Health inspection·February 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An observation of the Reflections Activity and Visiting Room on 02/20/23 at 12:14 PM revealed the room was also utilized for dining. Five residents were observed sitting at a table for restorative dining, while four other residents were sitting at additional tables in the same room. Staff A, restorative Certified Nursing Assistant (CNA), and the Speech Therapist (ST) were in the room assisting residents involved in the restorative program. During this observation, the five residents at the restorative table were served and assisted first, beginning around noon. The other four residents were served one at a time, between 12:15 PM and 1:15 PM. As per Staff C, CNA, who was noted bringing in a lunch tray to one of the four non-restorative residents, the restorative trays were delivered first, and then each unit is served, for those that eat in their rooms. The CNAs on the floor would bring in the trays for the non-restorative residents, from the food cart being used to serve residents in their rooms. At 1:15 PM, Resident #204 was taken back to her room and served lunch, after sitting in the Reflections Activity and Visiting Room for over an hour with no interaction. At times, Resident #204 was noted with her head down on her crossed arms, on the table. During an observation on 02/22/23 at 12:20 PM, the two restorative aides, Staff A and Staff B, were noted assisting four residents at the restorative table. The four restorative residents were well into their lunch, and a couple of them were nearly finished. Resident #92 was sitting at another table, and he was facing the restorative table, with Resident #47 at the same table but with her back toward the restorative table. Resident #92 was noted glancing over at the restorative table several times, and then started to leave the room. Staff A, restorative aide, told the resident his lunch would be coming shortly, so he needed to wait there. Resident #58 was also in the same room, but at a different table. At 12:35 PM, Residents #47 and #92 received their lunches. The residents at the restorative table were essentially finished eating, with two just finishing their desserts. At 12:39 PM, Resident #58 was served his lunch. During an interview on 02/22/23 at approximately 1:00 PM, Staff D, Licensed Practical Nurse (LPN) on the Reflections Unit, was asked why the three non-restorative residents were in that particular dining area. The LPN stated she was fairly new, only having been there 3 or 4 weeks, and was unsure. The LPN did agree that all the residents in the room should be provided their meals at the same time. During an interview on 02/22/23 at 1:07 PM, Staff A, restorative aide, explained all the residents in that dining area needed some cuing and that they used to send two carts about the same time. Staff A did state they just recently restarted dining in the dining area, and that different residents come into that room at times. When asked how long it had been since they started reusing the dining area, Staff A would not say. Page 1 of 6 105579 105579 02/23/2023 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/22/23 at 1:11 PM, the Director of Nursing (DON) explained the non-restorative residents in that dining included whoever is willing to get out of bed who has had weight loss and or needs additional oversight. When asked why the residents are not receiving their trays at the same time, the DON stated the kitchen probably doesn't know who is eating in that dining area. During an interview on 02/22/23 at 1:23 PM, Resident #47 stated it didn't bother her 'too much' that she had to wait for her lunch while the other ate. During an attempted interview with Resident #92 at 2:40 PM, the resident was unable to logically answer any questions or hold a conversation. Based on observation, interviews and record reviews, the facility failed to ensure staff limited the use of cell phones while on duty and providing care to 9 of 22 sampled residents (Residents #27, #15, #6, #89, #29, and #300); staff did not communicate in a foreign language while providing care to 9 of 22 sampled residents (Residents #27, #15, #6, #89, #29, and #300); and four of 22 sampled residents (Resident #204, #92, #47, #58) were treated in a dignified manner related to dining in 1 of 3 dining rooms (200 unit). The findings included: The facility's policy on Dignity (2001, Revised [DATE]) stated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility's Employee Handbook stated: The use of cellular telephones on [the facility's] premises is permitted only in your parked car in the parking lot or in the event of an emergency. While on duty, cell phones may be carried on your person in the off position and used for emergency medical aid only. Employees may use cell phones or walkie-talkies on the course when necessary to perform their