Health inspection·September 20, 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, policy review and interview, it was determined, the facility staff failed to report and thoroughly investigate allegations of neglect for 1 of 2 sampled residents (Resident #2). The findings included: Facility policy titled Abuse Reporting and Response - No Crime Suspected dated 10/04/22 documents The facility will report alleged violations related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of residents property and report the results of all investigations to the proper authorities within prescribed timeframe. Abuse Identification: Neglect: is defined as the failure of the facility, 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. Record review conducted on 09/19/23 revealed Resident #2 was admitted to the facility on [DATE] for rehabilitation and was transferred to the hospital on [DATE] for possible reaction to medication and status post fall. Resident #2 did not return to the facility. Interview conducted with the Director of Admissions on 09/19/23 at 11:15 AM revealed Resident #2 did not want to return to the facility. The Director explained she had a conversation with the hospital case manager, who advised her the resident did not want to come back because the staff left him to choke on his own vomit. The Director was asked if she shared that allegation to the Administrator or the Director of Nursing and replied, she believe she did. Interview with the Director of Nursing conducted on 09/19/23 at approximately 12 noon revealed the Director of admission did share the allegation that the staff left the resident to choke on his vomit and she then reviewed the record, and determined that no one had documented vomiting or choking. While speaking to the DON, a staff nurse, standing by her desk was completing a statement form regarding Resident #2. The DON explained she is getting statements now because she wanted the nurses to document the findings. The DON was asked why the investigation was being completed now and not previously when the facility received the allegation. The DON replied when the allegation was made the Page 1 of 2 105516 105516 09/20/2023 Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was alert, he was talking not choking, she can get ambulance records if needed and that if she investigated every allegation, she would be doing that all day. Interview with Staff A, a Registered Nurse, conducted via phone on 09/20/23 at 9:20 AM revealed she was the nurse on duty the night Resident #2 was transferred to the hospital. The nurse recalled she was at the nurses station completing her documentation and heard someone yelling for help, she walked down the hallway and saw the resident by the bed on his knees, she asked him what happened and the resident said he was going to the bathroom and felt weak, then he said he could not breathe and wanted to go to the hospital, so she called 911 and the paramedics took him to the hospital, the facility policy is to transfer the patient to the hospital if they request it. Record review revealed the facility documents and reportable event and incident logs failed to provide evidence the facility identified the allegation of neglect, reported the allegation to the appropriate agencies and completed a thorough investigation of the events. 105516 Page 2 of 2