conducted with the Director of Rehabilitation (DOR) Services on 11/01/2023 beginning at 12:30 p.m. The DOR confirmed she had worked with Resident #3 for the two months that he had been in the facility. She reported that he had not done well in therapy and actually had regressed in his skills. She said it was due to his decline in mental capacity. She confirmed she attended the Interdisciplinary meetings and had expressed her concern with the discharge plan to live at home with the family. She said she told the team, the resident needed 24 hour care and should not be left alone. She said the IDT talked about how the family was aware of the resident's needs and how they agreed they would provide the care. She reported that the resident was incontinent, needed total care with personal hygiene, could only take a few steps, needed a wheelchair for mobility, would not be able to prepare food for himself, and needed supervision or cueing with meals. An interview was conducted with the Home Health Agency Resident #3 was referred to on 11/01/2023 at 11:50 a.m. The Home Health Agency referral staff reported Resident #3 was marked as no admit in her system. She reported the referral did not include a physician's signature, which they must have to provide the care. She said the referral was faxed back to the facility, and they called the facility but had to leave a voice mail with instructions, to sign the referral and fax it back. She said they never received the signed referral back, so they were not able to provide any home care for Resident #3. 3) Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services after a hospitalization related to dizziness and deconditioning. Diagnoses listed on the face sheet included morbid obesity, diabetes, needs assistance with personal care, high blood pressure, muscle weakness, acute respiratory failure with hypoxia (the body is deprived of adequate oxygen supply), edema 105292 Page 8 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 (swelling), Obstructive Sleep Apnea (OSA), pain, depression, and anxiety. Level of Harm - Immediate jeopardy to resident health or safety A review of the admission MDS Assessment, dated 09/06/2023, Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A review of the resident's care plan revealed the following: Residents Affected - Some Problem: Resident has impaired health status related to severe morbid obesity, acute respiratory failure with hypoxia, diabetes, and sleep apnea. (Start Date: 09/19/2023) Goal: To achieve stable health status through next review. (Long Term Goal Target Date: 12/19/2023) Approach: Continuous Positive Airway Pressure mask at night. (Start Date: 10/03/2023) Oxygen at 2 liters via nasal cannula continuous as tolerated. Promote head of bed to be elevated to facilitate stable respiratory status. (Start Date: 09/19/2023) Problem: Resident intends to discharge to home, ensure that discharge needs and goals are met (Start Date: 09/12/2023) Goal: Resident's discharge goals and preferences will be identified and met with staff assistance through the review date. (Long Term Goal Target Date: 12/12/2023) Approach: Define roles and expectations with the resident and caregiver as needed. Ensure that both the caregiver (if there is one) and the resident understand the discharge instructions and identify tasks that they will need additional help with, training for and provide contact information of a person who can serve as a resource and can answer questions that may develop. (Start Date: 09/12/2023) Encourage resident/resident representative participation and selection of provider of home health care if/as ordered. Assist with consultation\ interview if necessary and offer home health care providers contact information. (Start date: 09/12/2023). Provide the post discharge plan of care to include written discharge instructions, i.e. current health status, list of medications, follow up appointments, community resources, etc. (Start Date: 09/12/2023) Review of the physician orders, dated 09/19/2023 to 10/28/2023, revealed: Continuous oxygen at 4 liters (L) by nasal canula (NC). Review of Resident #1's progress notes revealed the following: -On 09/26/2023 at 4:32 p.m., Resident #1 requires continuous oxygen at 2 liters (L) by nasal canula (NC). 105292 Page 9 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some -On 10/25/2023 at 10:45 a.m., SSD visited resident at bedside. Resident stated her last covered day will be 10/27/2023 that she is planning to discharge home on [DATE] with Durable Medical Equipment (DME) hospital bed bariatric. She has a bariatric wheelchair at home. Resident has her apartment key in her possession. -On 10/26/2023 at 7:35 a.m., Resident is morbidly obese. And constant complaints of shortness of breath when lying flat. Patient is using supplemental oxygen at all times. Physical Therapy recommended bariatric bed for comfort., Ease of breathing. Patient also needs bed rails to assist with repositioning in bed. -On 10/26/2023 facility staff gave Resident #1 instructions to call an ambulance transport company and arrange transportation to the resident's home. Resident #1 was not aware bariatric transport services should be requested. -On 10/27/2023 at 11:14 a.m., Resident #1 requires the head of bed (HOB) elevated 30 degrees, due to difficulty breathing when bed is lowered to provide care. -On 10/28/2023 at 8:25 a.m., Resident #1 will be discharged from the facility and transported on a stretcher by EMS (Emergency Medical Services) at 12 p.m. today. Family and resident have been informed. -On 10/28/2023 at approximately 2:00 p.m., the EMS transport service notified the facility Resident #1 could not be transported home because oxygen and oxygen equipment was not available in the home. -On 10/31/2023 at 1:57 p.m., Resident #1's oxygen (O2) was removed for 5 minutes to evaluate how the resident would tolerate room air saturation (percentage of oxygen in the blood). O2 Sat decreased to 89%. The normal O2 Sat range is 95%-100%. Interview was conducted with the SSD on 10/31/2023 at 3:18 p.m. The SSD said prior to discharge, Resident #1 told the facility staff a hospital bed and mechanical lift were the only items needed for a safe discharge as the Resident stated she had everything else. Interview was conducted with the NHA on 10/31/2023 at 3:29 p.m. The NHA said Resident #1 was her own person, but agreed the facility should have confirmed with the family whether oxygen and oxygen equipment was available at her new residence. A review of Resident #1's Transfer of Care/Discharge summary, dated [DATE], revealed the name of the medical equipment supplier without a corresponding phone number for the resident to contact the vendor if needed. A review of the Therapy Discharge Summary for Physical Therapy services provided from 8/31/2023 9/22/2023 signed by the Physical Therapist on 10/11/2023 showed the resident was unable to make significant functional gain due to medical complications including GI (gastro-intestinal) issues, diarrhea, and obesity. The discharge instructions read: 24 hour care, dependent assist with all ADLs. Discharge recommended location was same skilled nursing facility. A review of the Therapy Discharge Summary for Occupational Therapy services provided from 8/31/2023 9/24/2023 and signed by the Occupational Therapist on 09/27/2023 showed the patient's progress in 105292 Page 10 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0660 Level of Harm - Immediate jeopardy to resident health or safety therapy was hindered by medical issues, morbid obesity, decreased strength and endurance. The discharge recommendation was to continue therapy. Interview was conducted on 11/01/2023 at 10:15 a.m. with Resident #1. The resident was observed lying in bed with a nasal cannula delivering oxygen. When asked about the resident's discharge on [DATE], she stated facility staff did not ask her if she had oxygen at home prior to disch Residents Affected - Some 105292 Page 11 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to monitor one diabetic resident (#5) out of three residents sampled for blood glucose levels as ordered. Residents Affected - Few Findings included: Resident #5 was admitted to the facility on [DATE] with a diagnoses to include but not limited to osteomyelitis of vertebra, sacral, and sacrococcygeal region, adult failure to thrive, weakness, Pressure Ulcer Stage IV of the left hip, dysphagia, hypoglycemia, history of Bacteremia, Diabetes Mellitus, vascular dementia with other behavioral disturbance, and gastrostomy tube. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment; in Section G: Functional Status, resident required extensive assistance of two for bed mobility, extensive assistance of one for toileting, and totally dependent regarding eating; in Section K: Nutritional Status, resident had a feeding tube, and had a mechanically altered therapeutic diet; in Section M: Skin, on admission the resident had two Stage III pressure ulcers, and two Stage IV pressure ulcers. A review of the Physician Order Report, dated 09/01/2023 to 10/17/2023, showed the following: --Diet: puree, controlled carbohydrate diet (CCHO). --Humalog Kwik Pen insulin (insulin Lispro) insulin pen; 100 units/ml (milliliter); per sliding scale as of 09/02/2023 If blood sugar is 1-149, give 0 units. If blood sugar is 150-199, give 1 units. If blood sugar is 200-249 give 2 units If blood sugar is 250-299, give 3 units. If blood sugar is 300-349, give 4 units. If blood sugar is 350-399, give 5 units. If blood sugar is greater than 400, call MD. Subcutaneous for Type 2 diabetes. Before meals, and at bedtime: 6:00 a.m., 11:30 a.m., 4:30 p.m. 10:00 p.m. --Novolog U-100 insulin Aspart solution 100 unit/ml per sliding scale as of 09/17/2023 If blood sugar is less than 60, call MD. 105292 Page 12 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0684 If blood sugar is 150-199, give 2 units. Level of Harm - Minimal harm or potential for actual harm If blood sugar is 200-249 give 4 units If blood sugar is 250-299, give 6 units. Residents Affected - Few If blood sugar is 300-349, give 8 units. If blood sugar is 350-399, give 10 units. If blood sugar is greater than 400, call MD. Subcutaneous for type 2 diabetes. Before meals and at bedtime: 6:30 a.m., 11:30 a.m., 4:30 p.m. 9:00 p.m. A review of the Medication Administration Record (MAR) for September 2023 and the Vital Results for blood sugar results showed the following: -Diabetic Monitoring: hyperglycemia; increased thirst, blurred vision, frequent urination, increased hunger, and numbness or tingling in the feet. To be monitored on day shift and night shift. -Monitor every shift for progress with goal (s) .for resident to have increased ability to participate in feeding and oral intake and if concerns are noted, document and notify nursing / MD. -Novolog U-100 insulin Aspart solution 100 unit/ml per sliding scale as of 09/17/2023, before meals and at bedtime: 6:30 a.m., 11:30 a.m., 4:30 p.m. 9:00 p.m. There was no documentation a blood sugar was performed on the following dates and times: 09/24 at 6:30 a.m., 09/26 at 6:30 a.m., 09/27 at 11:30 p.m., 09/28 at 6:30 a.m. or 11:30 a.m., 09/29 at 6:30 a.m. -Novolog U-100 insulin Aspart solution 100 unit/ml per sliding scale as of 09/17/2023; If blood sugar is greater than 400, call MD; Before meals and at bedtime: 6:30 a.m., 11:30 a.m., 4:30 p.m. 9:00 p.m. There was no documentation the physician was notified of the blood sugars that were over 400 on the following dates and times: 09/22 at 11:30 a.m. the blood sugar was 554 mg/dl, given 10 units call MD. 09/25 at 9:00 p.m. it was 447 mg/dl (milligrams per deciliter or the concentration of a substance in a specific amount of fluid), 105292 Page 13 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0684 09/27 at 11:30 a.m. it was 400 mg/dl, Level of Harm - Minimal harm or potential for actual harm 09/28 at 9:00 p.m. it was 408 mg/dl, 09/29 at 11:30 a.m. it was 531 mg/dl, given 10 units waiting for MD order. Residents Affected - Few A review of the nursing progress notes revealed there was no documentation that the physician was notified regarding blood sugars over 400 mg/dl for 09/22/23, 09/25/23, 09/27/23, 09/28/23, and 09/29/23 (11:30 a.m.). A review of the Vitals Report dated 03/07/2023-10/17/2023, revealed between 09/01/23 and 09/29/23 staff documented the meal consumption for Resident #5 33 out of 86 times, only 38% of the time required. A review of the Comprehensive Care Plan, start date 09/10/2023, showed the following: Problem: Diabetes with insulin dependence. The long-term goal showed resident will have stable blood sugars through the next review of 12/10/2023. Interventions included but were not limited to: Administer sliding scale insulin per orders before meals and at bedtime. Problem: Nutritional Status-Resident is at nutritional risk related to: Impaired cognition with vascular dementia which potentially affects her desire to consume nutrition orally with a diagnosis of dysphagia, duodenal ulcer with hemorrhage, and anemia. Resident also has impaired ability to feed self and requires staff assistance to feed. Resident has a diagnosis of diabetes and insulin dependent with fluctuating blood sugars. Interventions included: Staff to offer to feed resident at meals puree, CCHO diet with thin liquids. During an interview on 10/17/2023 at 2:45 p.m. Staff A, Licensed Practical Nurse (LPN) stated, The resident was eating, but not well. An interview was conducted on 10/17/2023 at 3:46 p.m. with the Nursing Home Administer (NHA). The NHA verified the blood sugars were not documented as performed by nursing. She verified the elevated blood sugars (over 400) did not have documentation the physician was notified in the progress notes. She stated there were gaps in the documentation on the Vitals Report related to meal consumption. A review of the facility policy titled Diabetes-Clinical Protocol, undated, showed the following: Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with elevated blood sugar, impaired glucose tolerance, or confirmed diabetes, as well as factors that may influence glucose tolerance; for example, medications including Prednisone, thiazide diuretics or some antipsychotic medications. 105292 Page 14 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. For Residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment: f. usual patterns of eating and drinking; g. approximate intake over last 24 hours; recent change in intake/thirst; Resident's blood sugar history over 48 hours; j. usual patterns of blood sugars over recent months. Treatment / Management: 1. Based on the preceding assessment, including causes and complications, the Physician will order appropriate interventions, which may include: c. Oral hypoglycemia agents; and/or d. Insulin. Monitoring and Follow-up: 2. As indicated, the Physician will order appropriate lab tests (for example periodic finger sticks) and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes, etc. A. examples of blood glucose monitoring for various situations might include the following: (3) for the resident receiving insulin .monitor 3 to 4 times a day if on intensive insulin therapy or sliding -scale insulin. 4. The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. A. the staff will incorporate such parameters into the Medication Administration Record and care plan. A review of the facility policy titled Obtaining a Fingerstick Glucose Level, undated, showed the following: Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. Documentation: the person performing this procedure should record the following information in the resident's medical record: 6. Blood sugar results. follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and / or physician intervention is needed to adjust insulin or oral medication dosages), etc. Reporting 1. report results promptly to the supervisor and the Attending Physician. 105292 Page 15 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0684 3. Report other information in accordance with facility policy and professional standards of practice. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy, Care Plans, Comprehensive Person-Centered, not dated showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: Residents Affected - Few 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 105292 Page 16 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pain management for one resident (#6) of three residents sampled. Residents Affected - Few Findings included: On 10/17/23 at 09:15 a.m. an observation and interview was conducted with Resident #6 who reported experiencing increased pain when the facility Ran out of his pain medicine. Resident #6 stated he was Always in pain pain intensity increases and decreases; currently his pain level is okay. Review of the resident face sheet showed Resident #6 latest return to the facility on 6/29/22, with diagnoses including Stage 4 sacral pressure ulcer, osteomyelitis (inflammation of the bone), paraplegia, chronic nephritis (inflammation of the kidney) and chronic pain. Review of Resident #6's Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed his Brief Interview for Mental Status (BIMS) score was 15, indicating he was cognitively intact. Review of Resident #6's Care Plan initiated on 6/21/2017, showed the following: Problem: Resident #6 is at risk of experiencing acute pain and has chronic pain associated with slow healing ulcer, chronic osteomyelitis of multiple sites and paraplegia. He is able to sense pain and will notify staff members when he requires medication. The long-term target goal, dated 11/16/23, Resident #6 will verbalize pain reduction or pain relief following interventions through next review. Interventions included the following: -Administer analgesic (pain) medications (Oxycodone, Naproxen, Lidocaine patch) as per MD (medical doctor) order -Evaluate effectiveness of pain management interventions -Assess effects of pain on the resident -Monitor, record and treat any non-verbal signs of pain Review of Resident #6's Physician Orders, start date 6/7/23, end date open-ended, showed Oxycodone 15 mg (milligram) tablet every 6 hours (12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.) Review of Resident #6's Nursing progress notes revealed the following: -9/6/23 at 7:53 p.m.resident c/o (complains of) pain, writer called ARNP (Advanced Registered Nurse Practitioner) to get one time order for Oxycodone 5 mg (milligrams) time 3 from pharmacy until residents Oxycodone comes in. -9/26/23 at 4:41 p.m. revealed Resident a/o (alert and oriented) post oral surgery. 105292 Page 17 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0697 Level of Harm - Minimal harm or potential for actual harm -9/29/23 at 12:58 p.m. recorded as a late entry on 10/10/23 at 12:58 p.m. revealed Resident's pain needs are met with no issues at this time, signed by the NHA. -10/1/23 at 1:04 p.m. recorded as a late entry on 10/10/23 at 1:04 p.m. revealed Resident has no pain needs that are not being met, signed by the NHA. Residents Affected - Few Review of Resident #6 Physician progress notes revealed the following: -9/6/23 Medication /Therapy Monthly Management -The patient is on chronic pain management. -The patient is currently on the lowest therapeutic dose (having a good effect on the body). We will refill Oxycodone 15 mg every 6 hours for the next 60 days. Review of Resident #6 Medication Administration Record (MAR), dated 9/17/23-10/17-23 regarding presence of pain, revealed the following: On 9/28/23 night shift Resident #6 reported a pain rating of 8 on a 1-10 scale. On 9/28/23 the MAR for Oxycodone 15 mg tablets revealed Resident #6 did not receive the scheduled 12:00 a.m. dose; the 06:00 a.m. dose was documented as charted late at 11:57 a.m.; and the 12:00 p.m. dose was documented as charted late at 1:01 p.m. On 9/29/23 day shift Resident #6 reported a pain rating of 5. On 9/30/23 day shift Resident #6 reported a pain rating of 7. On 9/30/23 the 12:00 a.m. dose was documented as charted late at 3:55 a.m. On 10/2/23 day shift Resident #6 reported a pain rating of 2. On 10/7/23 day shift Resident #6 reported a pain rating of 5. On 10/9/23 day shift Resident #6 reported a pain rating of 8. On 10/10/23 night shift Resident #6 reported a pain rating of 8. On 10/11/23 day shift Resident #6 reported a pain rating of 7. On 10/13/23 day shift Resident #6 reported a pain rating of 8. On 10/13/23 the 12:00 p.m. dose was documented as charted late at 2:21 p.m. On 10/14/23 day shift Resident #6 reported a pain rating of 5. Non-pharmacological interventions were documented only three times during the time period to help relieve pain for Resident #6. 105292 Page 18 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/17/2023 at 10:00 a.m. an interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B stated at the beginning and end of each shift nurses count the number and amount of narcotics in the medication cart then sign the controlled drug shift audit log. When narcotic medications are received from the pharmacy two nurses sign the pharmacy packaging slip, verifying the number of packages received and the number/amount of narcotic medications. When a resident needs a narcotic medication, they are signed out on the log and documented in the medical record as administered. On 10/17/2023 at 10:30 a.m. an interview was conducted with Staff A, LPN. Staff A stated she was caring for Resident #6. Staff A stated at the beginning and end of each shift nurses count the number and amount of narcotics available in the medication cart then sign the controlled drug shift audit log. When narcotic medications are received from the pharmacy two nurses sign the pharmacy packaging slip, verifying the number of packages received and the number/ amount of narcotic medications. When a resident needs a narcotic medication, it is signed out on the log and documented in the medical record as administered. A random check of medication monitoring control record for Resident #6, revealed the number of Oxycodone 15 mg tablets matched the number of tablets documented on the Medication Controlled Monitoring Record. An interview was conducted with the Nursing Home Administrator (NHA) on 10/17/23 at 3:00 p.m. The NHA stated on 09/28/23 she became aware Resident #6 was missing Oxycodone 15 mg pills and she contacted the facility's pharmacy to request a copy of the packing slip for receipt of the pills. The NHA stated on 9/28/23 Staff D, LPN, Unit Manager (UM) confirmed the missing pills were delivered on 9/7/23. The NHA stated on 9/28/23 at 12:00 p.m. a report was filed with the local police department related to the missing pills. A review of the facility policy titled Pain-Clinical Protocol, version 2.1, revealed the following: Assessment and Recognition: 1-The physician and staff will identify individuals who have pain or who are at risk for having pain. 2-The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Treatment/Management: 1-With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. 2-The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. 3-Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. 105292 Page 19 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0697 Monitoring: Level of Harm - Minimal harm or potential for actual harm 4-a. The physician will adjust or discontinue medications, accordingly, based on effectiveness and side effects. Residents Affected - Few Review of the facility policy titled Care Plans, Comprehensive Person-Centered, undated, version 2.0 revealed the following: Policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: .3 The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4 Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: f. participate in determining the type, amount, frequency, and duration of care; g. receive the services and /or items included in the plan of care; 7 The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 105292 Page 20 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on a interviews and record reviews the facility failed to ensure a Registered Nurse (RN) was available for 8 consecutive hours every day, seven days a week, for a two-week period from 10/01/23 to 10/14/23. Findings included: A review was conducted of the form entitled, Calculating State Minimum Nursing Staff for Long Term Care Facilities, for the two-week period from 10/01/2023 to 10/14/2023. The instructions read, Enter the number of RN and LPN (Licensed Practical Nurse) hours actually worked per day for the dates above. The document revealed on Sunday 10/01/23, Saturday 10/07/23, Sunday 10/08/23, and Saturday 10/14/23, there were no Registered Nurse (RN) hours recorded. An interview was conducted on 10/17/2023 at 11:50 a.m. with the Nursing Home Administrator. The Administrator confirmed there had not been an RN in the building on 10/01/23, 10/07/23, 10/08/23, and 10/14/23. The Administrator stated the facility was advertising for an RN but did not have a consistent ability to have an RN present on the weekends. 