Health inspection·June 29, 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 interview, and record review, the facility failed to report an alleged violation of verbal abuse for 1 of 2 residents reviewed for abuse of a total sample of 37 residents, (#77). Findings: Resident #77 was admitted to the facility on [DATE] with admitting diagnoses of hereditary and idiopathic neuropathy, insomnia, major depressive disorder, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 12/27/22 revealed resident #77 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. A care plan for behavioral symptoms related to hollering out at others, easily agitated, involved himself in others' care, easily frustrated and did not follow facility guidelines was initiated 4/08/22. Interventions included to observe behaviors and document and report to physician of changes in behavior and/or if interventions were ineffective. Review of resident #77's progress notes for the month of June revealed no documentation regarding behaviors or incidents with staff or other residents. On 6/26/23 at 2:39 PM, resident #77's roommate stated about 2 weeks ago, one of the Certified Nursing Assistants (CNAs) assisting with a transfer was verbally abusive to resident #77. He recalled she said something derogatory about his mother. He stated he reported the incident to the 200 South Unit Manager (UM) and she stated she would take care of it. Review of the Grievance Log, Abuse Report Log and progress notes for resident #77 and his roommate did not show any documentation regarding the incident. On 6/28/23 at 11:32 AM, the 200 South UM stated she was aware of an issue involving a lift pad but could not recall the exact details. Upon entering the resident's room, resident #77 recalled the event. He stated there were several CNAs assisting his roommate with a transfer. Resident #77 said his roommate was asking them to use another lift pad and resident #77 was trying to tell them where it was in the room. He stated that was when CNA K told him to shut up and mind his own business and made a derogatory remark about his mother. The 200 South UM stated she did not know anything about the CNA telling resident #77 to shut up and the comment about his mother. Resident #77 and his roommate informed the 200 South UM the event was reported to Licensed Practical Nurse (LPN) N and the Page 1 of 5 105546 105546 06/29/2023 South Orange Health and Rehabilitation Center 1730 Lucerne Terrace Orlando, FL 32806

F 0609 Admissions Director. Level of Harm - Minimal harm or potential for actual harm On 6/28/23 at 12:15 PM, LPN N recalled an incident with a lift pad involving resident #77's roommate. She stated she spoke with the roommate that day and he told her the staff member was rude. She was unable to recall exactly what was said. LPN N stated she reported the incident and allegation to the 200 South UM and the Social Services Director (SSD). LPN N recalled she accompanied the SSD to the resident's room who spoke to him about the incident. LPN N clarified the SSD, 200 South UM and Admissions Director were in the room at the time. Residents Affected - Few On 6/28/23 at 12:20 PM, the SSD recalled the roommate told her a staff member was rude to resident #77. She reviewed the grievance log and verified there was no grievance regarding this incident. On 6/28/23 at 4:06 PM, the Administrator reported resident #77 had a care plan in the old electronic medical record (EMR) system that noted resident #77 had a behavior of embellishing stories. The Administrator did not say if that negated an investigation into an allegation of verbal abuse. The Administrator explained the roommate stated CNA K said something about resident #77's mother. She acknowledged CNA K told resident #77 to mind his own business. The Administrator stated it was an appropriate remark for CNA K to make as resident #77 was not listening to what the staff were trying to tell him. On 6/29/23 at 10:29 AM, the SSD reported she interviewed resident #77 on 6/18/23 and he reported CNA K told him to go (curse word) your mama. She explained their investigation also noted the CNA told the resident to mind his own business. The SSD said there was no justification for a staff member to make a remark like that to a resident. On 6/29/23 at 3:28 PM, in a meeting with the Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC), the Administrator reported an investigation into the allegation was initiated 6/28/23. She stated they were able to determine resident #77 and his roommate were assigned to CNA L on the date of the incident. CNA L needed help getting the roommate up for an appointment and asked 3 other CNAs to assist which included CNA K. The staff were having trouble with the transfer and resident #77 started yelling at them to use the blue pad in the resident's drawer. The Administrator stated that according to their investigation, resident #77 continued to yell and cursed at the staff. The investigation showed that CNA K did tell resident #77 to mind his own business and said, your mama but denied using a curse word. The Administrator stated CNA K's remarks were not the level of communication she would expect a staff member to have with a resident and acknowledged it was inappropriate. The Administrator stated her expectation for any employee who heard a resident make an allegation was to report it immediately. She acknowledged the staff member did not report the incident and confirmed she was not aware of the incident until brought to her attention by state surveyors. 105546 Page 2 of 5 105546 06/29/2023 South Orange Health and Rehabilitation Center 1730 Lucerne Terrace Orlando, FL 32806

