Health inspection·September 5, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to coordinate assessments for the residents with newly diagnosed mental disorders for 2 of 3 residents reviewed (Residents #8 and #16).Findings include: 1) Review of Resident #8's admission record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including post-traumatic stress disorder (onset date of 12/20/2023), anxiety disorder (onset date of 9/19/2023), bipolar disorder (onset date of 4/22/2025), major depressive disorder (onset date of 4/22/2025), generalized anxiety disorder (4/22/2025), and brief psychotic disorder (onset date of 10/17/2023). Review of Resident #8’s Care Plan Note from mental health provider with the date of service 8/26/2025 read, “Rationale behind diagnosis: MDD [Major Depressive Disorder], Recurrent: The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient and they have occurred without any underlying substance use or organic brain pathology… Bipolar Disorder: The patient’s history suggests that the patient has chronic episodes of depression and manic-like symptoms. These symptoms cause significant distress and functional impairment to the patient. There is no consistent substance use or organic brain disorder to explain these consistent mood symptoms. As bipolar disorder is a lifelong disorder, mood stabilizer medicine needs to be continued on a long-term basis… PTSD (Post Traumatic Stress Disorder): The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology.” Review of Resident #8’s Preadmission Screening and Resident Review (PASRR) dated 8/23/2023 showed it documented Resident #8’s secondary diagnosis as dementia. The PASSR documented, “No diagnosis of Suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required.” under Section IV. PASRR Screen Completion. There was no updated PASRR form completed for Resident #8 with the diagnoses of bipolar disorder, major depressive disorder, and generalized anxiety disorder. During an interview on 9/5/2025 at 11:30 AM, the Social Services Director stated that the process regarding PASRRs was that for new admissions, the PASRR was reviewed for accuracy and if there were changes, the PASRR was updated. During an interview on 9/5/2025 at approximately 12:05 PM, the Social Services Director stated that Page 1 of 5 105434 105434 09/05/2025 Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608

F 0644 Level of Harm - Minimal harm or potential for actual harm they would be updating Resident #8's PASRR, and it should have been updated when new diagnoses were identified. 2) Review of Resident #16’s admission record showed the resident was most recently admitted on [DATE] with diagnoses including paranoid schizophrenia with onset date of 5/13/2024. Residents Affected - Some Review of Resident #16’s psychiatry subsequent note with date of service 6/18/2024 read, “Rationale behind diagnosis… Schizophrenia (Not fully confirmed): The history of this patient shows that the patient has chronic and consistent psychosis. These symptoms cause significant distress and functional impairment to the patient. The patent has had a history of psychosis for more than one month, causing emotional and behavioral disturbance for six months or more. There is no consistent substance use or organic brain disorder to explain these chronic and consistent psychotic symptoms. The psychotic symptoms occur independent of exacerbation of other psychiatric comorbidities, and these psychotic symptoms cause severe distress to the patient.” Review of Resident #16’s PASRR dated 5/7/2024 showed it documented anxiety disorder and depressive disorder as mental illness under Section I. PASSR Screen Decision-Making. There was no psychotic disorder, paranoid schizophrenia or schizophrenia (not fully confirmed) documented. The PASSR documented, “No diagnosis of Suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required.” under Section IV. PASRR Screen Completion. During an interview on 9/5/2025 at 9:30 AM, the Regional Nurse Consultant confirmed Resident #16’s PASRR did not document Residen#16’s diagnoses of psychotic disorder, paranoid schizophrenia or schizophrenia (not fully confirmed). Review of the facility policy and procedure titled Role of Admissions and Social Services in PASRR” last reviewed on 1/15/2025 read, “Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs.” 105434 Page 2 of 5 105434 09/05/2025 Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608

