Health inspection·May 3, 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 record reviews and interviews, the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment was reported immediately to all outside agencies for one (Resident #1) out of the sampled three residents. Findings included: A review of the admission Record Report for Resident #1 showed she was admitted into the facility on [DATE] with a diagnosis that included but was not limited to unspecified dementia. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code (04 13/21). Progress Notes revealed the following note: [DATE] at 04:38- Certified Nursing Assistant (CNA) returned from 30-minute break and alerted nursing staff that resident was not breathing. Nursing assesses, code blue called, and CPR (cardiopulmonary resuscitation) was initiated. Provider made aware. 911 arrived and resident was pronounced expired at 4:42 a.m. by Emergency Medical Services (EMS). Family was called and informed that the resident expired. A code form was not completed for this event. A review of the care plans did not reveal a care plan related to code status. On [DATE] at 1:20 p.m., the Administrator (NHA) reported on 4/14 she received a call from the Director of Nursing (DON) concerned that she heard from the nurse practitioner that she spoke to Staff G, Registered Nurse (RN), and was concerned that she did not remain with her patient during the code process. After that, she called Staff G, RN, to suspend her pending investigation as to why she didn't remain with the patient. Staff G, RN, was supposed to meet with the Administrator and the DON on the following Monday or Tuesday, but she had a family emergency, and couldn't come in to meet until the 24th. When she came in on the 24th, they started the interview process and could not complete the Page 1 of 15 105599 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview as Staff G, RN, was upset and left the building. The NHA stated Sometimes the question can seem pointed. She and the DON were getting loud, and it was getting heated. The Administrator stated she excused the DON and the nurse stated she was not going to complete the interview process. Staff G, RN, had emailed regarding a complaint about the DON but not in response to completing the interview. The DON began to interview other staff. She came back with reports from staff that indicated there was a five-minute delay in giving CPR to Resident #1. The DON did not have a witness when she conducted her interviews and there should always be a witness, stated the Administrator. The NHA stated With that concern and delay for initiating treatment, a one-day neglect report was completed for the potential delay in initiating CPR. The Department of Children and Families (DCF) and law enforcement were contacted. The family was also notified of the investigation. Interviews were completed by the DON, and she provided information that there was a concern coming from Staff O, Licensed Practical Nurse (LPN), related to a delay in providing CPR. When the Administrator interviewed Staff O, LPN, there were no concerns. Staff O, LPN, stated he went to go to the bathroom in the breakroom and on his way back he was near the conference room door and heard code blue paged three times. They said 400 hall and he grabbed the crash cart and Staff M, RN, asked if he had the Automated External Defibrillator (AED), he said no she grabbed it and followed him down the hall. He went in the room and visually Resident #1 wasn't breathing, touched her wrist, she appeared warm, and no pulse. He opened the crash cart and set up the Ambu bag. Staff R, LPN, was on the left and Staff N, Certified Nursing Assistant (CNA), was on the right putting the board under her. Staff M, RN, opened the AED. As soon as he got air in the Ambu bag, he gave it to Staff R, LPN, and initiated compressions. After 2 sets they followed the AED directions and continued compressions until Emergency Medical Services (EMS) came. Staff responded immediately less than 30 seconds. They all worked together and did what they had to do. He said there was not really a delay. They all jumped in. Staff G, RN, came down with EMS. The CNA returned from lunch break and found Resident #1 unresponsive. It was approximately 4:10 a.m. No code sheet was completed. The CNA called for help to her hall partner. Staff G, RN, and Staff J, CNA, ran to the room. Staff G, RN, ran to the desk and paged code blue. She left the aide in the room. Staff G, RN, should have remained in the room. The interview between the Administrator, DON, and Staff G, RN, got heated because Staff G, RN, didn't stay with the resident instead of the aide. She should have sent the aide to get help. Resident #1 was full code. The family was trying to get her to agree to hospice and she wanted to be a full code. Staff G, RN, said she was on the phone making calls and wanted to be sure she was a full code. The nurse left the resident with two aides to call the code. The