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 a Discharge Return Not Anticipated Minimum Data Set (MDS) assessment was completed within 14 days and submitted to the Centers for Medicare and Medicaid Services (CMS) after a resident was discharged from the facility for 1 of 1 resident identified for Resident Assessment review of a total sample of 37 residents, (#54). Residents Affected - Few Findings: Review of resident #54's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Cellulitis of left orbit with sudden visual loss, Chronic Kidney Disease, Heart Failure, and Diabetes Mellitus. Review of the resident's medical record revealed an Entry MDS assessment dated [DATE] and an admission MDS assessment dated [DATE]. The record contained no other MDS assessments. Review of a Nursing Progress Note dated 03/06/23 at 9:49 AM showed the resident was discharged to home via ambulance on 03/06/23. On 06/28/23 at 12:50 PM, an interview was conducted with MDS Coordinator A and MDS Coordinator B. They both confirmed that resident #54 had been discharged to home and required a Discharge Return Not Anticipated MDS. MDS A said, Resident #54's Discharge Return Not Anticipated MDS had not been completed within the required timeframe. Review of the Facility's CMS Resident Assessment Instrument (RAI) Manual, dated October 2019, read, . 09. Discharge Assessment - Return Not Anticipated . Must be completed when a resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. Must be completed . within 14 days after the discharge date . 105546 Page 3 of 5 105546 06/29/2023 South Orange Health and Rehabilitation Center 1730 Lucerne Terrace Orlando, FL 32806

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of resident #16's medical record noted she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD). Review of resident #16's physician orders revealed Symbicort Inhalation Aerosol 160-4.5 micrograms/actuation 2 puffs inhale orally two times a day for COPD. Review of the 05/22/23 Consultant Pharmacist Medication Regimen Review recommended to To rinse mouth and expectorate after use. Rinsing after corticosteroids inhalers reduces oral candidiasis as per manufacturer's guidelines. Review of resident #16 Medication Administration Record (MAR) for May 2023 and June 2023 revealed the instructions to rinse mouth after the use of corticosteroids inhalers to prevent oral candidiasis was not included. On 6/29/23 at 3:30 PM, The Director of Nursing stated she was not able to get the information for the residents who were reviewed from the pharmacy and acknowledged the recommendation for resident #16 was not implemented. She said, I am very upset but this is a learning experience for me. Review of the Facility's Consultant Pharmacist Reports Policy, dated May 2022, read, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review MMR) includes evaluation the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy . The MMR also involves reporting of findings with recommendations for improvement. All findings are reported to the Director of Nursing and the attending physician, the medical director and the administrator. Procedures . G. Recommendations are acted upon and documented by the facility staff and/or the prescriber . 3). The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e.g., monitor blood pressure. 2. Resident #46 was admitted to the facility on [DATE] with diagnoses to include traumatic brain injury and bipolar disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 5/25/23 revealed resident #22 received the following medications daily for the seven day look back period, antipsychotics, antianxiety, hypnotic, and opioids. Review of the pharmacy recommendations for the months of April, May and June reflected no information for the month of May. 3. Resident #22 was readmitted to the facility on [DATE] with diagnoses to include anxiety disorder and depression. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 2/24/23 revealed resident #46 received the following medications daily for the seven day look back period, antidepressant, antianxiety, and opioids. 105546 Page 4 of 5 105546 06/29/2023 South Orange Health and Rehabilitation Center 1730 Lucerne Terrace Orlando, FL 32806

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the pharmacy recommendations for the months of January 2023-June 2023 reflected no information for the months of January, February, and March. Based on observation, interview, and record review the facility failed to implement a system to monitor and reconcile Pharmacy Recommendations to ensure all residents were being reviewed monthly for 3 of 5 residents (#37, #46, #22) and failed to implement a pharmacy recommendation for 1 of 5 residents reviewed (#16) reviewed for Unnecessary Medication Regimen Review, of a total sample of 37 residents. Findings: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic neuropathy, hyperlipidemia, unspecified dementia and depression. Review of resident #37's electronic medical record revealed he received Temazepam 7.5 milligrams (mg) daily for insomnia, Novolog insulin 100 unit/milliliter injected per sliding scale before meals and at bedtime for diabetes, Levemir insulin 20 units injected subcutaneously two times a day for Diabetes, Duloxetine 30 mg two times a day for depression and Atorvastatin 40 mg at bedtime for hyperlipidemia. Review of the pharmacy recommendations for the months of January 2023 through June 2023 revealed no documentation of pharmacy review conducted in January 2023, February 2023 and March 2023. 105546 Page 5 of 5