Health inspection·September 12, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure that alleged violations involving neglect, and misappropriation of resident property, were reported no later than 24 hours to the State Survey Agency for two (Residents #1 and #2) of 4 residents reviewed for reportable incidents. The findings include: 1. A review of the facility's adverse incidence report revealed that Resident #1 had an incident on 8/8/2023. A review of the clinical record for Resident #1 revealed an admission date of 3/14/23, with re- entries on 7/3/23, 7/31/23, 08/16/23, 8/27/23, and discharged on 8/29/23. Her diagnoses included Diabetes Mellitus, Cardiovascular accident, chronic kidney disease, seizure disorder and bipolar disorder. Physician's orders for Resident #1 dated 8/1/23 revealed orders for insulin Levemir 100 units/milliliter (ml) inject 11 units subcutaneous two times a day (BID) and Humalog 100 units/inject 6 units three times a day and sliding scale during meals. On 8/3/23 there was an orders to increase Levemir 100 units/milliliter (ml) inject 11 units subcutaneous two times a day (BID). There was no indication if the order to increase Levemir to 15 ml was executed (Copy obtained) Nursing progress notes authored by LPN A as late entry dated 8/8/23 indicated that at 11:15 am Resident #1's blood sugar was 377, 10 units of lispro administered, resident symptomatic with shortness of breath (SOB) respiratory distress unable to lay supine without increased SOB/fear. Grossly edematous to bilateral upper and lower extremities to include abdominal area. Physician assistant notified and orders received and implemented to increase Lasix to 40 mg by mouth daily. Floor manager updated on resident status. A joint interview was conducted with the Director of Nursing (DON) and the Risk Manager on 9/12/23 at 12:28 pm. The Risk Manager stated that on 8/8/23 around 2:00 pm, she was called to the unit by the unit manager to assess Resident #1, as she had a change in condition. Upon assessment, the resident was noted to be diaphoretic with altered mental status with a blood sugar reading of 428. When the Licensed Practical Nurse (LPN A) assigned to the resident was asked what the blood sugar during meals was and how many units of insulin she had administered, she stated that the blood sugar was 377, and she had given three units of Humolog. The risk manager then checked the resident's chart which indicated that she should have received 10 units of Humalog insulin per sliding scale and 6 units standard (total of 16 units). The risk manager also noted new orders to increase Lasix and Levemir that Page 1 of 3 105358 105358 09/12/2023 Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204

F 0609 Level of Harm - Minimal harm or potential for actual harm were written at 7:00 am which had not been entered in the computer system. She added that resident #1 was sent out to the hospital for evaluation and was admitted with diabetic ketoacidosis. 2. A review of a second adverse incident dated 7/17/23 indicated that LPN B notified the DON that LPN C had incorrectly signed off narcotic medication for Resident #2. Residents Affected - Few A review of the clinical record for Resident #2 revealed an admission date of 7/17/23 with diagnoses that included stroke with aphasia, dementia, hypertension, left hip pain, and fracture femur. Physician's orders for Resident #2 dated 7/17/23 indicated the resident was on oxycodone 5 mg every 4 hours as needed for pain. Care plan dated 7/17/23 indicated the resident had pain related to left hip fracture with interventions to administer medication as ordered and monitor effectiveness. An interview was conducted with the DON and the Risk Manger on 10/2/2023 at 3:50 pm. The DON stated that Resident #2's clinical record indicated she was admitted to the facility on [DATE] with an order for Oxycodone immediate release (IR) 5 milligrams (mg) ever 4 hours as needed. Medication arrived from the pharmacy on 7/19/23 at 01:00 am. LPN A signed off the medication on the narcotic record as administered on 7/16/23 at 10:00 pm and 7/17/23 at 2:00 am (at this time resident was not in the facility). DON added that LPN A did not cooperate with the facility for investigation and the sheriff's department was notified. When asked if a federal report was made related to the incidences on 7/17/23 and 8/8/23, they both replied, No. Both the DON and the risk manager stated that they thought that the adverse incident was sufficient. When asked what the facility policy was related to reporting, neither could identify what these allegations were related to. They then obtained the facility policy and confirmed that the incident on 8/8/23 was related to neglect and incident on 7/17/23 was related to misappropriation, therefore, a federal report should have been made and Department of Children and Families (DCF) should have been notified. A reviewed of the facility's policy and procedure titled, Administering Medications, last revised 12/2021, revealed: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed. The policy Interpretation and Implementation. section C, indicated that Medications shall be administered in accordance with the orders. (Copy obtained) Further review of the facility's policy titled, Abuse Prevention, last revised on 6/2020, page 2 revealed: Definitions (Page 2) Neglect, means the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Reporting/Response (Page 6) 105358 Page 2 of 3 105358 09/12/2023 Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204

F 0609 Level of Harm - Minimal harm or potential for actual harm The community will immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and/or designee, State Agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific time frames. (Copy obtained) Residents Affected - Few . 105358 Page 3 of 3