duties but not for personal reasons. It is expressly prohibited to use your phone or any type of electronic device to record (audio or video) at any time. 1. On 02/22/23 at 1:35 PM, a meeting was held with 5 alert and oriented members of the Resident Council. Those members included the Resident #27, Resident #15, and 3 additional members (Residents #6, #89, #29) that were attending each monthly meeting held on the 1st Wednesday of each month. During the meeting, Resident #27 and Resident #15 both complained, Staff use their phone while on duty. We find them hiding in our bathrooms on their phones. They don't respond when we call for assistance because they are on their phones 24/7. The staff are speaking in a foreign language to each other when they are providing care. Resident #27 had voiced these same concerns to a 2nd surveyor during Resident #27's initial interview conducted on 02/20/23 at 4:05 PM. The 3 additional Resident Council members (Residents #6, #89, and #29) all confirmed the allegations made by the Resident #27 and #15, stating that they, too, had witnessed staff on their cell phones while providing care and hiding out in the bathrooms while talking on their phones. They also confirmed that they have witnessed staff speaking in a foreign language to each other while providing care to residents. Review of the Grievance Log and Resident Council Minutes for January 2023 does show grievances filed regarding staff phone use and the use of foreign language by staff. The resolution noted on the grievance log was, on-going education. 105579 Page 2 of 6 105579 02/23/2023 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. On 02/20/23 at 10:43 AM, Resident #300 was interviewed about any concerns he had while living at the facility. The Resident's Minimum Data Set (MDS) assessment was completed on 01/23/23. The assessment documented the resident's Brief Interview for Mental Status (BIMS) was a 15 which indicated the resident is cognitively intact. During the interview, Resident #300 stated the Certified Nursing Assistants (CNA's) will come into the room to assist him and they will be talking on their phones during his care. He stated they also speak in a foreign language to each other while they are in his room, and he does not appreciate it. He stated it has been discussed at the Resident Council Meetings; however, it continues to happen. During an interview on 02/23/23 at 11:42 AM with a 2nd surveyor, Resident #300 added to his concerns. He stated the CNAs talk on their phones, using the ear buds, while they are assisting him with care. The resident stated the staff also go into his bathroom to talk on their phones. The resident explained that some are speaking English, but when they are talking in another language on their phones, it makes him feel uncomfortable, further stating, I don't know if they are laughing about me or something else. Resident #300 stated he was never allowed to talk on the phone when he worked, and they should not be allowed either. 105579 Page 3 of 6 105579 02/23/2023 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure reasonable accommodation of needs for 2 of 21 sampled residents, as evidenced by: Resident #24 lacked a call bell system that she could physically utilize to get staff assistance; and Resident #80 lacked an appropriately sized bed. Residents Affected - Few The findings included: Review of the policy, Equipment - General Use for All Residents, revised August 2026, documented, Our facility shall provide routine equipment for the general use of the resident population. 3. Request or the need for special equipment should be referred to the Social Services Department. 1. On 02/22/23 at 8:37 AM, while in a resident room speaking with Resident #75, the roommate on the other side of a drawn curtain, Resident #24 called out nurse nurse please help me . help me with my elbow. The surveyor explained she was unable to assist, but asked the resident to push her call bell for assistance. Resident #24 stated, I can't . it's not here. Observation revealed the call bell hanging from the bottom of the side rail with the call button nearly on the floor. Photographic Evidence Obtained. When the call bell was placed in the resident's hands, it was noted that her fingers were somewhat disfigured (arthritic). Resident #24 attempted to push the call light and didn't have the strength or ability in her finger to engage the call button. The surveyor engaged the light. Staff E, Certified Nursing Assistant (CNA) entered the room and said she was going to assist the resident with breakfast. The CNA was not paying attention to the resident, so the surveyor explained the resident had a request and needed other assistance. During an interview on 02/22/23 at 9:02 AM, Staff E confirmed Resident #24 could make her needs known and does use the call bell and volunteered, but sometimes has difficulty pushing the button. When asked if the facility uses other types of call bells, like the gray soft one (pneumatic), the CNA was unsure. The CNA had not told the nurse or a manager that the resident had difficulty with the current call bell, but agreed the resident had a right to be able to call for assist. During a supplemental observation on 02/22/23 at 12:15 PM, Resident #24 now had a soft pneumatic type call button. Staff E was in the room at the time and pointed out the new call button and stated the resident was able to use that one. Review of the record verified Resident #24 was alert and oriented with diagnoses to include multiple contractures of hands and other joints. 