105292 Page 21 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to advocate and provide medically related social services to ensure three (#8, #3, and #1) of five residents sampled for discharge had the community supports, services, and equipment to ensure a safe discharge to a safe and habitable location. Resident #8, a dialysis dependent resident, was discharged to his condemned mobile home with no arrangements for the continuation of life-saving dialysis treatment, home health services, or community support to ensure food availability and food preparation for special dietary needs. Resident #3, who suffered from severe cognitive impairment, was placed in a taxi cab by himself and sent home to live with family who was not present or prepared to care for the resident. Resident #3 had an invalid order for home health services and no way to access the home upon his arrival. The taxi cab driver contacted law enforcement and Resident #3 was transported to a higher level of care. Resident #1, who was dependent on oxygen, was discharged home without medical equipment to maintain her respiratory status. Residents Affected - Some The facility's system failure to ensure social services advocated and arranged for home health services, dialysis services, medical equipment, and community support services/resources resulted in the need for law enforcement intervention for Resident #8 and #3 and Emergency Medical Services intervention for Resident #1. The facility's failure created situations likely to result in serious injury, harm and/or death to Resident #8, Resident #3, and Resident #1 and resulted in the determination of Immediate Jeopardy on 09/23/2023. The findings of Immediate Jeopardy were determined to be removed on 11/02/2023 and the severity and scope was reduced to an E after verification of removal of immediacy of harm. Findings included: Cross Reference F660 1) A review of the job description for the Resident Services Director (RSD), which was the official job title of the Social Services Director at the facility according to the Nursing Home Administrator on 11/02/2023 at approximately 11:00 a.m. revealed: Summary: Has administrative authority and accountability for the provision of psychosocial needs of the residents and patients. Acts as a resident advocate, provides an ongoing program. Of activities designed to meet. The interest and physical, mental, and psychosocial well-being of each patient. Essential Duties and Responsibilities include: -Completes assessments, MDS (Minimum Data Set) assessments, care plans to collect and assess data relevant to patients' psychosocial needs, risk factors for psychosocial deterioration and responses to interventions. -Records progress notes in the clinical record including subjective findings, objective symptoms, observations of behavior, interventions provided to patient and patient's response to activity interventions. Reviews staff's chart entries for completeness and accuracy. -Delivers ABN (Advance Beneficiary Notice)/NOMNC (Notice of Medicare Non-Coverage) notices and reviews with resident/responsible party for signature. 105292 Page 22 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 -Participates in care plan meetings and assists residents in participating as well. Level of Harm - Immediate jeopardy to resident health or safety -Implements social service interventions that achieve treatment goals, address resident needs, link social supports, physical care and physical environment to enhance quality of life. -Coordinates discharge planning. Residents Affected - Some -Facilitates advance directive decision-making process. -Completes required forms and documents in advance with company policy and state and/or federal regulations. Other Requirements: -Monitors and ensures compliance with company policies, procedures, and state and federal law. Review of the undated facility policy titled Transfer or Discharge, Preparing a Resident for revealed: Policy Statement: Residents will be prepared in advance for discharge. Policy Interpretation and Implementation: A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and /or his or her family, at least twenty four (24) hours before the resident's discharge or transfer from the facility. Review of the undated facility policy titled Discharge Summary and Plan revealed: Policy Statement: When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy Interpretation and Implementation: -When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.) a discharge summary and a post - discharge plan will be developed which will assist the resident to adjust to his or her new living environment. -The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: -Special treatments or procedures (treatments and procedures that are not part of basic services provided); -Medication therapy (all prescription and over the counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident.) 105292 Page 23 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 -Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. Level of Harm - Immediate jeopardy to resident health or safety -The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: Residents Affected - Some - Where the individual plans to reside; - Arrangements that have been made for follow up care and services; - What factors may make the resident vulnerable to preventable readmission; and - How those factors will be addressed. -The discharge plan will be re-evaluated based on changes in the resident's condition or needs prior to discharge. -The resident/representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. -Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist in accommodating the resident's post-discharge preferences. -If it is determined that returning to the community is not feasible, it will be documented why this is the case and who made the determination. 2) Resident #8 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease (ESRD) requiring dialysis, temporary catheter in upper right chest for dialysis, diabetes, altered mental status, adult failure to thrive, unspecified sequelae of cerebral infarction, chronic pain, abnormalities of gait and mobility, and muscle weakness. A review of the MDS (Minimum Data Set) admission assessment dated [DATE] revealed the resident was able to make himself understood and he was able to understand others. The resident's BIMS (Brief Interview for Mental Status) score was 11, indicating moderately impaired cognition. In Section G: Functional Abilities, the resident was assessed as requiring extensive assistance with one staff for toileting, personal hygiene, and dressing; supervision with one staff for walking in his room or for short distances, with his balance described as unsteady. The resident was occasionally incontinent of urine and frequently incontinent of bowel. A review of the resident's care plan, dated 09/26/2023, revealed the following: Problem: discharge: Resident's discharge plan is uncertain at this time as he lost his home in the community. (Start date 09/26/2023) Goal: Resident will receive assistance with discharge planning should preferences change through the review date. (Long term goal target date: 12/26/2023) 105292 Page 24 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Approaches included: Ask about returning to the community with each assessment; Re-evaluate preferences regarding discharge planning regularly and PRN (as necessary). (Start date: 09/26/2023) Problem: Nutritional Status: Resident is at nutritional risk r/t (related to ): ESRD, new dialysis, hx (history) CVA (Cerebral Vascular Accident). (Start date: 09/27/2023) Goal: Resident's weight will remain less than +/- 5% weight change within a 30 day time period through next review. (Long term goal target date: 12/27/2023) Approaches included: Resident will attend dialysis as scheduled Tuesday, Thursday, Saturday; Resident will receive a no added salt diet, avoid potatoes, tomatoes, bananas, oranges related to high K (potassium) content. Problem: Cognitive Loss/Dementia: Resident has impaired cognitive skills as evidenced by deficits in short and long term memory (Start Date: 10/02/2023) Long Term Goal: Resident will continue to stay safe in his/her environment. (Target Date: 01/02/2024) Approaches included: Provide cue and prompting if resident is unable to complete a task independently; Staff will anticipate and meet resident's needs. (Start Date: 10/02/2023) A review of the Therapy Discharge Summary for Physical Therapy services provided from 9/20/2023 10/05/2023 for Resident #8 revealed the patient was unable to make significant functional gains due to being dialysis dependent and fatigued post dialysis. The discharge instructions included the resident's need for assistance with all Activities of Daily Living (ADLs). A review of the Transition of Care/Discharge Summary revealed Resident #8 would be going back to his home address on 10/06/2023. The document showed the resident was responsible for himself with no resident representatives or community support/resources listed. Special instructions on the form recommended for the resident to continue to avoid foods high in potassium and eat 6 small meals a day to aid in controlling blood sugars. A phone number for the Certified Dietary Manager was included to help the resident with food items but no directions were included to indicate how the resident would obtain or prepare food. The form included no information in the area of special treatments and procedures or medical equipment. The form was obsolete of: arrangements for transportation to Dialysis Center, the name, address, and phone number for the Dialysis Center, the scheduled days for Dialysis treatment, any continued arrangements to receive nursing or therapy services to include the name and contact information for a home health agency. Review of the Social Services Director (SSD) progress note dated 10/05/2023 revealed a referral had been made to a Home Health Agency. A telephone interview was conducted with the Home Health Agency on 10/19/2023 at 11:08 a.m. The Referral Intake Associate reported they did not have Resident #8 in their system to provide home health services following his discharge on [DATE]. The Referral Intake Associate confirmed they made no visits to Resident #8 after he was discharged from the facility on 10/06/2023 and no Physical Therapy, Occupational Therapy, or Registered Nursing services had been rendered. 