Health inspection·February 16, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the required Florida Do Not Resuscitate Order (FL DNRO) form was obtained and maintained in the resident's clinical record for 1 of 1 resident reviewed for Advance Directives of a total sample of # residents (#422). Findings: Clinical record review revealed that resident #422 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including encephalopathy, diabetes type II, and dementia. A physician order dated 11/28/22 for resident #422 was Do Not Resuscitate (DNR). Record review did not contain a yellow goldenrod colored FL DNRO form in the resident's electronic medical record. Review of the Red Book/DNR status paper backup-system binder, kept at the nurses' station on the 200 Unit did not contain a FL DNRO form included for resident #422. A copy of the physician's order dated 11/28/22 was inserted where the FL DNRO form should have been. Documentation in the binder instructed staff to go to the electronic medical record first to verify the resident's code status and indicated that the red book was a backup system and should only be the source during a power outage or electronic medical record (EMR) failure. However, the yellow goldenrod colored FL DNRO form was not in the resident's EMR. On 2/14/23 at 4:24 PM, Licensed Practical Nurse (LPN) C stated that on admission, nurses communicate with the resident/responsible party regarding their code status, and document the decision in the clinical record. LPN C explained that if DNR was selected, it had to be verified by another nurse, and the paperwork would be completed by the Social Services Director (SSD) who would ensure all the required signatures were obtained. The Red Book/DNR binder was reviewed with the LPN who confirmed a FL DNRO form was missing, and that only the physician's order for DNR was included in the binder. LPN C stated the SSD, and the Medical Records personnel were responsible to ensure the Red Book/DNR binder was current. On 2/14/23 at 4:37 PM, the Assistant Director of Clinical Services/Unit Manager (ADCS/UM) for the 200 Unit stated two nurses were required to verify code status if DNR was selected. She said the SSD assists with completing the process by getting the FL DNRO form with all the required signatures, and that should be completed within 24-48 hours of determination of the DNR status. The ADCS/UM stated resident #422 was admitted to the facility on [DATE] and was not able to make her own decisions. In Page 1 of 6 105577 105577 02/16/2023 Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discussion with the resident's son on 11/28/22, DNR status was chosen, and the FL DNRO form should have been completed at that time or within 24-48 hours. The ADCS/UM reviewed the resident's EMR, and the Red Book/DNR backup system binder. A FL DNRO form was not found by the ADCS/UM. The ADCS/UM stated the FL DNRO form was needed for communication and explained that if the resident needed to be transferred from the facility to the hospital, Emergency Medical Services (EMS) would not accept or honor the facility's physician order; the FL DNRO form was required. On 2/14/23 at 4:52 PM, the SSD stated the FL DNRO form was required for any transfer of the resident. She stated the physician's order for DNR was for nurses in the facility, but if the resident needed to be transferred to the hospital, the FL DNRO form was required. She verbalized that when the facility received a physician's order for DNR, the FL DNRO form should be in place within 24-48 hours. The SSD stated she was responsible to have the FL DNRO form completed. On 2/14/23 at 5:17 PM, the SSD provided an envelope stamped with date of 2/06/23 sent to the resident's son with a copy of the FL DNRO form to be signed. She explained the form was signed and returned today 2/14/23 and would be faxed to the physician for his signature. The SSD confirmed the process should have been addressed when the physician order was obtained on 11/28/22. 2/15/23 at 2:35 PM, the Director of Clinical Services (DCS) and the Regional Consultant Nurse stated the facility identified the missing DNR for resident #422, and a Performance Improvement Project (PIP) was initiated on 2/10/23. The DCS stated she developed the PIP, and it was discussed with everyone who had a part in it which included the SSD and SS Assistant. When asked the process to develop the PIP, the DCS stated the usually the Inter Disciplinary Team (IDT) would discuss the concern, develop a plan, the plan would be bought to the Quality Assurance and Performance Improvement (QAPI) committee, and a PIP would be initiated. She stated the PIP for the DNR had not gone through the process and had not been discussed with the IDT. On 2/15/23 at 3:09 PM, the Regional Director of Clinical Services stated the DCS informed her on 2/10/23 regarding not having a DNRO for resident #422. She recalled she told the DCS to develop a plan. She stated the PIP was not initiated yet as it had not been reviewed by the QAPI committee or the IDT. The facility's policy Advanced Directives & Code Status, with effective date of September 2019 and revision date of 9/2022 read, The State of Florida DNR form . will be used to communicate a resident's DNR code status wishes to 911/Emergency Medical Services (EMS) should the resident be found unresponsive. The policy QAPI-Nursing, Social Services, Risk Management Palm Healthcare Management 2021 read, QAPI identifies opportunities for improvement, addresses gaps in systems, and involves performance improvement plans with monitoring of interventions. 