Health inspection·November 30, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to respond to grievances for one out of one resident (Resident #44) reviewed for grievances. The resident's family member (Brother) established communication with the facility concerning complaints regarding the resident's loss of items, but no grievance was filed. There were 68 residents residing in the facility at the time of the survey. Findings included: On 11/28/2023 at 12:24 PM, Resident #44 stated that he lost his pajamas about 2 weeks ago. He stated that he told his brother about it and believed that his brother spoke to the nurse over the phone about it. He stated, he had not found the pajamas yet. Review of Resident #44's face sheet revealed an admission date of 10/17/2023. Review of Resident #44's Minimum Data Set (MDS) assessment dated [DATE] to identify his cognitive patterns showed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment. Review of the facility's grievance file from October 10, 2023 to November 26, 2023 revealed no grievance was filed on behalf of Resident #44. On 11/30/2023 at 08:09 AM, Resident #44 stated that he didn't tell the staff, but he was certain that he told his brother about his missing property over the phone; however, he didn't know for certain that his brother told the staff. On 11/30/2023 at 10:34 AM, during an interview with Resident #44's brother regarding the missing pajamas, Resident #44's brother stated, Yes, he told me that he lost his pajamas just the bottom part, a gray bathrobe, and some shirts. I called the facility and they transferred me to the laundry. I spoke to a guy there. They said they would take care of it, but I haven't had a chance to talk to them again. On 11/30/2023 at 12:42 PM, during an interview with the Environmental Services Manager (ESM) regarding Resident #44's loss items, she stated, Since I've been here, a month ago, we have some complaints, about 4 of them. It's mostly because the names are not showing in the resident's clothes. That apparently, my team lead [Staff C] received a call on Thanksgiving Day. They found the clothes the next day, and he took them to the room. He said, that he didn't report it because he received the call directly and he took the clothes to the resident. Page 1 of 4 105508 105508 11/30/2023 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/30/2023 at 12:53 PM, during an interview with Staff C (Environmental Services Team Lead) regarding the loss items, Staff C stated, I don't know when the clothes were brought down. When I received the call on Thanksgiving Day, I went and looked for them. The clothes were not missing. They were just not delivered yet to the resident. They were already washed, packed, and was waiting to put in the bag to send to the resident. The next day, the clothes were delivered to the resident's room, November 24th. From the time we pick up the clothes, we have 3 days to deliver them. I didn't report it because I found them. Review of the facility's undated grievance policy and procedure revealed: Policy statement: The resident, family members, and/or legal representative have the right to voice complaints about treatment, care or violation of resident rights without fear of discrimination or reprisal. Policy Interpretation and implementation: To ensure that resident's, families', and/or legal representative's grievances or complaints are promptly evaluated and appropriate action taken, the following procedure is established. This procedure highlights four (4) elements in regard to grievances. 1. Designation of Employee Handling Grievances: Should a resident, resident's family or resident's legal representative have a grievance in regard to treatment or care that is, or fails to be furnished,he/she may take said grievance to the Social Services Director or designee if he/she is not available. The Social Services Director is designated to receive and process complaints to resolution. If the Social Services Director cannot handle the complaint satisfactorily, he/she refers it to the Administrator or Executive Director. 2. Documentation of Grievance: It shall be the responsibility the receiving Supervisory Staff member or Licensed Nurse to write the grievance and forward it to the Social Service Director. A tracking log is utilized for complaints and/or grievances. Such details shall be included so that specific remedial action can be taken. The details of the written grievance, having been reviewed and agreed to by the person bringing the grievance, shall be forwarded to the Social Services Director for follow-up action. Final review of the report is done by the Administrator. 105508 Page 2 of 4 105508 11/30/2023 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Residents complained the call lights were left unanswered for over 15 minutes in multiple occasions when they called for assistance. There were 68 residents residing in the facility at the time of the survey. The findings included: On 11/28/23 at 10:38 AM, during the resident council meeting, several residents reported that sometimes staff take more than 15 minutes to answer the call lights. The residents then stated, The staff don't come to the rooms unless a resident presses the call button for assistance. They do rounds once in a while. Review of the facility's undated policy and procedure for the call light revealed: Purpose: It is the policy of East Ridge Retirement to have a functioning call system so that Residents can feel safe and call for assistance when needed. Key Procedural Points: 6. Some residents may not be able to use their call light. Be sure to check on these residents frequently. 7. Answer the resident's light as soon as possible. During an interview with resident # 266 on 11/27/23 at 09:27 AM. The resident stated that the call light to ask for assistance was never responded to. The resident stated that the staff didn't know if the resident had an emergency, because they didn't come to the resident's room when the call light was activated. During a tour by the facility hallways on 11/29/2023 at 11:40 AM, the call light for assistance was observed to be on in room # 2314 for more than 10 minutes. A nurse was in a room taking care of a resident, the Certified Nursing Assistant (CNA) was not around. Interview with Administrator on 11/29/2023 at 11:42 AM. The Administrator stated, one CNA was on her break and the other one on the floor should have attended to the call for resident's assistance. The Administrator stated the CNA will take care of the resident as soon as possible. During a tour by the facility on 11/30/2023 at 09:54 AM, the call light for assistance was observed on in room # 2308 the light was observed to be on for more than 15 minutes. Staff B, Registered Nurse was at the medication cart close to the room. Staff A, Certified Nursing Assistant was in the area, no one responded to the call light. Interview with Staff A on 11/30/2023 at 09:56 AM. She stated, she was on her way to respond to the call light. She stated, she did not go because the nurse was close to the room to respond to the 105508 Page 3 of 4 105508 11/30/2023 East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

F 0725 call. Level of Harm - Minimal harm or potential for actual harm Interview with Staff B on 11/30/2023 at 09:58 AM. She stated, she was preparing medication for one resident, and she thought the CNA would respond to the call light. Residents Affected - Some 105508 Page 4 of 4