105292 Page 25 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 A review of Resident #8's progress notes revealed: Level of Harm - Immediate jeopardy to resident health or safety -admission note, dated 09/19/2023: The resident was alert, verbalizing appropriately, tearful at times and stated he was unsure of dialysis. Residents Affected - Some -Social Services Director (SSD) note, dated 09/20/2023: The resident appeared alert and oriented x 3, with a plan of discharge to remain in the facility long term care for now. -An IDT (Interdisciplinary team) note, on 09/26/2023, documented a continued need for a skilled level of care and continued work with therapy. The note indicated the discharge plan was uncertain at this time as he lost his home in the community. -10/02/2023 a note by the SSD indicated the plan for discharge was to go out of state to Indiana. -10/04/2023 the resident was presented with a Notice of Medicare Non-Coverage (NOMNC) showing the LCD (last covered day) of Medicare coverage to the facility was 10/05/23 and the resident chose not to appeal this decision. - SSD note, dated 10/05/2023: The resident would be going home to the address noted on his face sheet from admission and a name and address for the Home Health Agency was listed. -10/06/2023 a nurse's note confirmed the resident had been discharged to home by taxi. - Progress note, dated 10/09/2023 at 1:00 p.m., revealed the Administrator received a call from the Social Worker at the Dialysis center where Resident #8 had been receiving services. The Social Worker asked the Administrator why they discharged the resident to a condemned trailer and also apprised the Administrator the resident had missed his last dialysis treatment, on 10/07/2023. The Administrator told the Dialysis Social Worker the facility was not aware the resident's home was condemned and didn't know he had skipped dialysis the day after he was discharged home. The Administrator explained to the Dialysis Social Worker, as documented in her progress note written on 10/09/2023, she had met with the resident with the facility SSD to explain to the resident he was welcome to remain at the facility during the Medicaid pending process. The Administrator documented the resident informing her and the SSD he wanted to return home and showed both of them he had his keys to his home to let himself back in. After the phone call, the Administrator and the facility SSD drove over to the resident's home and saw the home was a trailer that generally was in good repair, but had two windows broken out. The resident was sitting outside of the trailer and told the facility staff his neighbors were working on fixing up the trailer for him. After receiving permission, the SSD looked inside of Resident #8's trailer and documented garbage, filth, a horrible odor, and a piece of orange paper in the doorway. The orange paper was a condemned notice. When the facility staff told Resident #8, he could not remain living in a condemned trailer he became verbally abusive. The facility staff phoned 911 and the police officer who responded told the resident he could not remain in a condemned trailer and if he did, he was trespassing. When the officer offered the resident three choices --going to the hospital, jail, or returning with the facility staff to the facility, he chose to return to the facility. Upon returning to the facility the resident was evaluated by Psychiatric services who determined the resident was a danger to himself and he was involuntarily admitted to the hospital. 105292 Page 26 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An interview was conducted with the NHA (Nursing Home Administrator) and the SSD on 10/17/2023 at 5:00 p.m. The NHA reported they were not aware the trailer had been condemned and didn't know why the Home Health Agency hadn't called them to let them know the resident's trailer was condemned. The NHA said the resident told them his home was ok, he showed them his keys indicating he would be able to get into the trailer, and he could discharge to his home. The SSD reported she just hadn't revised the care plan to indicate he had a home in the community. They confirmed they had not investigated the home and the condition of the home. They confirmed they discharged the resident as he requested and had not followed up on the resident's statement that he lost his home in the community as documented in the 09/26/2023 care plan and IDT progress note. A call was placed to the Dialysis Social Worker on 11/02/2023 at 3:10 p.m. She confirmed the dialysis facility had not been notified of the resident's discharge from the nursing home to his mobile home. She stated she would have questioned that discharge as she was aware the mobile home had been condemned. She stated she knew about the trailer from his initial hospitalization paperwork, which led to his transfer into the nursing home. She reported the resident had been receiving dialysis at her facility for a year or two and agreed the address and schedule should have been on his discharge paperwork for him due to his fluctuating cognition. Resident #8 was re-admitted to the facility on [DATE] from the hospital. On 11/02/2023 at 9:00 a.m. an interview was conducted with Resident #8. He stated he was found at his mobile home by the lady in charge (NHA), was taken back to the hospital (for an involuntary admission), and then came here (back to the facility). He confirmed he received dialysis services and touched the dressing on his catheter located in his upper right chest, then held up his right arm to expose his new permanent vascular access for dialysis. When asked if he went to dialysis when he was discharged home on [DATE], he stated he hadn't been told the address or the schedule for his dialysis treatments when he was sent home so he had not gone. 2) Resident #3 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization with diagnoses to include senile degeneration of brain, altered mental status, vascular dementia, severe with agitation, schizophrenia, and major depressive disorder. A review of the 08/01/2023 admission Minimum Data Set (MDS) Assessment, Section C: Cognitive Abilities, showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident's mental status was described as inattentive with disorganized thinking. In Section G: Functional Abilities, the resident was assessed as needing extensive assistance with two staff for bed mobility, transferring, and toileting; extensive assistance with one staff for locomotion around the facility in a wheelchair, dressing, eating, and personal hygiene; and his gait was not steady. The resident was always incontinent of bowel and bladder. A review of the care plan, dated 08/18/2023, revealed the following: Problem: discharge: Resident has chosen to discharge home with family. Plan to return to community or other care setting at this time. (Start Date: 08/18/2023) Goal: Resident will receive assistance with discharge planning should his preferences change through the review date. 105292 Page 27 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 (Long Term Goal Target Date: 11/14/2023) Level of Harm - Immediate jeopardy to resident health or safety Approaches included: Resident preferences regarding his discharge planning regularly and PRN (as necessary). (Start Date: 08/18/2023) Residents Affected - Some Problem: Cognitive Loss/Dementia: Resident has impaired cognitive skills as evidenced by deficits in short and long term memory with diagnosis of senile degeneration of brain, altered mental status, vascular dementia with severe agitation. (Start Date: 08/09/2023) Goal: Resident will continue to stay safe in environment. (Goal