Health inspection·March 30, 2023

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 2 of 3 sampled residents (Residents #90 and #153) received a notification of Medicare Non-Coverage (NOMNC) (CMS Form 200052) informing them of their rights to appeal the decision to terminate skilled services before such services are discontinued and/or before the resident's discharge from the facility. Residents Affected - Few The findings included: 1. Review of the NOMNC for Resident #90 revealed that skilled services started on 12/4/2022 and had an expected end date of 12/29/2022. The Skilled Nursing Facility Beneficiary Protection Notification Review form completed by the facility's Social Worker on 3/30/2023 revealed that the facility initiated the discharge12/27/2022 from Medicare Part A Services (skilled rehabilitation services) when benefit days for Resident #90 were not exhausted. Record review revealed the Electronic Clinical Records documented that Resident #90 was admitted to the facility on [DATE] with the following primary diagnoses: Fracture Of Upper End Of Left Humerus, Fracture With Routine Healing; Disorders Of Bone Density And Structure, Syncope And Collapse; Osteophyte, Vertebrae; Cervical Spine ; Fracture Of Left Pubis, Fracture With Routine Healing; Laceration of Head, Injury Of Head; History Of Falling.; Major Depressive Disorder, Difficulty In Walking, Muscle Weakness (Generalized), And Hypokalemia. Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 presented with cognitive deficit scoring 10/15 on the Brief Interview of Mental Status, indicating moderately impaired cognition. Review of the activities of daily living (ADL) plan of care dated 2/15/2023 showed that Resident #90's dependance from staff ranged from set-up only, limited assistance, and extensive assistance for ADL's. During an interview with the Social Worker (SW) on 3/20/2023 at 11:55 AM, he informed that Resident #90's family members visit regularly. The SW acknowledged that the family are involved in the Resident's care. He also reported that upon termination of skilled services he had contacted the resident's sister (Not the person with Power of Attorney) to report that Resident #90's skilled services would be discontinued. The SW offered no evidence of what transpired from that conversation. An attempt to interview Resident #90 on 03/30/23 at 12:32 PM was unsuccessful, The resident was not Page 1 of 12 105485 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few available. Nevertheless, the resident's Nurse informed that the resident had cognitive deficits that would qualify Resident #90 as a poor historian, regarding her care. 2. Review of the NOMNC, showed that Resident #153 started receiving skilled services on 1/21/2023. The last covered day was on 2/19/2023. The NOMNC signed by the SW revealed that the Resident's Representative was contacted via telephone on 2/15/2023. Eventually, the facility discontinued skilled services on 2/19/2022 when Resident #153 had not exhausted all of her Medicare Part A services. On 3/30/2023, during a subsequent interview with the Social Worker, he confirmed that the resident's wife comes to the facility on a regular basis and is very involved in the resident's care. Yet, the NOMNC was not signed by the wife to indicate that she was notified and understood her rights to appeal the decision to discontinue skilled services. Review of the Social Worker (SW)'s progress notes dated February 15, 2023 showed that on 2/15/2023 at 11:55 AM, the Social Worker called Resident #153's family member to inform that the resident would be discharge back to an assisted living facility. However, there were no other notes to indicate that the Social Worker had discussed the termination of skilled services with the family member and their rights to appeal the decision. Record review revealed resident #153 was admitted to the facility on [DATE] and discharged on 2/20/2023. Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #153 obtained a score 3/15 on the Brief Interview for Mental Status. This score indicates that Resident # 153 had severe cognitive deficits. Resident # 153's admitting diagnoses included: Parkinson's Disease, Covid-19, Acute Respiratory Failure with Hypoxia, Shortness of Breath, Personal History of Covid-19, Altered Mental Status, Unspecified, Other Alzheimer's Disease, Metabolic Encephalopathy, Hypertension, Gastro-Esophageal Reflux Disease without Esophagitis, Muscle Weakness, Benign Prostatic Hyperplasia, Abnormalities of Gait and Mobility, Sepsis and Other Acute Kidney Failure. Review of the activities of daily living (ADL) plan of care dated 1/22/2023 showed that Resident #153's dependance from staff ranged from set-up only, extensive assistance, to extensive assistance for ADL's. During the exit conference on 3/30/2023 at 3:30 PM, the facility provided no evidence that the resident's rights to appeal the decision to terminate skilled services were honored and respected. 105485 Page 2 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

