Health inspection·May 25, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident records review and facility policy review the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflects resident's oral status to identify dental care needs for 1 (Resident #123) of 3 residents reviewed for accuracy of assessment. Residents Affected - Few The findings included: The Resident Assessment Instrument Manual (RAI version 3.0) noted the steps for assessment for dental status included, Conduct exam of the resident's lips and oral cavity with dentures or partials removed if applicable. Use a light source that is adequate to visualize the back of the mouth. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. Review of the clinical record for Resident #123 revealed an admission date of 3/29/22. The admission MDS with an assessment reference date of 4/7/22 noted the resident had, obvious or likely cavity or broken natural teeth. Review of dental services progress notes dated 8/18/22 documented fracture of tooth #29 and severe nonrestorative decay with recommended extraction on teeth #2, 3, 8, 9, and 10. Note dated 1/31/23 documented fractured teeth including #3, 7, 8, 9, 10, with recommendation to extract teeth #2, 3, 7, 8, 9, 10, and 20. Review of the dental service progress note dated 4/5/23 noted the resident had severe cervical decay on all existing dentition. The dental service progress note dated 5/4/23 noted the resident was still waiting to go to oral surgeon for extractions. On 5/22/23 at 12:12 p.m., during an interview, Resident #123 was observed to have several chipped or broken teeth. Resident #123 said a few months ago she broke the teeth in the upper back of her mouth while eating. Review of the Significant Change MDS with an assessment reference date of 4/6/23 noted Resident #123 did not have any dental concerns, including obvious or likely cavity or broken natural teeth. On 5/25/23 at 9:30 a.m., MDS coordinator Licensed Practical Nurse Staff B verified the Significant Change MDS dated [DATE] did not accurately reflect Resident #123's dental status, including the Page 1 of 13 105524 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0641 obvious broken natural teeth. She said, I still don't know how I missed it. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105524 Page 2 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, review of facility guidelines manual, resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1 (Resident #121) of 27 residents reviewed for activities of daily living (ADLs). Residents Affected - Few The findings included: The facility Clinical/Rehabilitation Guidelines Manual, ADL Care, specified: Proper ADL care is vital to all residents within our center. To ensure that the process and expectations of ADL care are clear, consistently assessed in order to maintain compliance. Review of the clinical record revealed Resident #121 had an admission date of 2/9/23 with diagnoses including cerebral infarction with left hemiparesis (weakness), blind in right eye and muscle weakness. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/16/23 documented Resident #121 required extensive assistance of one person for personal hygiene and required the assistance of two for bathing. The MDS noted Resident #65's cognitive skills for daily decision making were moderately impaired. On 5/22/23 at 10:00 a.m., and 3:36 p.m., Resident #121 was observed in bed dressed in a facility gown. He was unshaven with approximately three days growth and was unkempt. The resident said he had left hemiparesis and said the staff get him out of bed at times. On 5/23/23 at 8:55 a.m., Resident #121 was observed in bed, he was unshaven and said he had not been shaved in a few days. He said he gets one shower a week but had not had one lately and did not know why. The resident's hair was greasy. On 5/24/23 at 9:53 a.m., Licensed Practical Nurse Unit Manager Staff F, said the process for resident showers was for the Certified Nursing Assistant (CNA) to follow the shower schedule and if a resident declined a shower, the aide would go back and offer it again. The aide notifies the nurse and then the nurse will speak with the resident and encourage them to take a shower. If they decline then the aide offers a bed bath. On 5/24/23 at 10:10 a.m., Certified Nursing Assistant (CNA) Staff J said the process for showers was to follow the shower assignment and complete the Shower Review form where we document the shower and any issues we find. If a resident refuses a shower, she will tell the nurse. She tries and comes back later and asks again or offers a bed bath if they refuse a shower. Review of the shower schedule showed showers were assigned by rooms not residents' names. The schedule showed Resident #121 was scheduled for a shower on the 7:00 a.m. to 7:00 p.m., shift on Mondays and Thursdays. Review of the CNA documentation for April 2023 showed Resident #121 did not receive his scheduled shower on 4/17/23 and received a bed bath on 4/3 and 4/27/23. 