Target Date: 11/09/2023) Approaches: Staff will encourage resident to participate in cognitive stimulating activities and administer medications/monitoring for effectiveness. (Reviewed/Revised: 08/19/2023) Problem: ADL's Functional Status/Rehabilitation Potential: Resident is not independent with upper and lower body dressing. (Start date.: 08/14/2023) Approach: Provide assistance with dressing. Resident needs extensive assistance of 1 to two staff members for bathing, grooming, oral care, bed mobility, and transfers. Up in wheelchair or Geriatric chair per preference for out of bed activities. (Reviewed/Revised: 08/19/2023) Problem: Falls: Resident at risk for falling related to unsteady gait. (Start date: 08/09/2023) Approaches: Wheelchair with anti-tippers for mobility; Give resident verbal reminders not to ambulate/transfer without assistance; Place call light in reach at all times. (Reviewed/Revised: 09/19/2023) Problem: Behavioral symptoms: Resident slides self out of wheelchair onto floor. (Start Date: 09/19/2023) Approach: Assist with repositioning as resident will allow, and encourage resident to stay in well supervised area. (Start Date: 09/19/2023) Problem: Delirium: Resident presents some confusion at times. Requires reorientation, appears forgetful. (Start date: 08/18/2023) Approach: Staff will give simple directions. Allow sufficient time for resident to respond, communicate, and make decisions. (Start date: 08/18/2023) Problem: Communication: has difficulty understanding others related to cognitive loss and dementia. (Start date: 08/18/2023) Approach: Allow time for information to process when speaking to resident. (Start date: 08/18/2023) A review of the Therapy Discharge Summary for Physical and Occupational Therapy services provided from 7/26/2023 - 9/22/2023 showed: 105292 Page 28 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The Physical Therapist documented the resident's inability to make significant functional gain which was limited by poor cognition and the inability to learn new information. The resident was able to transfer and ambulate with minimal assistance. The Discharge recommendations from the Physical Therapist was for 24 hour home care with caregiver assistance and support of family and home health services. The Occupational Therapist documented the resident's progress was hindered by cognitive deficits. The recommendation stated the family should assist with personal and domestic tasks and home health services. A review of progress notes for Resident #3 revealed the following: -Nurses admission note, dated 07/27/2023, revealed the resident required total assistance for his Activities of Daily Living (ADL), but he was able to feed himself after staff set up the meal and provided cueing during the meal. The resident was described as alert and oriented to himself and able to answer simple yes and no questions. -On 07/28/2023 at 1:52 p.m., the SSD documented she attempted to contact the resident's next of kin several times but got no answer, so she left a voice mail. -Nurses notes from 07/28/2023 through to 08/08/2023 continued to document the resident as alert and oriented x 2, able to understand and follow simple commands, without any signs or symptoms of distress. -A note labeled IDT (Interdisciplinary Team) documented on 07/31/2023 staff had tried to contact the family but was unable to make contact and left a message. -On 08/08/2023 at 1:23 p.m., an IDT note documented the resident under skilled level of care, receiving physical and occupation therapy, making minimal progress as his cognition was a barrier to progress. There was to be a new review date by the insurance company on 08/15/2023 and the D/C (discharge) plan was to d/c home with a family member. -On 08/11/2023 the IDT note documented an attempt to contact the resident's family member to provide an update on the resident but was unable to contact the family and a message was left. -On 08/13/2023 a nurse's note revealed the resident was alert with noted confusion, not able to make his needs known to staff but understood simple commands. -On 08/15/2023 the IDT weekly review described the resident as making slow progress toward therapy goals, he remained a fall risk as he frequently attempted to get up from the wheelchair unassisted and was difficult to redirect due to impaired cognition. He remained at moderate nutritional risk and was followed by the RD (Registered Dietitian). He remained appropriate for skilled level of care. -On 08/21/2023 a nurse documented the resident as alert and oriented x 3, with periods of confusion, but able to make his needs known. He required the assistance of one staff member with ADLs, stand by assistance for transfers, and he was incontinent of bowel and bladder. -On 08/22/2023 the IDT documented the resident continued to require a skilled level of care and was receiving therapy. An insurance update had been sent with the outcome pending. His discharge plan 105292 Page 29 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 remained to discharge home with family. Level of Harm - Immediate jeopardy to resident health or safety -On 08/29/2023 the facility attempted to contact the family and left a voice mail with an update on the resident. Residents Affected - Some -On 09/05/2023 an IDT note revealed the resident continued at a skilled level of care and was working with therapy. The note showed he was making progress toward his goals. His cognition remained a barrier to his safe discharge. His discharge plan was home with family when all of his goals were met. -On 09/12/2023, at the weekly IDT meeting, the note revealed the resident continued to require a skilled level of care with therapy. His impaired cognition remained a barrier to a higher level of safety. His discharge plan was to go home with family. A new review date for his insurance was 09/15/2023 with the insurance company asking the facility to prepare the resident and family for discharge. -On 09/12/2023 the SSD (Social Services Director) contacted the resident's family to inform them the resident would be discharged after 09/15/2023. She received no answer and left a voice mail. -On 09/14/2023 the SSD documented a note showing it was her third attempt to contact the resident's family about an insurance review and documented her desire to discuss a safe discharge with them. There was no answer, and she left a message, but received no response. -On 09/18/2023 the IDT documented the resident propelling up and down the hallways with attempts to transfer himself without assistance. The note documented the resident was not strong enough to do so and would remain at risk for falls. He continued to work with therapy services to increase his strength. -Later that day, on 09/18/2023, the nurse documented the patient remained severely confused to time and environment. He was not able to make his needs known. He was cooperative with taking medication. He continued to throw himself on the floor numerous times throughout the shift and was seen scooting across the floor several times during the shift. The physician had been made aware of the behaviors and Ativan (as needed) was given but not effective. -On 09/20/2023 the SSD documented the resident's Power of Attorney (POA) had been informed of the resident's NOMNC letter, but he refused to sign the letter. -On 09/20/2023 the SSD documented her visit, with the Maintenance Director to the resident's home to inform the family the resident's last covered day would be 09/22/2023 with a discharge home on [DATE]. Her note revealed several unsuccessful attempts at contacting the family by phone, therefore she felt an in-person visit was necessary. She documented the family had refused to sign the NOMNC letter so the resident would be discharged . -On 09/23/2023 at 8:20 a.m., the SSD documented the family had been informed of the resident's discharge and transported home by a cab service. A review of the Transition of Care/Discharge Summary report revealed the resident was not identified as being responsible for himself and was being discharged back to his home address on 09/23/2023. Under the heading of Special Instructions, therapy had documented: Pt (patient) has been receiving skilled PT/OT since admission at this facility. Pt reached max (maximum) potential and is unsafe to 105292 Page 30 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some ambulate by himself. Pt is WC (wheelchair) bound and is independent with WC mobility within the facility. Pt recommended continued use of WC upon DC (discharge) for safe mobility. The Home Health Agency was to provide the wheelchair. A name and phone