Health inspection·March 28, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report suspected staff abuse of a resident to the state licensing authority for 1 of 4 residents reviewed for Abuse, of a total sample of 12 residents, (#5). Residents Affected - Few Findings: Review of the medical record revealed resident #5, a vulnerable [AGE] year old male was admitted to the facility from an acute care hospital on 1/23/23 with diagnoses of spinal stenosis (narrowing), failure to thrive, malnutrition, impaired cognitive functioning and awareness symptoms, peripheral vascular disease (impaired circulation in the limbs), Chronic Obstructive Pulmonary (Lung) Disease, right foot drop, and contractures (muscle/tendon shortening/rigidity). The Minimum Data Set Quarterly Assessment with Assessment Reference Date 10/26/23 noted resident #5 scored 9 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. The assessment showed the resident had no indicators of psychosis, and he had not rejected evaluation or care. The resident had functional and range of motion limitations of his upper and lower limbs, was dependent on staff to complete Activities of Daily Living (ADLs) and mobility functions in and out of bed, was always incontinent of bowel and bladder functions, and received high-risk anti-depressant medication during the look-back period. The Order Summary Report documented resident #5 had active physician's medication orders that included Remeron 15 milligrams at bedtime for depression. On 3/27/24 at approximately 2:00 PM, resident #5 was in his room lying in bed and stated, I don't want to talk. Review of the Comprehensive Care Plan included focuses for malnutrition, psychosocial well-being risks, limited physical mobility, ADL self-care performance deficits, impaired cognitive function/dementia and thought processes, memory loss, dependence on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, immobility, and chronic disease processes, and communication deficits with interventions that included to ensure/provide a safe environment. The August 2023 Reportable Event Log noted an allegation of abuse concerning resident #5 occurred on 8/17/23 at 9:45 PM. On 3/27/24 at 3:15 PM, Certified Nursing Assistant (CNA) B recalled an incident that occurred during the 3:00 PM to 11:0 PM shift on 8/17/23. She explained she had assisted CNA A to provide resident Page 1 of 2 105325 105325 03/28/2024 Space Coast Healthcare and Rehabilitation Center 125 Alma Blvd Merritt Island, FL 32953

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #5 incontinence care. She said she was uncomfortable with the actions of CNA A towards the resident, and she reported it to the nurse. She said the same day, she provided a hand-written statement to the former Unit Manager. In an interview on 3/26/24 at 1:54 PM, the Nursing Home Administrator (NHA) recalled on 8/17/23, he submitted online State Agency (SA) reports and contacted local law enforcement after he learned CNA B reported resident abuse allegations against CNA A. He explained the incident was investigated, the facility had substantiated the allegation, and CNA A was suspended immediately after the incident and subsequently her employment was terminated. The NHA could not recall if a licensing board complaint was submitted online or by telephone. At 3:54 PM, the NHA said he understood the facility's investigative responsibility included submission of a complaint to the state licensing board and he believed a letter was mailed however, he had not located any documentation for confirmation. On 3/27/24 at 11:15 AM, the Director of Nursing (DON) said she recalled resident #5's incident in August 2023. She explained that she was not involved with the state board reporting nor aware of where the record or case number confirmation was located. She said the facility's investigation found CNA A's actions toward resident #5 were unacceptable and her employment had been terminated. Attempts to reach CNA A by telephone on 3/26/24 at 3:01 PM and 3/27/24 at 2:28 PM were unsuccessful. Review of a the state online Department of Health Administrative Actions record provided by the NHA noted one public complaint against CNA A had been previously reported on 8/19/14. On 3/28/24 at 9:05 AM, the facility provided a copy of an Online Complaint for CNA A with a case number confirmation that was submitted to the state licensing board by the NHA on 3/27/24. On 3/28/24 at 1:40 PM, the NHA said the state licensing board was investigating the complaint and requested additional information from the facility. On 3/27/24 at approximately 11:15 AM, the DON conveyed it was important to protect vulnerable residents and report suspected staff abuse to the licensing board for investigation. Review of the facility's standards and guidelines titled Abuse Policy Document ID# 42023686 dated 10/18/22 read, . if licensed staff member is found at fault - must be reported to the applicable licensing board. Complaints about a nursing assistant must be reported to the State Specific Agency for Nursing Assistants. 105325 Page 2 of 2