105577 Page 2 of 6 105577 02/16/2023 Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide ongoing monitoring and re-evaluation of physical restraints for 1 of 1 resident reviewed for physical restraints from a total sample of 42 residents. (#48) Residents Affected - Few Findings: Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Huntington's disease, psychosis, dementia, anxiety, dysphagia, dysarthria, anarthria, and osteoporosis. The Minimum Data Set (MDS) Quarterly assessment with Assessment Reference Date (ARD) of 11/21/2022 noted that staff assessments indicated the resident was cognitively impaired, required dependent to extensive staff assistance for activities of daily living (ADLs), noted that no falls occurred since the prior assessment, and no restraints or alarms were used during the look back period. On 2/13/2023 at 2:23 PM, resident #48 was observed in a reclining position physically restrained by thickly padded black inner thigh/leg belts with extension straps wrapped around a chair. The straps were secured together and fastened with a buckle behind the chair. The resident was restrained at the inner thighs and secured to the chair at the pelvis. The device placement and set up prevented the resident from rising or accessing her body, and she could not remove it. The medical record did not contain any orders for the use of physical restraints. The care plan interventions included, Broda chair with leg strap, padded leg and footwell cushion related to positioning for Huntington's disease, 6/19/22, revised 9/06/22, and Broda chair for positioning, revised 2/13/23. On 2/14/2023 at 9:49 AM, resident #48 was observed in a reclining position and restrained by black padded inner thigh/leg straps with extensions wrapped around a chair. The straps were secured together and fastened with a buckle behind the chair. The resident was unable to rise or remove the straps as her pelvis was immobilized by being secured to the chair. On 2/14/2023 at 4:36 PM, resident #48 was observed among other residents in the 100-unit resident lounge in the same position observed on 2/14/2023 at 9:49 AM with the same restraint device applied in the same manner. On 2/14/2023 at 5:05 PM, Certified Nursing Assistant (CNA) A said resident #48 required the leg/thigh restraints to keep her from falling out of the chair. The CNA explained the resident, wears them all the time. On 2/14/2023 at 5:08 PM, the 100 Unit Manager (UM) stated resident #48 was a fall risk and required the restraint device to secure her to the chair. The UM recalled the thigh straps and a lap waist belt had been applied by staff regularly for at least 6 months. On 2/15/2023 at 9:09 AM, Licensed Practical Nurse (LPN) B demonstrated how staff applied the restraint by 3 straps that included one strap threaded between the resident's legs with thick padding for each inner thigh/leg. The LPN showed the surveyor how the strap extensions wrapped through and 105577 Page 3 of 6 105577 02/16/2023 Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few around the chair coming together and how they were secured together with a buckle behind the chair. LPN B explained the device was not used for positioning and the resident was not able to remove it. She said the restraint was needed to keep the resident safe from falling, like a seat belt. Review of the medical record revealed therapy referrals were made after falls without injury on 12/15/2021, 1/10/2022, 1/24/2022, 2/26/2022, 3/04/2022, 4/16/2022, 5/10/22, and 5/25/2022. The therapy screen completed on 5/19/2022 noted the resident was evaluated by Occupational Therapy (OT) on 5/20/2022 with recommendations for, a lap belt/support specifically designed for Huntington's disease patients (residents) that will provide the least restrictive and most appropriate and safe support to address severe choric movements, rendering her at risk for frequent falls. Staff educated. No further interventions recommended. Subsequent therapy screens were completed on 8/12/2022, 10/29/2022, 12/13/2022, and 1/28/2023 that noted the resident did not have a decline in functioning. The Certified Nursing Assistant (CNA) [NAME] resident care information read, Maintenance Nursing - Have pt sit in her Broda chair during the day, dated 8/23/2022 and, Broda chair with leg strap, padded leg and footwell cushion r/t positioning for Huntington's Disease, dated 9/06/2022. On 2/15/2023 at 10:59 AM, the Director of Rehabilitation stated resident #48's condition had worsened since admission, and she had multiple falls. She said the resident's plan of care included use of a Broda chair, lap belt, and a chair package with a foot box, and abdomen and leg straps. She explained