105524 Page 3 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the CNA documentation for May 2023 documented Resident #121 did not receive his scheduled shower on 5/1/23, 5/4/23, 5/8/23 and 5/15/23. The documentation showed the resident received one scheduled shower on 5/18/23. He received a bed bath on 5/11/23 and 5/22/23. There was no documentation in the clinical record Resident #121 declined his showers. On 5/25/23 at 8:33 a.m., the Director of Nursing (DON) said Resident #121 had a COVID infection from 5/3/23 through 5/14/23 so he did not receive a shower. The resident was in a private room with a shower in the bathroom. The DON said she located a CNA shower sheet for Resident #121 dated 5/5/23 indicated a bed bath was provided. On 5/11/23 the CNA shower sheet documented a bed bath was provided and a shower on 5/18/23. The DON provided the March 2023 CNA documentation for Resident #121. The form documented the resident received a bed bath on 3/2/23, 3/6/23, 3/9/23, 3/16/23, 3/23/23, 3/27/23 and 3/30/23. The March 2023 CNA documentation provided showed Resident #121 received no scheduled showers for the month of March 2023. 105524 Page 4 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

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, interviews, and record reviews, the facility failed to provide care and services in accordance with professional standards of practice for 1 (Resident #144) of 2 sampled residents receiving intravenous medications. Residents Affected - Few The findings included: The facility policy for Catheter Insertion and Care (Midline Dressing Changes) noted Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. General Guidelines included changing the midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact or compromised in any way. Review of the clinical record for Resident #144 revealed an admission date to the facility of 4/27/23. The resident was transferred to the hospital on 5/9/23, returned to the facility on 5/12/23. On 5/14/23 Resident #144 was transferred to an acute care hospital with return anticipated. On 5/16/23 Resident #144 returned to the facility. Review of the Medication Administration Record (MAR) for May 2023 revealed orders dated 5/6/23 for Dressing Change every week and as necessary for IV (intravenous) maintenance. The order was discontinued on 5/10/23. There was no documentation on the MAR the dressing was changed from 5/6/23 through 5/10/23 to the resident's right upper arm intravenous catheter insertion site. On 5/12/23 the MAR notes a physician's order for a dressing change every week and as necessary to the right upper extremity for IV maintenance. The order was discontinued on 5/15/23. There was no documentation on the MAR the dressing was changed from 5/12/23 through 5/15/23. On 5/21/23 the MAR notes a physician's order for a dressing change to the right upper arm intravenous line every week and as necessary every night shift every Sunday for intravenous maintenance. On 5/21/23 during the night shift signed off on the MAR indicating the dressing change was done. On 5/22/23 at 11:12 a.m., Resident #144 was observed in bed with a midline intravenous catheter inserted to the right upper inner arm. The dressing was dated 5/6/23 indicating the last dressing change was done on 5/6/23. The dressing border was peeling off and lifting. On 5/22/23 at 4:56 p.m., Resident #144 was in bed in his room. The dressing dated 5/6/23 remained in place to the right upper arm. The dressing was reinforced with tape around the edges. Resident #144 said someone placed the tape around the edges of the dressing since it was losing its seal. On 5/24/23 at 9:33 a.m., Resident #144's midline catheter insertion site to the right upper extremity remained with the dressing dated 5/6/23. Resident #144 said no one had changed the IV dressing to the right upper arm. On 5/24/23 at 10:35 a.m., Unit Manager Staff C said the midline dressing should be changed every seven days to prevent infection. Unit Manager Staff C verified the dressing to Resident #144's midline 105524 Page 5 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0684 insertion site was dated 5/6/23. Level of Harm - Minimal harm or potential for actual harm On 5/25/23 at 11:31 a.m., the Assistant Director of Nursing (ADON) acknowledged Resident #144's midline catheter dressing was not changed every seven days according to the physician's orders and the facility policy. Residents Affected - Few 105524 Page 6 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to implement individualized care planned interventions to address the behavioral health needs of 1 (Resident #135) of 2 residents reviewed for behavioral health. The findings included: Review of the clinical record revealed Resident #135 had an admission date to the