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 Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by physician for 1 of 6 residents reviewed for medication administration (Resident #89).Findings include: Residents Affected - Few Review of Resident #89's physician order dated 5/27/2025 read, Midodrine HCl Oral Tablet 2.5 MG [milligram] (Midodrine HCl), Give 1 tablet by mouth three times a day for Orthostatic hypotension, Hold for SBP [Systolic Blood Pressure] of greater than 130. Review of Resident #89's Medication Administration Record (MAR) for July 2025 for administration of Midodrine HCl 2.5 MG tablet showed the following documentation: X for BP (blood pressure) and pulse and code 9 (other- see nurse's notes) on 7/8/2025 at 1:00 PM, 142/65 (systolic/diastolic blood pressure) for BP and 96 for pulse and checkmark for administration of the medication on 7/14/2025 at 5:00 PM, and X for BP and pulse and code 4 (held per parameters) on 7/27/2025 at 9:00 AM. Review of Resident #89's medical records showed no progress notes related to Midodrine HCl 2.5 MG tablet on 7/8/2025 at 1:00 PM and all blood pressures for 7/8/2025 were documented as having a systolic blood pressure of less than 130. Further review showed no blood pressure and notes documented for Midodrine HCl 2.5 MG tablet on 7/27/2025 at 9:00 AM. Review of Resident #89's MAR for August 2025 for administration of Midodrine HCl 2.5 MG tablet showed the following documentation: NA (Not Applicable) for BP and pulse and checkmark for administration of the medication on 8/1/2025 at 5:00 PM, 132/69 for BP and 92 for pulse and checkmark for administration of the medication on 8/6/2025 at 5:00 PM, NA for BP and pulse and checkmark for administration of the medication on 8/12/2025 at 5:00 PM, 131/74 for BP and 78 for pulse and checkmark for administration of the medication on 8/17/2025 at 5:00 PM, 136/72 for BP and 78 for pulse and checkmark for administration of the medication on 8/18/2025 at 9:00 AM, 136/72 for BP and 78 for pulse and checkmark for administration of the medication on 8/17/2025 at 1:00 PM, 136/72 for BP and 78 for pulse and checkmark for administration of the medication on 8/17/2025 at 5:00 PM, and 132/64 for BP and 74 for pulse and checkmark for administration of the medication on 8/31/2025 at 5:00 PM. Review of Resident #89's MAR for September 2025 for administration of Midodrine HCl 2.5 MG tablet showed the following documentation: 131/66 for BP and 68 for pulse and checkmark for administration of the medication on 9/1/2025 at 5:00 PM, and 131/66 for BP and 68 for pulse and checkmark for administration of the medication on 9/2/2025 at 5:00 PM. Review of Resident #89's physician order dated 5/10/2025 read, Novolog FlexPen 100 UNIT/ML [milliliter] Solution pen-injector, Inject 8 unit subcutaneously before meals for DM [Diabetes Mellitus]. Review of Resident #89's MAR for June 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: code 4 (held per parameters) on 6/1/2025 at 11:30 AM, pl (Sic.) on 6/2/2025 at 6:30 AM, no entries on 6/3/2025 at 6:30 AM, 14 (insulin coverage not needed) on 6/7/2025 at 6:30 AM, pl on 6/15/2025 at 6:30 AM, pl on 6/16/2025 at 6:30 AM, and 14 on 6/27/2025 at 6:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 6/1/2025 at 11:30 AM, 6/2/2025 at 6:30 AM, 6/3/2025 at 6:30 AM, 6/7/2025 at 6:30 AM, 6/15/2025 at 6:30 AM, 6/16/2025 at 6:30 AM, and 6/27/2025 at 6:30 AM. 105434 Page 3 of 5 105434 09/05/2025 Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #89's MAR for July 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: no entries on 7/7/2025 at 6:30 AM, code 4 on 7/19/2025 at 11:30 AM, code 14 on 7/21/2025 at 6:30 AM, pl on 7/27/2025 at 6:30, and code 14 on 7/29/2025 at 6:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 7/7/2025 at 6:30 AM, 7/19/2025 at 11:30 AM, 7/27/2025 at 6:30, and 7/29/2025 at 6:30 AM. Further review showed a note documenting blood sugar as 89 on 7/21/2025 at 6:30 AM, with no documentation regarding physician notification. Review of Resident #89's MAR for August 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: code 14 on 8/4/2025 at 6:30 AM, code 14 on 8/5/2025 at 6:30 AM, code 4 on 8/7/2025 at 6:30 AM, pl on 8/17/2025 at 6:30 AM, code 14 on 8/18/2025 at 6:30 AM, no entries on 8/19/2025 at 11:30 AM, code 14 on 8/24/2025 at 11:30 AM, no entries on 8/29/2025 at 6:30 AM, and code 4 on 8/31/2025 at 11:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 8/4/2025 at 6:30 AM, 8/5/2025 at 6:30 AM, 8/7/2025 at 6:30 AM, 8/18/2025 at 6:30 AM, 8/19/2025 at 11:30 AM, 8/24/2025 at 11:30 AM, 8/29/2025 at 6:30 AM, and 8/31/2025 at 11:30 AM. Further review showed a note documenting blood sugar as 108 on 8/17/2025 at 6:30 AM, with no documentation regarding physician notification. Review of Resident #89's MAR for September 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml showed the following documentation: code 14 on 9/1/2025 at 6:30 AM, code 4 on 9/1/2025 at 11:30 AM, code 14 on 9/2/2025 at 6:30 AM, code 4 on 9/2/2025 at 11:30 AM, and code 14 on 9/3/2025 at 6:30 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml on 9/1/2025 at 11:30 AM, 9/2/2025 at 6:30 AM, 9/2/2025 at 11:30 AM, and 9/3/2025 at 6:30 AM. Further review showed a note documenting blood sugar as 117 on 9/1/2025 at 6:30 AM, with no documentation regarding physician notification. Review of Resident #89's physician order dated 5/10/2025 read, Novolog FlexPen 100 UNIT/ML Solution pen-injector, Inject as per sliding scale; if 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units, subcutaneously before meals and at bedtime for DM.” Review of Resident #89's MAR for June 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale showed the following documentation: no entries on 6/3/2025 at 6:00 AM, 196 for BS (blood sugar) and 3 (absent from building) on 6/19/2025 at 4:00 PM, 293 for BS and code 3 on 6/19/2025 at 9:00 PM, no entries on 6/24/2025 at 9:00 PM, and no entries on 6/26/2025 at 9:00 PM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale on 6/3/2025 at 6:00 AM, 6/19/2025 at 4:00 PM, 6/19/2025 at 9:00 PM, 6/24/2025 at 9:00 PM, and 6/26/2025 at 9:00 PM. Review of Resident #89's MAR for July 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale showed the following documentation: 205 for BS and code 15 (pulse below 60/minute) on 7/27/2025 at 6:00 AM. Review of Resident #89's medical records showed no progress notes related to injection of 8 units 105434 Page 4 of 5 105434 09/05/2025 Plaza Health and Rehab 4842 SW Archer Road Gainesville, FL 32608

F 0684 of Novolog FlexPen 100 unit/ml per sliding scale on 7/27/2025 at 6:00 AM. Level of Harm - Minimal harm or potential for actual harm Review of Resident #89's MAR for August 2025 for injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale showed the following documentation: no entries on 8/1/2025 at 9:00 PM, 290 for BS and code 9 (other see nurse's notes) on 8/11/2025 at 6:00 AM, 152 for BS and pl on 8/17/2025 at 6:00 AM, and no entries on 8/29/2025 at 6:00 AM. Residents Affected - Few Review of Resident #89's medical records showed no progress notes related to injection of 8 units of Novolog FlexPen 100 unit/ml per sliding scale on 8/1/2025 at 9:00 PM, 8/17/2025 at 6:00 AM, and 8/29/2025 at 6:00 AM. Further review showed a note for 8/11/2025 at 6:00 AM that read, “Blood Sugar 290. Sprint soft drink at bedside.” During an interview on 9/5/2025 at 8:42 AM, the Director of Nursing (DON) stated that if she held a scheduled dose of insulin because the blood sugar was low, she would call the doctor and document the order [to give or hold insulin]. It would be the same for blood pressure medications. During an interview on 9/5/2025 at 8:50 AM, Staff I, Licensed Practical Nurse (LPN), stated, Set doses [of insulin] at mealtimes are usually because the resident is expected to spike [their blood sugar with eating]. I would give the morning dose [of the scheduled insulin] right before their meal, and then do the sliding scale after they eat. If the blood sugar was low, I would reach out to the doctor. I would give the blood sugar result and get an order to hold or give the insulin. I would actually write a note [not just use number codes within the MAR]. I may check 9, but I would write a note saying, Don't give per MD [Medical Doctor], or get a one-time order to give [the insulin]. The note is also to communicate with everyone. I would call the doctor if a resident's blood pressure was above the parameter for [administering] Midodrine. I would still let them know. I would still reach out, even if I planned on giving the medication, but I would double check [the blood pressure]. During an interview on 9/5/2025 at 11:03 AM, Physician #1 stated, “[Resident #89's name] is a brittle diabetic. If they check the blood sugar in the morning and it is low, I expect to be called. If it [the blood sugar] is 50-60, I consider that too low, and I expect to be contacted. They would need to contact me to see whether to hold the insulin or do something else to prevent worsening hypoglycemia. For the Midodrine, if it [the systolic blood pressure] is 131, they should hold it per protocol and document it. If the blood pressure is low, they should reach out to me. If they are not giving Midodrine when the blood pressure is within the parameter, she could have worsening hypotension, and if they are holding it when it exceeds parameters, she could have hypertension. I would be more concerned if they are giving the Midodrine when it is above parameters, due to supine hypertension.” Review of the facility policy and procedure titled “Medication Administration” last reviewed on 1/15/2025 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication of refusals of medication by the resident. Procedure: 3. Medications should be administered in a timely manner in accordance with the physician's orders. 105434 Page 5 of 5