Health inspection·August 15, 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 observation, record review, and interview, the facility failed to make prompt efforts to resolve grievances for one (Resident #2) of three sampled residents. Findings included: A review of the admission Record showed Resident #2 was initially admitted into the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the Minimum Data Set (MDS), Section C, Cognitive Patterns dated 07/09/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Section G, Functional Status, showed Resident #2 needed extensive assistance with one-person physical assist for bed mobility, dressing, toilet use, and personal hygiene. He needed limited assistance with one-person physical assist for transfer and locomotion on and off the unit. Resident #2 was independent with walking in the room and eating. Section P, Restraints and Alarms. showed the resident did not use bed rails. A review of the Order Summary Report with active orders as of 08/01/23 did not reveal an order for bed rails or grab rails. A review of the discontinued orders revealed the following: Bed rails to be applied for resident safety and comfort (06/13/23-06/13/23) and Continue grab rails for patient safety and for fall prevention, medically necessity documented in chart (06/02/23-07/08/23). A review of the Progress Notes revealed the following: 05/29/23 (Social Services Note)- The resident informed the Social Services Director (SSD) that shoes he received from an outside provider do not fit. The resident has not made any attempts himself to resolve, nor does he have any family to assist. The SSD with permission of resident took shoes in possession and will attempt to follow up with provider. SSD to report outcome as appropriate. 05/31/23 (Social Services Note)- The SSD met with the resident to discuss/ follow up on new regulation as it pertains to removing side rails. Resident #2 expressed his displeasure as the side rails Page 1 of 6 105574 105574 08/15/2023 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few allow for independence and assist with bed mobility. The SSD discussed possible alternatives to be pursued in place of. The SSD will monitor and assist. 05/31/23 (Social Services Note)- Regarding side rails resident further stated not only do they assist him with bed mobility due to Parkinson's and Arthritis, but they also give him a sense of security. Resident #2 had multiple falls in the past and stated I do not want to fall anymore. A review of the progress notes showed Resident #2 had a fall on 02/22/23. A mental health services note dated 06/29/23 showed Resident #2 was upset regarding not having bed rails on his bed, as this is a new regulation in place at this facility. A review of the Grievance/Complaint Log for May and June 2023 revealed no grievances related to Resident #2's shoes and bed rails. On 08/14/23 at 11:13 a.m., Resident #2 was observed in bed. Bed rails were not observed on the bed. He stated he had bed rails and staff removed them. He stated his shoes were too tight and had no other shoes. The shoes were observed sitting in the chair next to the bed. On 08/15/23 at 10:56 a.m., the Interim Risk Manager stated the bed rail issue was relatively new. If a resident needed bed rails, then the resident was evaluated and they [the facility] go from there. No concern was voiced to her related to his shoes. She said this could certainly be addressed if they [facility staff] were aware of the concern. On 08/15/23 at 11:36 a.m., the SSD said a former SSD who was responsible for the long-term care residents wrote the progress notes related to the shoes and the bed rails. The SSD said the former SSD never mentioned anything to her about bed rails or Resident #2's shoes being too small. The SSD stated she did not know if there was a follow up to the bed rail concern. They removed bed rails across the board per the statute. Bed rails were being looked at on a case-by-case basis based on the resident's functionality. Resident #2 only mentioned to her that he had missing shoes, but not that the shoes were too little. The SSD stated the former SSD should have contacted the provider to get the resident refitted for the shoes. The Podiatrist came in quite often. The expectation was to follow up. On 08/15/23 at 1:34 p.m., the Director of Nursing (DON) said the doctor did not assess Resident #2 for bed rails. He put the order in for fall prevention and safety. She explained the federal regulation to the doctor and that the resident could only use bed rails as an enabling device. The DON said they needed to try the scoop mattress or trapeze, but they did not want to do that at that point. On 08/15/23 at 1:11 p.m., the administrator reported the doctor wrote the order for the bed rails because Resident #2 needed the rails for patient safety and falls. That was not a valid reason to have bed rails. If there was a real safety concern, then he could have the bed rails. When the doctor put in the order for that reason, he did not have a fall. Patient safety and security was not a reason for the bed rails. The administrator stated she was not aware of the resident having shoes that did not fit. The policy provided by the facility Administrators/Staff Development- Grievance revised May 2016 revealed the following: 105574 Page 2 of 6 105574 08/15/2023 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0585 Policy Level of Harm - Minimal harm or potential for actual harm The facility will promptly and responsibly investigate these grievances to initiate timely resolution and determine if the facility has areas that need correction to achieve our desire of providing quality care and a safe environment. Residents Affected - Few Procedure 4. The Social Services Director shall handle the grievances for the facility, enlisting assistance from the appropriate Department Managers, as needed. 5. The Social Services Director will make every attempt to resolve the grievance in a timely manner and will keep the resident and/or their representative aware of the progress towards resolution. 6. The Social Service Director will keep a summary log of all grievances, which will be brought to the monthly QAPI meeting for review and further action, if necessary. The log will be signed by the Medical Director. 105574 Page 3 of 6 105574 08/15/2023 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

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 interviews and record review the facility failed to report timely misappropriation of resident property related to a pack of narcotic pills for one (Resident #6) out of 2 reportable events reviewed. Findings include: Resident #6 was readmitted to the facility on [DATE] and initially admitted to the facility on [DATE]. Her medical diagnoses included but were limited to chronic pain syndrome, specific disorders of bone density and structure, intraductal carcinoma in situ of left breast, polyneuropathy, and cognitive communication deficit. An interview was conducted with Resident #6 on 8/15/23 at 1:50 p.m. She was observed in her wheelchair writing on a piece of paper at a desk in her room. She stated she had her Percocets [pain medication] go missing one time, but the facility did well with that. They got me more medications and I got my dose that night. They gave me Ibuprofen instead and that was fine. The resident appeared to be comfortable during the interview without any complaints or grimacing of pain and she indicated she currently received her medications without concerns. Review of Resident #6's physician orders showed an order dated to start on 5/3/23, without an end date for Percocet oral tablet 5-325mg (Oxycodone w/acetaminophen) give 1 tablet by mouth two times a day for pain. Further physician order review showed an order which started on 1/19/2023 for Motrin IB (ibuprofen) oral tablet 200mg give 2 tablets by mouth every 8 hours as needed for pain. Review of Resident #6's June medication administration record (MAR) showed, on 6/28/23, her morning dose was signed off as 9 indicating other/see nurse notes Further review of Resident #6's MAR showed her next dose of Percocet scheduled to be given at bedtime was administered as ordered for a pain level of 5 out of 10. Further review showed the resident received her ordered 2 tablets of Motrin IB on 6/28/23 at 12:56 p.m. for a pain level of 3 out of 10. Review of Resident #6's nursing note dated 6/28/23 at 12:00 p.m. showed Percocet Oral Tablet 5-325mg give 1 tablet by mouth two times a day for pain. Medication not available ARNP [Advanced Registered Nurse Practitioner] aware resident will miss today's dose. Review of the facility's reportable log revealed no documentation related to misappropriation of resident property related to Resident #6. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 8/15/23 at 10:03 a.m. The DON said on June 28th [Resident #6] wanted her 'as needed' medication and there was no medication to give. They gave her Tylenol and that held her over for the time being. So, they [nurses] called the pharmacy and the pharmacy said it was too soon to fill the script. Then they called me [DON] I was on my way in, and the pharmacy has to have approval from us [NHA and DON] to release extra medications because then the facility has the responsibility to pay for the medication and they will only do that if it comes from one of us [DON or NHA]. The NHA stated we also notified our consulting pharmacist because he is the one who has to release the medication. The DON said I came in and I checked all the medication carts there was no other discrepancies. Anyone who had that cart within the last 72 hours ended up getting drug screened. The NHA said the resident 105574 Page 4 of 6 105574 08/15/2023 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few [Resident #6] gets 2 cards delivered at a time. Approximately 3 weeks prior to the missing narcotics the resident had 2 cards delivered which was signed off by an agency nurse and added them into the medication cart. When we did the audit all the way back from the time of delivery, we discovered that the count was always right because narcotics were being added and removed and that someone took the narcotic pack and the narcotic sheet that paired with that narcotic pack so, we could not say what happened to it. We spoke with the pharmacist, we reported to the police on 6/28/23, and our regional nurse, we did not report this to the DCF (Florida Department of Children and Families) or the State Agencies . Further interview was conducted with the DON on 8/14/23 at 12:00 p.m. He clarified Resident #6 received her ordered Motrin not Tylenol. Review of the facility's Abuse Neglect, Exploitation and Misappropriation policy revised on July 2021 revealed, POLICY: The center recognizes each resident's right to be free from abuse, neglect, an exploitation (ANE), misappropriation of resident property and maltreatment, including, but not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical. [sic]restraint not required to treat resident's symptoms. .This center reports suspicions of crimes committed against a resident of this center in accordance with section 1150 B of the Social Security Act to at least one law enforcement agency and the State Survey Agency. DEFINITIONS OF ABUSE .MISAPPROPRIATION Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Use of a resident's telephone without their expressed permission. .2. TRAINING Upon hire, each new employee shall be informed of what constitutes abuse, neglect and exploitation (ANE) and misappropriation of resident property, the reporting requirements, including their obligation to report and how to report. Training shall include definitions of .misappropriation .and our policy and procedure regarding .misappropriation of resident property. Every employee shall receive annual training on the requirements of the center's policy and procedure on .misappropriation of resident property and the requirements of the Federal and State laws. 3. EMPLOYEE OBLIGATION All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating the resident's rights. Any employee who witnesses or has knowledge of an act of .misappropriation of resident property, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that caused the allegation 105574 Page 5 of 6 105574 08/15/2023 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0609 Level of Harm - Minimal harm or potential for actual harm involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury to the immediate supervisor, or the Director Quality Assurance, or the Executive Director of the center . Residents Affected - Few 105574 Page 6 of 6