facility of 11/22/22. The admission Minimum Data Set (MDS) assessment with an assessment reference date of 11/28/22 listed diagnoses including depression, and dementia. The resident's cognition was moderately impaired as indicated by a Brief Interview for Mental Status of 11. Resident #135 was able to be interviewed. The resident indicated it was very important for her to have books, newspapers, magazines to read, listen to music she likes, keep up with the news, do things with groups of people, go outside, and get fresh air when the weather is good, participate in religious services or practices. The assessment noted it was very important for the resident to do her favorite activities. The admission MDS dated [DATE], and the Quarterly review MDS assessment dated [DATE] noted Resident #135 did not voice the presence of symptoms of feeling down, depressed, hopeless, or little interest or pleasure in doing things. The care plan initiated on 11/23/22 noted Resident #135 had depression related to Dementia. The goal was for the resident to exhibit indicators of depression, anxiety, or sad mood less than daily by review date 6/6/23. The interventions included monitor, document and report any signs and symptoms of depression, including sadness, hopelessness, anxiety, tearfulness. Offer nonpharmacological interventions such as one to one conversations, hand massage, offer activities (going outside, music), encourage deep breathing and relaxation, assist to a quieter environment. On 5/17/2023 at 12:33 p.m., the Social Service Quarterly Note documented, There has been no change in the resident's cognitive function since last evaluation. Resident can communicate needs. The resident has no mood problems identified. Resident's usual mood: Resident's Mood Interview score of 0 is not significant for signs or symptoms of depression. Resident does receive Mirtazapine (an antidepressant)15 milligrams daily. The resident has not had a change in psycho-social well-being. Resident's psycho-social well-being: Resident has adjusted to facility life. Resident has ample family support. The resident receives psychological/psychiatry services. Resident's psychological/psychiatry needs: Resident receives psych services as needed. Current care plan and or care plans were reviewed, and no changes were indicated. On 5/17/2023 at 10:46 a.m., the Activities progress note documented, the resident's level of activity participation was two to four times a week, Resident's usual participation Resident's favorite activities, special accomplishments, and/or new interests are Resident's favorite activities, special accomplishments, and/or new interests are N/A (not applicable). Resident preferred activity Group 105524 Page 7 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few activities Independent activities The resident displays the following behavior no concerns identified at this time. Activity care plan reviewed no changes required. Describe significant changes that have affected activity participation N/A. The record revealed a Psychotherapy note dated 5/23/2023 at 1:00 p.m., noting the reason for referral/presenting problem was Depression. The practitioner documented Resident #135's mood was depressed, affect flat, judgement fair. The treatment plan included individual psychotherapy with an anticipated length of 12 weeks. The treatment goals included for the resident to engage in stress management skills, including daily engagement in pleasurable solitary activities, support system contacts, distraction and refraining or acceptance to decrease the severity of depression and anxiety. The clinical record lacked documentation nonpharmacological interventions were consistently implemented to address the resident's depression. On 5/22/23 at 10:41 a.m., Resident #135 was observed sitting in a chair in her room with her head resting on a bedside table in front of her. The television was on, but the resident was not watching it. The resident appeared sad, withdrawn and had a furrowed brow. Resident #135 said she was sad, and just sits here in the room but provided no other details. Resident #135 shrugged her shoulders when asked if she'd like to participate in activities. The resident spoke briefly about her past life events. On 5/23/23 at 8:13 a.m., Resident #135 was observed in her room. The television was on, but she was not watching it. The resident showed no interest in conversation and displayed no emotions. She shrugged her shoulders when asked if she was sad. She said, I'm alright. She showed pictures of family members and said she enjoyed talking to others at times. On 5/24/23 at 3:45 p.m., Resident #135 was observed in her room the television was on, but she was not watching it. The resident was sitting in a chair with her head resting on the bedside table in front of her. Review of the Medication Administration Record (MAR) for May 2023 noted 0 (none) was