code was called less than 30 seconds. Within 10 seconds, staff were in the room to do CPR. They expected Staff G, RN, to stay in the room. Aides can do CPR if they are CPR certified. Staff E, CNA, stated she didn't initiate CPR because she was not aware of her code status. Staff G, RN, called Staff P, Nurse Practitioner, to inform her that Resident #1 coded. When she asked what the time of death was, and nurse stated she had not expired yet and Staff P, Nurse Practitioner asked why she on the phone with her and not assisting the resident. Staff G, RN, stated she knew Staff E, CNA, could do CPR so she went to call the code blue. After Staff G's, RN, interview on 04/25, the DON informed her that she spoke with Staff O, LPN, and there was a concern of a delay. They contacted regionals and decided to report neglect and delay in initiating CPR. The nurse should direct the code, call code blue, aides should be the runners. On [DATE] at 1:53 p.m., the DON stated 80% of nurses were not CPR certified in the facility. She stated Staff G, RN, did not initiate CPR timely, saying Resident #1 stated she didn't want to be hospice and wanted to be full code a few days ago. The nurse went to the room and said you're right she's not breathing and left to call the code. Why 105599 Page 2 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few didn't she send the CNAs to call the code? What happened was neglect. The DON continued The nurse left her patient. The nurse didn't deny any of the things that happened. The nurse asked what's the difference between and RN and CNA initiating CPR. She didn't instruct the CNA to initiate CPR. The nurse walked into the room and didn't initiate CPR. There was a time delay by her leaving the patient. She walked past two phones in the hallway on the way to the nursing station and couldn't work the phone at the desk. The DON stated the immediate report submitted to the agency was inaccurate. It was neglect. Staff G, RN, didn't instruct anyone to do anything. Resident #1 was a retired nurse who said she wanted to live a couple days ago. The CNA that stayed in the room was CPR certified. The DON reported she had written people up about not being in the room during CPR in the past. The DON said Staff E, CNA, stated Staff G, RN, never came back to the room. She only stated let her make some calls and left the room. Staff E, CNA, stated she didn't know Resident #1 was a full code. Why didn't the CNA initiate CPR? You can't get to the desk in three to five seconds. Staff G, RN, was on the phone with the nurse practitioner and calling the family while CPR was being done. The nurse said there was nothing wrong with this. They DON stated they need to get the CPR certified nurses and spread them out in the building. The DON stated There's a nurse working in the facility that had not been CPR certified since 2019. She stated Corporate and the Administrator stated staff does not have to be CPR certified. On [DATE] at 1:01 p.m., Staff P, Nurse Practitioner, stated around 4:30 in the morning she received a call from Staff G, RN, stating that Resident #1 was coding and EMS was coming. She asked if she wanted her to call the family and said paramedics had yet to arrive. Told her to hang up and all hands-on deck to assist with the code. After that, the paramedics arrived. The next day, Staff P, Nurse Practitioner told the DON that they need to implement the process of the code and to stay with the patient until the patient was moved to the Emergency Room. She never had anyone to call her in the middle of the code and especially about calling the family. Normally the rule was you stay with the patient until 911 arrived or paramedics show up and then you call the family. Staff G, RN, said the code was running while she was talking to her. Staff P, Nurse Practitioner stated she told Staff G, RN, that she was the primary care nurse and would have the most information about the resident to inform the paramedics. She told her to hang up the phone and go back over there. She should have initiated CPR. Staff P, Nurse Practitioner, stated she does not know how long it took to get to point A or B, but it was no longer than thirty seconds. Staff G, RN, called her after she called 911. She didn't know if an extra 30 seconds to a minute would revive her. Resident #1 was not eating and refusing meds. She stated she heard about two aides in the room after the fact. The staff need more education. CPR should have been initiated that second. On [DATE] at 12:55 p.m., the Administrator stated she was notified about the possible delay on 04/14. The information about the delay was reported to the DON on 04/14. and the day one report was done on 04/25. The Immediate Report was completed on [DATE]. The Five-Day Report was reported to the Abuse Registry on [DATE], Department of Children and Families on [DATE], and law enforcement on [DATE]. The Patient Protection Abuse, Neglect, Mistreatment, and Misappropriation Prevention policy