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 records review, interview, and the facility's abuse and fall policies review, the facility failed to thoroughly investigate an incident resulting to injury of unknown origin for 1 of 3 sampled residents (Resident #57); and the facility failed to rule out abuse or neglect subsequent to the incident. Residents Affected - Few The findings included: Review of the Facility's policies and procedures on Falls outlined in section 2, documented: Nurse shall assess and document the following: a. Vital signs b. Recent injury, especially fracture or head injury c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in cognition or level of consciousness e. Neurological status f. Pain g. Frequency and number of falls since last physician visit .etc. In section 5 of the Fall Policy it is noted that: The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc, In section 6. It is outlined that Falls should be categorized: a. 105485 Page 3 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0610 Those that occur while trying to rise from a sitting or lying to an upright position; Level of Harm - Minimal harm or potential for actual harm b. Those that occur while upright and attempting to ambulate; and Residents Affected - Few c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. In section 7. It is noted that falls should be identified as witnessed or unwitnessed events. Review of the Abuse Investigation and Reporting Policies outlined pertinent staff duties in investigating incidents of unknown origin be it abuse. mistreatment, neglect or injury of unknown sources. It is documented that all injuries of unknown sources shall be promptly reported and thoroughly investigated by facility management. At a minimum, the investigation should include: h. Interviews with staff members who have had contact with the resident during the period of the alleged incident; i. Interview the resident's roommate. j. Review all events leading up to the alleged incident Review of the Electronic Clinical Record of Resident # 57 showed that he was admitted to the facility on [DATE]. Resident # 57's most recent primary admitting diagnoses included: Segmental and Somatic Dysfunction of Cervica Region, Osteoarthritis of Hip, Acute Kidney Failure, Muscle Weakness, Difficulty in Walking, Hypokalemia, Absolute Glaucoma, History of Falling, Systolic Congestive Heart Failure, Pain and Acute Respiratory Failure with Hypoxia. Section C of the Minimum Data Set (MDS) revealed Resident #57 scored 8 of 15 on the Brief Interview of Mental Status (BIMS), indicating Resident #57 had significant cognitive deficits. Review of the activities of daily living (ADL) performance levels showed that Resident # 57 dependance from staff ranged from set-up only, supervision, extensive assistance to total dependence for ADL's. The Care Plan dated 8/7/2022 noted that: Resident # 57 was at risk for falls related to weakness and decreased endurance. The plan further 105485 Page 4 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0610 documented the following: Level of Harm - Minimal harm or potential for actual harm Staff will: o Residents Affected - Few Ensure that Resident # 57 will not sustain serious injury through the review date. o Administer meds as ordered. Monitor for & report adverse side effects. o Place Bed in lowest position for safety o Place Bilateral mats- safety precautions o Keep frequently used items & call bell with easy reach. Encourage use of call bell for assistance. o Ensure that Resident #57 is wearing appropriate footwear when ambulating or mobilizing in w/c. The Nursing Progress Notes dated 11/4/2022 showed a documented incident by Employee C, a Licensed Practical Nurse. Employee C documented: Patient overheard yelling out for help. Upon arriving, assigned Nurse stated that she observed patient halfway in the bed with the right side of his head pressed against the grab bar, slight bleeding noted. Patient can't explain how fall occurred due to confusion. Pressure immediately applied to site. Patient is stabilized in bed awaiting 911 for transfer. Remains alert to self. Denies pain. Call to MD (Medical Doctor) awaiting call back, spouse aware. Report exchanged with ER