entered on 5/22/23, 5/23/23, and 5/24/23 for social isolation, and withdrawal and no nonpharmacological interventions implemented on 5/22/23, 5/23/23, and 5/24/23. On 5/25/23 at 8:58 a.m., the Social Service Director said, I do the initial assessment and the quarterly resident assessments for cognition, mood and behaviors. She said Resident #135's niece visited frequently, and the resident perked up. She said, I have noting in place for her right now, and there is no process in place right now to address her depression. I guess I will visit her more often and see about getting her out of her room more often. On 5/25/23 at 10:32 a.m., the Activity Director said she did not have any specific activities to address the psychosocial needs of residents with depression or PTSD (Post Traumatic Stress Disorder). She said, We provide one to one visits; it seems to work best for them. The Activities Director provided a handwritten note on a paper titled Shopping list noting Resident 105524 Page 8 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0740 #135 refused one on one activity on 5/20/23, and 5/24/23, refused ice cream social on 5/23/23 and refused church services today (5/25/23). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105524 Page 9 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of facility policy and procedure, resident and staff interviews, the facility failed to ensure 1(Resident #62) of 5 residents reviewed for medication administration received the physician ordered intravenous antibiotic without unnecessary interruption to treat an infection in a surgical wound. Residents Affected - Few The findings included: The facility policy Medication Administration General Guidelines (revised 8/2014) documented, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of scheduled time . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility . Review of the clinical record revealed a hospital history and physical dated 5/11/23 documented Resident #62 had a lumbar fusion on 4/20/23 and was sent to the skilled nursing facility for therapy on 4/24/23. On 5/11/23 the resident was sent to the emergency room due to green drainage from the incision. A culture was done and showed escherichia coli (a bacteria causing infections). The clinical record showed Resident #62 returned to the facility on 5/18/23 with diagnoses including post laminectomy (surgical procedure of vertebra), and infection of the surgical site. The admission orders dated 5/18/23 included to administer Ertapenem Sodium (antibiotic) solution one gram intravenously every 24 hours for 56 days, starting on 5/18/23 and ending on 7/13/23 for post operative spinal infection. Review of the nursing administration note dated 5/21/23 at 10:26 p.m., showed documentation the Ertapenem was not administered as ordered. The nurse noted the medication was pending delivery. Per the pharmacy the medication will be delivered on 5/22/2023. Review of the Medication Administration Record (MAR) for May 2023 showed the Ertapenem scheduled for 5/21/23 at 9:00 p.m., was administered on 5/22/23 at 4:25 p.m., 19 hours after the scheduled dose. On 5/22/23 at 2:21 p.m., Resident #62 said he did not receive his antibiotic the previous night, the nurse said the medication was not available. He said he got the infection to his surgical incision at the facility in April 2023 after his admission for rehabilitation. On 5/23/23 at 2:50 p.m., the Director of Nursing (DON) said when an intravenous medication is not available from the pharmacy, the nurse was responsible to get the medication from the Emergency Drug Kit (EDK), the Registered Nurse would mix it and the medication administered as ordered. She said all the nurses have access to the EDK. On 5/23/23 at 3:11 p.m., observation of the EDK with Licensed Practical Nurse (LPN) Staff L showed Ertapenem Sodium 1 gram was included in the kit and was available to use as needed on 5/21/23. 105524 Page 10 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0760 Level of Harm - Minimal harm or potential for actual harm On 5/24/23 at 9:51 a.m., Unit Manager LPN Staff F said on 5/21/23 the nurse on duty was from a staffing agency and did not have access to the EDK. She said the Registered Nurse on duty on 5/21/23 had access to the EDK but did not know how to mix the Ertapenem, causing the delay in administering the intravenous antibiotic. She said she notified the physician of the missed dose of antibiotic the next day on 5/22/23. Residents Affected - Few 105524 Page 11 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, resident and staff interviews the facility failed to provide timely assistance with referrals for outside oral surgery services to meet the needs of 1(Resident #123) of 3 residents reviewed for dental services. Residents Affected - Few The findings included: Review of facility policy titled Social Services release date 11/15/2005 which