number for a home health agency was included on the form. The form was signed by the resident who was not responsible for himself and had cognitive deficits documented throughout his stay at the facility. An interview on 11/01/2023 at 11:50 a.m. was conducted with the referral staff for the home health agency listed on Resident #3's discharge paperwork dated 09/23/2023. The referral staff reported Resident #3 was marked as no admit in her system. She reported the referral did not include a physician's signature, which they must have to provide the care. She said the referral was faxed back to the facility, and they called the facility but had to leave a voice mail with instructions, to sign the referral and fax it back. She said they never received the signed referral back, so they were not able to provide any home care for Resident #3. A review of hospital records dated 09/23/23 at 1:31 p.m. described the resident as having a history of dementia and presenting to the emergency room due to homelessness. The resident's history was obtained from the paramedics as the resident presented with dementia. The note included the resident's recent stay at the facility where his insurance ran out. The facility, according to the hospital note, had tried to get in touch with the family but were unsuccessful and ultimately put the resident into a cab. The cab took the resident to an address listed on the resident's contact sheet. The note described the cab driver's reluctance to leave the resident at a home that did not appear to be lived in. Attempts by the hospital to contact the family were unsuccessful as well. Resident #3 remained at the hospital for a few days prior to being discharged to another long-term care facility. A review of a local law enforcement report, dated 09/23/2023, revealed the cab driver who took Resident #3 to his home from the facility notified the police of the resident's inability to enter his home. The police officer notified the facility the resident was sitting outside of his home without the ability to enter the home. The police officer had the resident taken to the local hospital where he was admitted . In an interview with the Administrator and the SSD, on 10/17/2023 beginning at 3:30 p.m., the SSD stated due to the family member not responding to phone calls, she went to the home with the facility's Maintenance Director on 09/20/2023 to discuss the NOMNC document and the resident's potential discharge. She reported the family member answered the door and after the SSD explained the NOMNC and applying for Medicaid so Resident #3 could remain at the facility, the family member said no. The family member would not sign the NOMNC and was not interested in applying for Medicaid. The SSD reported during the visit, the family member opened the garage door to the home to show them that work was being done inside the garage to accommodate the resident upon his return. The family member said the work wasn't done yet so he wasn't ready for the resident to return to the home. The SSD reported that because she and the Maintenance Director had spoken with the family member on 09/20/2023 about the resident's plans to return home on [DATE], and the resident would have discharge documents for the family to reference upon his return, she sent the resident home alone in a taxi cab. The SSD reported the family member said they were expecting the resident back and they would provide the care. A telephone interview with Resident #3's family member on 11/07/2023 at 10:30 a.m. revealed he called the facility on 09/22/2023 around 3:00 p.m. and spoke with an unknown staff member to request for the resident to remain in the facility for another week. He said he told the staff member he would come in on Monday, 09/25/2023, to pay privately for the extra time. The family member stated they must not have received his message because they sent Resident #3 out the next day. The family member 105292 Page 31 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0745 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some confirmed he did not sign the NOMNC because he wasn't going to appeal the decision. He was told the resident had to leave the facility or pay privately and that was what he was going to do. The family member confirmed he was not ready for the resident to return on 09/23/2023 because the construction was not completed. An interview was conducted with the Nursing Home Administrator (NHA) and the SSD on 10/17/23 at 3:30 p.m. The NHA stated the facility had not received return phone calls from the family about Resident #3's stay or his pending discharge. Neither facility staff could remember whether the family had ever visited the resident at the nursing home. The Administrator and the SSD stated looking back, this was not a safe discharge. 3) Resident #1 was initially admitted to the facility on [DATE] for rehabilitation services after a hospitalization related to dizziness and deconditioning. Diagnoses listed on the face sheet included morbid obesity, diabetes, needs assi 105292 Page 32 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to 1) establish a system of receipt and disposition of all controlled substances in sufficient detail to enable an accurate reconciliation; and 2) determine that drug records are in order and an account of all controlled drugs is maintained and periodically reconciled for two residents (#4 and #6) of three residents sampled. Findings included: On 10/17/23 at 09:15 a.m. an observation and interview was conducted with Resident #6 who reported experiencing increased pain when the facility Ran out of his pain medicine. Resident #6 stated he was Always in pain pain intensity increases and decreases; currently his pain level is okay. Review of the face sheet showed Resident #6 latest return to the facility on 6/29/22, with diagnoses including Stage 4 sacral pressure ulcer, osteomyelitis (inflammation of the bone), paraplegia, chronic nephritis (inflammation of the kidney) and chronic pain. Review of Resident #6's Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed his Brief Interview for Mental Status (BIMS) score was 15, indicating he was cognitively intact. Review of Resident #6's Physician Orders, start date 6/7/23, end date open-ended, showed Oxycodone 15 mg (milligram) tablet every 6 hours (12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m.) On 10/17/2023 at 10:30 a.m. an observation and interview was conducted on the South Hall with Staff A, LPN. Staff A stated she was caring for Resident #6. Staff A said at the beginning and end of each shift nurses count the number and amount of narcotics available in the medication cart then sign the controlled drug shift audit log. She stated when narcotic medications are received from the pharmacy two nurses sign the pharmacy packaging slip, verifying the number of packages received and the number/amount of narcotic medications. On 10/17/23 at 09:30 a.m. Resident #4 was observed lying in bed and stated he has Oxycodone for his pain ordered and he requests it when he has pain. A review of the face sheet for Resident #4 revealed he was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, acute kidney failure, anxiety, and chronic pain. A review of the MDS, dated [DATE], revealed in Section C: Cognitive Patterns a BIMS score of 15, indicating Resident #4 was cognitively intact. A review of the Physician orders for Resident #4 revealed a start date of 9/13/23 and an open-ended end date for Oxycodone 15 mg, 1 tablet every 6 hours as needed for chronic pain. On 10/17/23 at 10:00 a.m. an observation and interview was conducted on the North Hall with Staff B, Licensed Practical Nurse (LPN). Staff B stated at the beginning and end of each shift nurses count the number and amount of narcotics in the medication cart then sign the controlled drug shift audit log. She stated when narcotic medications are received from the pharmacy two nurses must sign the pharmacy packaging slip, verifying the number of packages received and the number/amount of narcotic 105292 Page 33 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 medications. Level of Harm - Minimal harm or potential for actual harm On 10/17/23 at 3:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated, Staff E, LPN told the Interim DON that when Resident #4 requested pain medication Oxycodone 15 mg tablets were not available. Staff E called the facility's pharmacy and requested additional pills. Staff E, LPN was informed by the pharmacy staff that 30 pills for Resident #4 were delivered on 9/20/23. The NHA stated on 9/22/2023 at 11:30 a.m. she became aware of the 30 missing Oxycodone 15 mg pills, she contacted the facility's pharmacy to request a copy of the packing slip. She stated the packing slip is proof the facility received Oxycodone 15 mg pills for Resident #4. The NHA stated after receiving the packing slip and photos of the medication packages from the pharmacy another search of the facility was conducted and the pills were not found. The NHA said on 9/22/23 at 11:30 a.m. a report was filed with the local police department. The NHA stated she believed the medication was diverted and identified an agency nurse had signed for the missing pills. The NHA stated on 09/28/23 she became aware Resident #6 was missing thirty Oxycodone 15 mg pills and contacted the facility's pharmacy to request a copy of the packing slip for receipt of the pills. The NHA stated on 9/28/23 she and Staff D, LPN, Unit Manager (UM) confirmed the missing pills were delivered on 9/7/23. The NHA stated she believed the medication was diverted and identified an agency nurse had signed for the missing pills. A formal statement was requested from both nurses working the shift and one nurse did not comply. The NHA said on 9/28/23 at 12:00 p.m. a report was filed with the local police department. The NHA said to prevent narcotic diversion the Interim Director of Nursing (DON) reviewed the facility's Accepting Delivery of Medication policy, with staff nurses and the facility's expectation for two nurses to sign the narcotic medication receipt packaging slips. She said agency staff nurses should know two signatures are required when narcotics are received. Residents Affected - Few Review of the facility policy titled Accepting Delivery of Medications, undated, version 1.2. showed the following: Policy: All staff shall follow a consistent procedure in accepting medications. Policy Interpretation and Implementation: -A nurse shall personally accept each medication delivery -Before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/ order receipt -If an error is identified the nurse verifying the order shall: a. inform the delivery agent of any discrepancies and note them on the delivery ticket; c. if the number of a medication or packages of medications is incorrect, and the medication is not an emergency order, return the order to the pharmacy; and d. if the number of a medication or packages of medications is incorrect, and the medication is an emergency order, and write that information on the delivery ticket/ order receipt. 4. Two nurses shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 105292 Page 34 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Inservice Education Sheet, dated 9/21/23, revealed staff education was conducted by the Interim Director of Nursing. The education was titled, Checking Medication During Pharmacy Delivery, with the objective to check in and account for all medications appropriately when pharmacy delivers medication, revealed five of the facility's ten nurses' signatures. There were no signatures indicating agency staff nurses received the education or an education plan for agency nurses. Residents Affected - Few 105292 Page 35 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the medical record had complete and accurate documentation related to meals and wounds for two residents (#2 and #5) out of nine residents sampled. Findings included: Resident #5 was admitted to the facility on [DATE] with a diagnoses to include but not limited to osteomyelitis of vertebra, sacral, and sacrococcygeal region, adult failure to thrive, weakness, Pressure Ulcer Stage IV of the left hip, dysphagia, hypoglycemia, history of Bacteremia, Diabetes Mellitus, vascular dementia with other behavioral disturbance, and gastrostomy tube. A review of the quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment; in Section G: Functional Status, resident required extensive assistance of two for bed mobility, extensive assistance of one for toileting, and totally dependent regarding eating; in Section K: Nutritional Status, resident had a feeding tube, and had a mechanically altered therapeutic diet; in Section M: Skin, on admission the resident had two Stage III pressure ulcers, and two Stage IV pressure ulcers. A review of the Physician Order Report, dated 09/01/2023 to 10/17/2023, showed the following: Diet: puree, controlled carbohydrate diet (CCHO). A review of the Vitals Report dated 03/07/2023-10/17/2023, revealed between 09/01/23 and 09/29/23 staff documented the meal consumption for Resident #5 33 out of 86 times, only 38% of the time required. During an interview on 10/17/2023 at 2:40 p.m. the Nursing Home Administer (NHA) stated they were getting the wound care notes for Resident #5 from the doctor's office because they were not present in the record. She stated she did not know why the notes were not in the medical record, They are supposed to be. Wound care notes dated 05/30/2023, 09/05/2023, 09/12/2023, 09/19/2023, and 09/26/2023 were provided for review after the facility received them from the physician's office. During an interview on 10/17/2023 at 2:45 p.m. Staff A, Licensed Practical Nurse (LPN) stated the Resident #5 had a sacral wound as well as heel wounds. She stated wound care was done by the floor nurses and the wound care Advanced Practice Registered Nurse (APRN). She stated the APRN saw the resident weekly and did the dressing changes, measured the wounds, and gave wound care orders. She stated, The resident was eating, but not well. A review of the Comprehensive Care Plan, start date 04/16/2023, revealed the following: Problem: Nutritional Status-Resident is at nutritional risk related to: Impaired cognition with vascular dementia which potentially affects her desire to consume nutrition orally with a diagnosis of dysphagia, duodenal ulcer with hemorrhage, and anemia. Resident has impaired ability to feed self and requires staff assistance to feed. Resident has a diagnosis of diabetes and insulin dependent with fluctuating blood sugars. 105292 Page 36 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0842 Interventions included: Staff to offer to feed resident at meals puree, CCHO diet with thin liquids. Level of Harm - Minimal harm or potential for actual harm Problem: Pressure Ulcer/Injury-Resident had a skin breakdown: pressure ulcers to sacrum, bilateral ankles related to poor nutrition and immobility with a diagnosis of macrocytic anemia, Diabetes (insulin dependent), obesity, and osteomyelitis of vertebrae, sacral and sacrococcygeal region. Residents Affected - Few Long term goal with a target of 10/17/2023: Resident will not develop additional pressure ulcers. Interventions included: Assessing the pressure ulcer for stage, size, presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly. Resident #2 was admitted to the facility on [DATE] with a diagnosis including but not limited to, acute and chronic respiratory failure, tracheostomy weakness, dysphagia, cognitive communication disorder, Diabetes, gastrostomy, dyspnea, and hypoglycemia. A review of the Form 5000-3008 showed Resident #2 was on Vivonex 70 milliliter (ml) per hour, water flush 30 ml every 4 hours (per gastrostomy tube or tube feeding). A record review of the Physician orders revealed no tube feeding orders for Resident #2. An interview was conducted on 10/17/23 at 3:10 p.m. with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN verified there were no tube feeding orders in the medical record for Resident #2. She stated, The order must have come in but was not put into the system yet. A review of the facility's policy titled Medication Orders, not dated, revealed the following: Purpose: Purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Supervision by a Physician: 2. A current list of orders must be maintained in the clinical record of each resident. Recording orders: 4. Enteral orders-When recording orders for enteral tube feedings, specify the type of feeding, amount, frequency of feeding and rationale if prn (as needed). The order should always specify the amount of flush following the feeding. A review of the facility's policy titled Wound Care, not dated, revealed the following: Purpose: Purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time of the wound care was given. 105292 Page 37 of 38 105292 11/02/2023 Eagle Lake Nursing and Rehab Care Center 1100 66th St N Saint Petersburg, FL 33710

F 0842 3. The name and title of the individual performing the wound care. Level of Harm - Minimal harm or potential for actual harm 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Residents Affected - Few 10. the signature and title of the person recording the data. 105292 Page 38 of 38