dated 10/2021 provided by the facility revealed the following: Reporting Allegations of Abuse 105599 Page 3 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0609 In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Level of Harm - Minimal harm or potential for actual harm 1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. Residents Affected - Few 4. Report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 105599 Page 4 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to have systems in place supported by policies and procedures to ensure there was an adequate number of staff present at all times who were properly trained and/or certified in CPR (Cardiopulmonary Resuscitation) for Healthcare Providers to be able to provide CPR until emergency medical services arrive and failed to document the code event and interventions associated with the code on the code form per policies and procedures for three of the three sampled residents. Findings included: A review of the admission Record Report for Resident #1 showed she was admitted into the facility on [DATE] with a diagnosis that included but was not limited to unspecified dementia. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code (04 13/21). Progress Notes revealed the following note: [DATE] at 04:38- Certified Nursing Assistant (CNA) returned from 30-minute break and alerted nursing staff that resident was not breathing. Nursing assesses, code blue called, and CPR was initiated. Provider made aware. 911 arrived and resident was pronounced expired at 4:42 a.m. by Emergency Medical Services (EMS). Family was called and informed that the resident expired. A code form was not completed for this event. A review of the care plans did not reveal a care plan related to code status. A review of the admission Record Report for Resident #2 revealed she was admitted into the facility on [DATE] with a primary diagnosis of wedge compression fracture. Section C Cognitive Patterns of the quarterly MDS dated [DATE] indicated the resident had a BIMS score of 06 out of 15 indicating severe impairment. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code ([DATE]). Progress Notes revealed the following note: [DATE] at 23:41- At 1720 during the middle of passing medications, a CNA called about the patient bleeding from the mouth. The patient was bloody and unresponsive. Called for help. Staff performed 105599 Page 5 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0678 CPR and 911 was called. EMS arrived at 1730 and took the patient out at 1740. The physician, family, and the Director of Nursing (DON) were notified. Level of Harm - Minimal harm or potential for actual harm A code form was not completed for this event. Residents Affected - Some A review of the care plans did not reveal a care plan related to code status. On [DATE] at 2;57 p.m. Staff A, CNA, stated she was taking the linen out of the other resident's room and looked in rooms as she was walking by and saw blood all over Resident #2. Called for the nurse. She was bleeding and not looking good. The nurse checked her and sent her to get the AED and they put the AED pads on her. They did CPR and waited for the AED to kick in. EMS came and took her away. She had their machine on and it was doing compression when EMS took her out. She was not CPR certified. Another nurse took over CPR until EMS came. Staff A, CNA, stated she helped with the CPR but did not have a certification, it expired two years ago. A review of the admission Record Report for Resident #3 revealed the resident was admitted into the facility on [DATE] with a diagnosis that included but was not limited to hypertension. Section C Cognitive Patterns of the 5 Day MDS dated [DATE] showed Resident #3 had a BIMS score of 06 out of 15 indicating severe impairment. A review of the Order Summary Report with active orders as of [DATE] revealed the following order: Full Code ([DATE]). Progress Notes showed: [DATE] at 0415- Resident found without pulses or respirations. Code paged. Automated External Defibrillator (AED) applied and CPR started. [DATE] at 0425- 911 here and resident evaluated. Code called off. A code form was not completed for this event. A review of the care plans did not reveal a care plan related to code status. An Inservice/Training Sign in Form dated [DATE] showed a training topic of documentation. Eleven staff signatures were verified on this form. Documentation provided by the facility showed only eighteen out of a total of twenty- six nurses had a CPR certification. Documentation provided by the facility showed only eight out of a total of fifty-three CNAs had a CPR certification. On [DATE] at 1:20 p.m., the Administrator reported on 4/14 she received a call from the Director of Nursing (DON) concerned that she heard from the nurse practitioner that she spoke to Staff G, Registered Nurse (RN), and was concerned that she didn't remain with her patient during the code process. After that, she called Staff G, RN, to