states, General services, which social service department may assist, oversee, or manage, could include . Making referrals for and obtaining services from outside resource. Review of the progress notes in the clinical record for Resident #123 revealed: On 8/18/22 a dental progress note documented fracture of tooth #29 and severe nonrestorative decay with recommended extraction on teeth #2, 3, 8, 9, and 10. On 1/31/23 a dental progress note documented fractured teeth including #3, 7, 8, 9, 10, with recommendation to extract teeth #2, 3, 7, 8, 9, 10, and 20. A dental specialist referral form dated 3/10/23 documented recommended extraction of teeth #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 15. The referral noted to call the dental insurance and find a preferred provider. The dental note dated 3/28/23 documented stated she is in pain on the upper posterior. She mentioned being at the oral surgeon's office, with the recommendation to extract all upper teeth. On 3/31/23, The Social Worker documented, Resident requesting to be seen by an oral surgeon . to learn the dentist will see the resident on Wednesday 4/5/23. The dental progress note dated 4/5/23 documented extraction consent generated with plan to extract teeth #2, 3, 4, 7, 8, 9, 10, and 20. The dental progress note dated 5/4/23 documented she stated still waiting to go to OS (oral surgeon) for extractions. The dental progress note dated 5/18/23 documented presents multiple root tips and fractured teeth #2, 3, 4, 7,8, 9, 10, 20, 23, 24, 25, and 26. Patient prefers/requested referral for the oral surgeon to have them all extracted at once or faster. On 5/22/23 at 12:12 p.m., Resident #123 was observed to have several chipped or broken teeth. Resident #123 said a few months ago she broke the teeth in the upper back of her mouth while eating. The resident said she was being followed by a dentist at the facility and will be going to an oral surgeon. The resident said her mouth hurts but it is not too bad. I have told them my mouth hurts. The resident rated her pain level a 6 on a one to ten scale. She said, I don't tell the staff because they want to give me Tylenol which doesn't help with it. The resident said she has been waiting for months for an appointment with the oral surgeon. On 5/24/23 at 1:05 p.m., the Social Services Director (SSD) said she has been working at the 105524 Page 12 of 13 105524 05/25/2023 Port Charlotte Rehabilitation Center 25325 Rampart Blvd Port Charlotte, FL 33948

F 0791 Level of Harm - Minimal harm or potential for actual harm facility for three months. She said Resident #123 was being seen by the contracted dental group who came to the facility. Resident #123 requested to see the oral surgeon for extractions. She brought it up to the contracted dental group and, went after them and after them, it has taken three months to receive the referral to the outside oral surgeon. The SSD said she did not know if a three month delay to obtain a referral was routine. She said, I don't know if it's acceptable or not. My background is in hospitals. Residents Affected - Few On 5/24/23 at 1:20 p.m., interviewed the Director of Nursing (DON) and facility Administrator about the dental care for Resident #123. The DON said the resident was being scheduled for her appointment with the oral surgeon. She said she was unaware the resident had complained of pain in March 2023 and the recommendation for extractions had been made several months previously. The DON described the process for identifying needs such as this is that the facility reviews any follow up appointments in the morning meeting. Dental consultations are reviewed the day after they are done to ensure they don't miss anything. She said, we should have assessed and addressed her pain and checked her diet. The DON and administrator stated there was no facility policy specific for dental or ancillary services. We follow the regulation. On 5/25/23 at 10:20 a.m., during a phone interview the dentist who had seen Resident #123 at the facility said she recalled several months ago recommending to the resident to have many teeth extracted and to be fitted for dentures. The dentist said the resident said she wanted to have them all done at once which they can't do in the facility, so she was referred for oral surgery. She said, I give my recommendations to the facility, and it is their responsibility to follow up. The Dentist said, It is always a risk for infection. She had a lot of decay as well but we did not do x-rays so I can't say for sure if there is an underlying infection. I saw her last week and she did not have any swelling, no puss, had some mild pain during exam. I would not leave this untreated, but it is not urgent. I don't think it should take so many months to follow up but that is both the facility, my office responsibility. I will check with my office as to what happened. 105524 Page 13 of 13