2. An observation on 02/21/23 at 2:18 PM revealed Resident #80 as being quite tall and large, lying in a regular facility bed. During an interview at this time, the resident stated she was able to physically assist by rolling to one side or the other for personal care, but the bed was quite small. Resident #80 also stated she was 6' 1 (6 foot, 1 inch), and the bed was too short. An observation at that time revealed her feet were right at the end of the bed. Resident #80 stated she had asked for a longer bed and was told they didn't have one. Review of the record revealed Resident #80 was admitted to the facility on [DATE], and moved to her current room as of 06/21/22. Further review of the record revealed an admission weight of 272.8 pounds, and a current weight 341.8 pounds. 105579 Page 4 of 6 105579 02/23/2023 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 02/23/23 at 2:44 PM, the Unit Manager was asked about the provision of a larger bed for Resident #80. The Unit Manager agreed she should have been offered a larger bed. The Director of Nursing (DON) was nearby and agreed with the need, further stating the resident had gained weight since her admission. During an interview on 02/23/23 at 3:44 PM, the Unit Manager informed the surveyor the larger bed had been ordered. Residents Affected - Few 105579 Page 5 of 6 105579 02/23/2023 Savannas Park Health and Rehabilitation Center 1655 SE Walton Road Port Saint Lucie, FL 34952

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide requested beautician services to 1 of 1 sampled resident (Resident #7). The findings included: During an interview on 02/20/23 at 10:26 AM, Resident #7 stated she would like a haircut, as she pulled her long pony-tail up to show the surveyor. When asked if she had requested a haircut with the facility's beautician, the resident stated she had asked but they say nothing. Review of the record revealed Resident #7 was admitted to the facility on [DATE], and had transferred to her current room on 02/22/21. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating she was alert and oriented with minimal confusion. This same MDS documented the resident needed extensive to total assistance for all Activities of Daily Living (ADLs) except for eating. During an interview on 02/23/23 at 10:44 AM, the facility beautician stated she works Thursday and Friday mornings at that facility. When asked about Resident #7, the beautician stated she had gone to her several times to offer services, and more often than not the resident was in bed and stated, not today . maybe tomorrow. The beautician explained she had encouraged the resident to have the CNAs (Certified Nursing Assistants) get her up, but then when she returned to the room, the resident was still in bed. The beautician stated a list was kept with the receptionist for each week's service. Resident #7 was not on that week's list for beautician services. During an interview 02/23/23 at 10:48 AM, the Administrative Assistant / Receptionist explained when the resident or family requested beauty salon services, she would put the resident's name on the list. The receptionist provided a binder with previous weeks of beauty salon requests. The receptionist explained the resident would initial or sign the appointment sheet upon receipt of services. When asked what happened if a resident did not receive services for some reason, and the receptionist stated the beautician would normally add the resident to the next week's list. Review of the appointments revealed the most current appointment was scheduled for 02/09/23 and 02/10/23. Next to this appointment, the resident was in bed and refused. Resident #7 had not been added to the list for 02/16/23. Further review of the appointments revealed Resident #7 was scheduled on 02/02 02/03/23, 08/30/22, and 08/24 - 08/25/22. All of these dates documented the residents name on the schedule, but lacked any resident initials, signature, or rationale for the lack of services. During an interview on 02/23/23 at 1:56 PM, the Reflections Unit Manager stated she was unaware Resident #7 had been on the appointment schedule, further explaining she did not have a list of the beauty salon appointment. 105579 Page 6 of 6