suspend her pending investigation as to why she didn't 105599 Page 6 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some remain with the patient. Staff G, RN, was supposed to meet with the Administrator and the DON on the following Monday or Tuesday, but she had a family emergency, and couldn't come in to meet until the 24th. When she came in on the 24th, they started the interview process and couldn't complete the interview as Staff G, RN, was upset and left the building. Sometimes the question can seem pointed. She and the DON were getting loud, and it was getting heated. The Administrator stated she excused the DON and the nurse stated she was not going to complete the interview process. Staff G, RN, had emailed regarding a complaint about the DON but not in response to completing the interview. The DON began to interview other staff. She came back with reports from staff that indicated there was a five-minute delay in giving CPR to Resident #1. The DON did not have a witness when she conducted her interviews and there should always be a witness, stated the Administrator. With that concern and delay for initiating treatment, a one-day neglect report was completed for the potential delay in initiating CPR. The Department of Children and Families (DCF) and law enforcement were contacted. The family was also notified of the investigation. Interviews were completed by the DON, and she provided information that there was a concern coming from Staff O, Licensed Practical Nurse (LPN), related to a delay in providing CPR. When the Administrator interviewed Staff O, LPN, there were no concerns. Staff O, LPN, stated he went to go to the bathroom in the breakroom and on his way back he was near the conference room door and heard code blue paged three times. They said 400 hall and he grabbed the crash cart and Staff M, RN, asked if he had the Automated External Defibrillator (AED), he said no she grabbed it and followed him down the hall. He went in the room and visually Resident #1 wasn't breathing, touched her wrist, she appeared warm, and no pulse. He opened the crash cart and set up the Ambu bag. Staff R, LPN, was on the left and Staff N, Certified Nursing Assistant (CNA), was on the right putting the board under her. Staff M, RN, opened the AED. As soon as he got air in the Ambu bag, he gave it to Staff R, LPN, and initiated compressions. After 2 sets they followed the AED directions and continued compressions until Emergency Medical Services (EMS) came. Staff responded immediately less than 30 seconds. They all worked together and did what they had to do. He said there was not really a delay. They all jumped in. Staff G, RN, came down with EMS. The CNA returned from lunch break and found Resident #1 unresponsive. It was approximately 4:10 a.m. No code sheet was completed. The CNA called for help to her hall partner. Staff G, RN, and Staff J, CNA, ran to the room. Staff G, RN, ran to the desk and paged code blue. She left the aide in the room. Staff G, RN, should have remained in the room. The interview between the Administrator, DON, and Staff G, RN, got heated because Staff G, RN, didn't stay with the resident instead of the aide. She should have sent the aide to get help. Resident #1 was full code. The family was trying to get her to agree to hospice and she wanted to be a full code. Staff G, RN, said she was on the phone making calls and wanted to be sure she was a full code. The nurse left the resident with two aides to call the code. The code was called less than 30 seconds. Within 10 seconds, staff were in the room to do CPR. They expected Staff G, RN, to stay in the room. Aides can do CPR if they are CPR certified. Staff E, CNA, stated she didn't initiate CPR because she was not aware of her code status. Staff G, RN, called Staff P, Nurse Practitioner, to inform her that Resident #1 coded. When she asked what the time of death was, and nurse stated she had not expired yet and Staff P, Nurse Practitioner asked why she on the phone with her and not assisting the resident. Staff G, RN, stated she knew Staff E, CNA, could do CPR so she went to call the code blue. After Staff G's, RN, interview on 04/25, the DON informed her that she spoke with Staff O, LPN, and there was a concern of a delay. They contacted regionals and decided to report neglect and delay in initiating CPR. The nurse should direct the code, call code blue, aides should be the runners. On [DATE] at 1:53 p.m., the DON stated 80% of nurses were not CPR certified 105599 Page 7 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in the facility. She stated Staff G, RN, did not initiate CPR timely. Resident #1 stated she didn't want to be hospice and wanted to be full code a few days ago. The nurse went to the room and said you're right she's not breathing and left to call the code. Why didn't she send the CNAs to call the code? What happened was neglect stated the DON. The nurse left her patient. The nurse didn't deny any of the things that