nurse. The Nursing Progress showed that on 11/4/22 at 5:10 PM, Employees C's notes were struck out as incorrect documentation. However, No new entry was made. No documentation explained why Employee C's notes were incorrect. On 03/29/23 at 10:22 AM, an interview with Employee C revealed that she has been working at the facility since 2011. Employee C stated that Resident #57 is very confused and at times calls 911. Resident # 57 always believed that he was at the Army base. Employee C said that she remembered the incident of 11/4/22, and since that fall, they use floor mats to protect Resident #57. Employee C said that she is not sure why they struck out her notes and documented that her information was incorrect. Employee C said that since the fall incident, they have closely watched Resident# 57 to ensure that he does not fall. 105485 Page 5 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/29/23 at 10:31 AM, the Director of Nursing (DON) informed that she has been working at this facility for two years. She said that the reason why Employee C's incident notes were crossed out was because the resident did not actually fall. The DON acknowledged that she crossed-out the nurse's documentation. The DON added that the resident did not fall out of bed as the nurse had reported because the nurse and the Certified Nursing Assistant (CNA) would first have to assess the resident on the floor before putting him back in bed, which was not done. The DON ensued and informed that normally when a staff inadvertently does a wrong documentation, they would discuss the matter with the nurse and have the nurse correct the documentation in Point Click Care (PCC). The DON attested to the fact that the issue was not discussed with Employee C who documented the fall incident of 11/4/22. The DON was then asked to provide documentation of the incident and the Neuro Checks. The DON explained that the nurses' progress notes are usually linked with incident/investigation reports, and once the investigation report is struck out, the nurses' notes are thereby struck out. The DON said, she could not provide evidence of what had actually occurred on the day of 11/4/22. Upon insisting that the struck out incident report be provided, the DON finally acknowledged that she had not conducted an incident investigation, but provided a copy of the incident report. Review of the incident report dated 11/4/22 revealed it was prepared by another unidentified staff member at 5:10 PM, whereas the incident notes were written by Employee C. The report showed that Resident #57 had a skin tear on top of the scalp; he was only oriented to person; For predisposing environmental factors, other was selected; and, there was no witness. Review of the Nurses' Progress notes dated 12/9/22, documenting the fall of that day, showed that Resident #57 slid out of his wheelchair while sitting by the nursing station. He sustained no injury per assessment. Review of the Hospital records dated 11/04/22 at 1:29 PM and referencing the resident's fall/incident of 11/4/22 revealed that Resident #57's Chief complaint was C2 fracture fall out bed. The section of the hospital final report with heading titled History of Present Illness documented the following: Patient is a pleasant [age] male . He apparently fell out of bed and had some complaints of neck discomfort. He states that he feels better at this point in time. Patient denies having prior history of issues with his cervical spine. States that he has no numbness or tingling and no new weakness. He was placed on hard cervical collar was seen in outside facility where CT scan revealed suspicion of a small anterior fracture of the C2 vertebral body. The X-ray diagnostic report completed on 11/6/22 confirmed a fracture of the Cervical spine at the C2 level. The Report concluded that the fracture was a non-displaced fracture C2. There was very little change in position of the cervical spine with attempted flexion and extension. No subluxation. According to the Director of Nursing, none of the aforementioned protocols were followed since Resident #57's injuries were considered fall-related. Yet, no investigation was done to identify its source. On 3/30/2023 at 2:34 PM, during an observation in the room, Resident #57 was observed sitting in his wheelchair. The bed was observed in high position and the floor mats were placed erect on the left side of the bed, by the window. 105485 Page 6 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0610 The facility provided no additional information during the exit conference conducted on 3/30/2023 at 3:30 PM with the Administrator, the Director of Nursing, and Associates. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105485 Page 7 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 provide care and services that included adaptive eating equipment to improve and maintain independence in eating for 1 for 7 sampled residents (Resident #70). Residents Affected - Few The findings included: During the observation of the lunch meal conducted on 03/27/23 at 12:30 PM and the breakfast meal conducted on 03/28/23 at 8 AM, it was noted that the meal trays were delivered to the room of Resident #70 and were set up by staff in front of the resident while sitting up in bed. During the meal observations it was noted that the resident had some cognitive impairment, failed to answer surveyor questions and vision issues that included the resident shutting eyes while trying to self-feed. Further observation noted that the resident was having food spillage while attempting to self-feed due to the vision issues. A review of the tray meal tickets did not contain documentation of adaptive eating equipment such as built-up utensils or scoop plate. A review of the clinical record of Resident #70 noted the following: * Date Of admission: [DATE] * date of birth : 2/25/58 * Diagnoses: Legally Blind, DM (Diabetes Mellitus) 2, Chronic Ulcer Lower Left Leg, Pressure Ulcer Left Foot Stage IV, and Bipolar Disorder. Current Physician Orders included: * 9/1/22 - Prostat AWC 30 ml BID (Twice daily) -Wound Heeling * 8/31/23 - Nutrition Intake QID (4 times per day) * 8/31/22 - Hydration Protocol 120 ml /Shift * 8/31/23 - No Concentrated Sweets * 101/10/22 - Med Pass 2 .0 -120 ml QHS (every evening) MDS (Minimum Data Set) assessment dated : 2/16/23: Sec B: Understood & Understands Sec: BIMS= 13, indicating intact cognition Sec G: Supervision with Eating 105485 Page 8 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0676 Sec K: 67/146, Therapeutic Level of Harm - Minimal harm or potential for actual harm Sec M: Pressure Ulcer/ Stage IV (1) Care Plan Review: date = 2/15/22 Residents Affected - Few * Risk for Weight Loss/Dehydration= Below Ideal Body Weight, Legally Blind. * Utilizes Rim Plate A review of the tray meal tickets (Breakfast, Lunch, and Dinner) and interview with the Dietary Manager (DM) on 03/28/23 noted no documentation of a Rim Plate to be provided with all meals. The interview with the DM noted that she was not aware that the resident's care plan documented a Rim Pale for all meals to assist the resident with independent feeding and lower meal spillage during eating. Interview with Skilled Therapy Director on 3/29/23 noted the Rim Plate was ordered on by Speech Therapy during dates of service on 2/9/22 - 2/15/22. It was further revealed through submitted documentation that the resident was discharged to the hospital on [DATE]. Further review noted that upon a 08/31/22 readmission back to the facility, all physician orders including the Rim Plate were discontinued. Interview with the North Unit Charge Nurse on 3/29/23 noted that when residents are discharged and readmitted that all physician orders are discontinued. It was further stated that Skilled Therapy should have been reevaluated upon the 08/31/22 readmission, the resident should have been re-screened for the need and use of the Rim Plate to aide in self-feeding. On 03/29/23 the Director of Skilled Therapy submitted a Multidisciplinary Screening Form - PT (Physical Therapy)/OT (Occupational Therapy)/ST dated 03/29/23 that included documentation an Occupational Therapy screen was completed, and Resident #70 will benefit from a Rim Plate during all meals due to blindness and difficulty with self-feeding. Also noted that the resident was referred to Restorative Dining Program for assistance with feeding. The Director confirmed that the the resident failed to be re-screened for the Rim Plate (Assisted Eating Device) upon readmission to the facility 08/31/23. 105485 Page 9 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, it was determined that the facility failed to follow physician ordered therapeutic diet of No Concentrated Sweets/Carbohydrate Controlled Diet for 16 facility residents that included 2 of 2 sampled residents (Resident #8 and #70). The findings included: During the review of the approved menu for the week of 03/26/23 it was noted that an 8-ounce portion of skim milk was to be included for breakfast and dinner meals for residents with physician ordered No Concentrated Sweet/Carbohydrate Controlled diets. During the observation of the lunch tray line in the main kitchen on 03/28/23 at 7:30 AM, it was noted that an 8-ounce portion of Regular Milk was included on trays prepared to be served to No Concentrated Sweets/Carbohydrate Controlled Diets. An interview conducted with the Dietary Manager (DM) at the time of the meal observation and was noted to state that she was unaware the approved menu documented skim milk for No Concentrated Sweets/Carbohydrate Controlled diets. It was also stated by the DM that the facility does not keep Skim Milk in supply in the dietary department. The surveyor informed the DM that the Regular Milk could not be served for No Concentrated Sweets/Diabetic diets and to inform the Administrator and Consultant Dietitian for swift resolution of the issues. On 03/24/23 at 9 AM the surveyor was informed that an emergency food supply contained 8-ounce portions of shelf Skim Milk and would be used until skim milk could be purchased or delivered to the facility. The surveyor informed the DM that the shelf skim milk is room temperature and needed to be served at a palatable temperature for the residents. Upon review of the facility's Diet Census for 03/28/23, it was noted that there was currently 16 residents with physician ordered No Concentrated Sweets/Carbohydrate Controlled Diet. It was further noted that 2 of 2 sampled resident's Resident #8 and #70 were 2 of the 16 residents. 105485 Page 10 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included: ensure dish machine is properly sanitizing resident dishware, maintain cleanliness of food storerooms, and proper cleaning of food preparation equipment. The findings included: During the initial kitchen observation tour conducted on 03/27/23 at 9 AM conducted with the Dietary Manager, the following were noted: 1) During the tour, it was noted that the dish machine was in use by facility staff washing resident dishware. The Dietary Manager stated that the dish machine sanitizes by high temperature. At the request of the surveyor a temperature test was conducted by the Dietary Manager (DM). The temperature first test was recorded at 160 degrees F Wash and 160 F degrees Final Rinse. The surveyor informed the DM that the final rinse temperature did not meet the minimum regulatory temperature of 180 degrees F. It was also discussed that dietary staff should have been aware that the dish machine was not sanitizing. The surveyor granted 3 more temperature tests that concluded with the same temperature findings. The surveyor informed the DM that the dish machine could not be utilized until the final rinse temperature of 180 degrees was met. The surveyor also requested documentation if the dish machine required outside vendor repair. The DM stated that resident dishware would be washed and sanitized in the 3-compartment sink and the dish machine repair vendor would be contacted to assess and repair the final rinse temperature. On 03/28/23 at 10 AM the DM submitted documentation of dish machine repairs that documented that the dishwasher was found to be not sanitizing due to mineral build-up in the rinse tubing that would not allow water flow. The rinse piping was cleared with delime solution. Tested and Rinse Gauge indicating 186 degrees F. Further documented that this is an on-going issue and recommend the installation of a mineral/lime removing system, i.e. scale stick, sediment filter etc. in order to prevent sanitation failure in the future. Following the review, it was further discussed with the DM that the system needs to be monitored more closely and to make necessary improvements to the dish machine. 2) During the observation of the dish machine room, it was noted that the wall area behind the machine had numerous areas of dried brown food matter. It was discussed with the DM that the wall areas need to be cleaned on a more regular basis. 3) During the observation of the dish machine room, it was noted that numerous wall tiles located near the base of the wall were broken and missing (6), and the wall area was heavily soiled. It was discussed with the DM that food and debris can become trapped and increase and spread negative bacteria in the dish machine room. 4) Observation of the Food Dry/Canned Food Storage Room, it was noted that the entire floor area was heavily soiled and stained. Floor areas under food shelving were particularly soiled and stained. Room walls were also noted to be soiled and stained. During interview, the DM was noted to state that the room floor is long overdue for replacement. 105485 Page 11 of 12 105485 03/30/2023 Hamlin Place of Boynton Beach 2180 Hypoluxo Road Lantana, FL 33462

F 0812 Photographic evidence obtained for example #1 - #4. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 105485 Page 12 of 12