the chair package was a one-piece device with thick padding for skin protection that attached to the back of the chair, and was used to keep the resident, down in the chair. The medical record revealed the facility did not attempt less restrictive interventions, complete ongoing re-evaluation and monitoring, or plan for minimal time for use of a lap belt or thigh/leg straps. On 2/15/2023 at 4:31 PM, the Director of Clinical Services stated the facility was restraint free and did not have policies and procedures for restraint use. On 2/16/2023 at 2:36 PM, the Licensed Practical Nurse (LPN) MDS Coordinator said modifications were completed to the MDS assessments for ARD 11/21/2022 quarterly, ARD 8/21/2022 annual, and ARD 5/23/2022 quarterly to indicate trunk and limb restraints in a chair were used daily for resident #48 during the look back periods. 105577 Page 4 of 6 105577 02/16/2023 Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination for 2 of 3 residents reviewed for PASRR, out of a total sample of 42 residents (#62 & #103). Findings: 1. Resident #62's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, unspecified psychosis, hypertension, and chronic kidney disease. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 11/10/22 revealed resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. The document indicated his active diagnoses included depression (other than bipolar) and psychotic disorder (other than schizophrenia). Resident #62's electronic medical record (EMR) revealed diagnoses of major depressive disorder with an onset date of 7/13/21, adjustment disorder with depressed mood with an onset date of 2/21/22 and other psychotic disorder not due to a substance or known physiological condition, with an onset date of 12/16/22. The record contained a Level I PASRR screening form dated 5/20/21 which did not indicate resident #62 had a mental illness (MI) or suspected MI. The record did not contain a Level II PASRR screening form. 2. Resident #103's medical record revealed she was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and cognitive communication deficit. The MDS Significant Change assessment with ARD of 12/01/22 revealed resident #103 had a BIMS score of 00, which indicated she had severe cognitive impairment. The document indicated her active diagnoses included anxiety disorder, depression (other than bipolar) and psychotic disorder (other than schizophrenia). Resident #103's EMR revealed diagnoses of anxiety disorder, major depressive disorder, and unspecified psychosis. The record indicated each diagnosis had an onset date of 5/26/22 and was present upon admission. The record contained a Level I PASRR screening form dated 4/29/22 which did not indicate resident #103 had an MI or suspected MI. The record did not contain a Level II PASRR screening form. On 2/15/23 at 2:23 PM, the Social Services Director (SSD) stated a new admission from the hospital should have a Level I PASRR Screening completed by the hospital prior to admission. She explained the clinical team and SSD review the PASRR upon admission. If the screening form is identified as inaccurate, the SSD and Director of Nursing complete a new Level I PASRR. She acknowledged a new PASRR would need to be completed if a resident received an MI diagnosis after admission. The facility's policy and procedure for Pre-admission Screening for Serious Mental Illness (SMI) and Intellectually Disabled (ID) Individuals (PASRR), revised July 2021, read, If it is learned after admission that a Serious Mental Illness (SMI) or Intellectually Disabled (ID) Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 105577 Page 5 of 6 105577 02/16/2023 Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to request a Preadmission Screening and Resident Review (PASRR) level 2 evaluation for 1 of 3 residents reviewed for PASARR from a total sample of 42 residents (#48). Residents Affected - Few Findings: Resident #48 was admitted to the facility 8/13/2021 with diagnoses of Huntington's Disease, psychosis, dementia, anxiety, dysphagia, dysarthria, anarthria, and osteoporosis. Review of the medical record revealed the resident's Level 1 PASRR completed 5/31/2018 showed the resident met criteria that required a Level II PASRR evaluation was completed, and there was not a Level II evaluation completed. On 2/15/2023 at 1:55 PM, the Director of Nursing (DON) said the Interdisciplinary Team (IDT) reviews the PASRR screen for accuracy, and the DON is responsible for the follow up process. On 2/16/2023 at 11:55 AM, the Social Services Director acknowledged a Level 2 PASRR should have been done, and, on 2/16/2023 at 2:51 PM, the Social Services Director stated no Level 2 PASRR was requested or completed, and she initiated the request on 2/16/2023. The facility's Risk Management/Social Service policy and procedure manual for PASRR, revised July 2021, read, Procedure: 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is learned after admission that a Serious Mental Illness (SMI) or Intellectually Disabled (ID) Level II screening is indicated; it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 105577 Page 6 of 6