happened. The nurse asked what's the difference between and RN and CNA initiating CPR. She didn't instruct the CNA to initiate CPR. The nurse walked into the room and didn't initiate CPR. There was a time delay by her leaving the patient. She walked past two phones in the hallway on the way to the nursing station and couldn't work the phone at the desk. The DON stated the immediate report submitted to the agency was inaccurate. It was neglect. Staff G, RN, didn't instruct anyone to do anything. Resident #1 was a retired nurse who said she wanted to live a couple days ago. The CNA that stayed in the room was CPR certified. The DON reported she had written people up about not being in the room during CPR in the past. Staff E, CNA, stated Staff G, RN, never came back to the room. She only stated let her make some calls and left the room. Staff E, CNA, stated she didn't know Resident #1 was a full code. Why didn't the CNA initiate CPR? You can't get to the desk in three to five seconds. Staff G, RN, was on the phone with the nurse practitioner and calling the family while CPR was being done. The nurse said there was nothing wrong with this. They DON stated they need to get the CPR certified nurses and spread them out in the building. There's a nurse working in the facility that had not been CPR certified since 2019 from her audits. She stated Corporate and the Administrator stated staff does not have to be CPR certified. On [DATE] at 10:38 a.m., Staff D, Staffing Coordinator, stated the scheduling was based off the census. Aides were 2.05 and nurses were 1.2. All staff have a set schedule and it rotates every two weeks unless they are PRN (as needed). They all rotate weekends and work every other weekend. The master schedule rotates every two weeks. She fills in with PRN when staff wants a day off. If there's a hole in the schedule, they use the PRN schedule. She schedules based on discipline and how many she needs per hallway. Does not know which staff were CPR certified. No one ever asked her to look at it. She could have staff on the schedule and none of them could be CPR certified because that was something she did not look at. On [DATE] at 1:21 p.m., the DON stated there was no other documentation but the two statements by the nurse on the code in the progress notes. She stated that the staff did not do a code sheet. She stated the Administrator told her they did not have to do one (code sheet). She did a documentation in-service on [DATE] regarding documentation in general. On [DATE] at 12:47 p.m., the DON stated she had been doing code drills, but had no idea that she was doing drills with were noncertified staff. She look it up and the board of nursing says if you are a CNA, LPN, or RN you have to have a CPR certification. On [DATE] at 12:50 p.m., the Administrator stated they did not have a system in place related to sufficient staff to ensure there was staff in the building that were CPR certified prior to the incident with Resident #1. She went through the two-week schedule and highlighted to make sure they had at least one staff on each side of the building moving forward. They are going to be tracking. Wanted to make sure there was at least one person on each side of the building. They would only have one nurse to do a code. The Administrator stated she had never done a code and didn't know that it could require more than one staff member. On [DATE] at 12:53 p.m., the DON stated 100% of staff should be certified. She was trying to lessen the risk to make sure they had sufficient staff. The DON stated the documentation related to code had always been on the code form. The form had not been completed not one time. The code form should 105599 Page 8 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be part of the chart. She had a code the second week she worked in the facility and only two people showed they were strong with doing a code. She was unaware that a lot of the staff were not CPR certified. Seen that it was weak during the code drills but didn't know why. The Job Description for the charge nurse, LPN/staff nurse, LPN provided by the facility revised 01/16 revealed the following: Special Nursing Care Responsibilities-Based on State Nurse Practice Act Emergency procedures: properly administer oxygen, suctions, performs CPR, and uses the ambu bag. The policy provided by the facility Code Management revised [DATE] revealed the following: Critical Notes: Licensed staff are responsible for following applicable state laws, practice acts, administrative codes, declaratory statements and/or other guidance issued by their state licensing board; as well as, applicable ProMedica Senior Care policy, to assist them in exercising professional judgement, and determining whether the performance of a procedure is within their score of practice and appropriate for the location of patient/resident care services. Each staff member is responsible for complying with the standard of care applicable to their practice. