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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105358 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105358 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Post Acute 1750 Stockton St Jacksonville, FL 32204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)