Health inspection·November 8, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect a resident from repeated physical abuse for 1 of 1 sampled resident reviewed for abuse (Resident #1). The findings included: A review of the Facility's policy Abuse Prevention, issued on 10/04/22 and reviewed on 07/18/23, Documented: It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Procedure #4 documented: To identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors, which might lead to conflict or neglect, such as verbally aggressive behavior and physically aggressive behavior. A review of the facility's abuse log revealed a resident (Resident #2) to resident (Resident #1) substantiated allegation specifically, of abuse on 10/14/23 and 10/26/23. Resident #1 was assaulted by Resident #2 on 10/14/23. Resident #2 was transferred to the hospital for unrelated concerns on 10/14/23. Resident #2 returned to the facility on [DATE]. Without any interventions in place, Resident #1 was again assaulted by Resident #2 on 10/26/23. Both residents resided in a locked memory care unit in adjacent rooms. Record review revealed Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had cognitive deficit and was independent with activities of daily living. The resident was care planned for wandering with decreased attention span. Record review revealed Resident #2 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive deficit, and required supervision with set-up help only for activities of daily living. The resident was care planned for behavior problems, tends to be aggressive with other residents if they actually go into his room/bed. On 10/14/23 altercation with another resident in which he struck the resident in the face. The resident has exhibited physically aggressive behavior towards others related to impulse control. An intervention dated 10/14/23 included a psych consultation for aggressive/assaultive episodes. A review of Resident #1's progress note dated 10/14/23 at 9:50 AM revealed the resident was involved in an altercation with another resident (Resident #2), in which the other resident (Resident #2) walked up to Resident #1 and slapped him on his head and forehead, unprovoked, causing injury to his nose and forehead. First aid was provided, and appropriate entities were notified. Page 1 of 2 105516 105516 11/08/2023 Darcy Hall of Life Care 2170 Palm Beach Lakes Blvd West Palm Beach, FL 33409

F 0600 Level of Harm - Minimal harm or potential for actual harm A review of Resident #2's progress note dated 10/14/23 at 11:26 AM revealed the resident was placed on 1:1 supervision. Resident #2 was later transferred to the hospital the same day for unrelated reasons. Resident #2 was readmitted to the facility on [DATE], in the same room adjacent to Resident #1. There was no evidence Resident #2 was evaluated by psych. Residents Affected - Few An interview was conducted with the facility's Risk Manager (RM) on 11/08/23 at 12:00 PM. The RM acknowledged the assault/abuse of Resident #1 by Resident #2 on 10/14/23. The RM reviewed abuse allegations and investigation of Resident #1 by Resident #2 on 10/26/23. The RM stated Resident #2 shoved Resident #1 after striking a nurse. The RM stated Resident #2 was transferred to the hospital for increased agitation and restlessness. When Resident #2 returned to the facility on [DATE], his room was changed. Resident #1 was observed sitting in a chair in his doorway looking out into the hallway on 11/08/23 at 12:45 AM. An interview was conducted with the unit manager (UM) on 11/08/23 at 12:45 PM. The UM stated Resident #1 usually sat in his doorway, or in hallway next to nurse cart (parked outside room W5). The UM further stated after 2nd incident with Resident #2, the resident was moved from his room (adjacent to Resident #1) to another room (opposite end of the hallway). A review of Resident #2's orders revealed an order dated 10/29/23 for an antipsychotic medication (mood stabilizer). 105516 Page 2 of 2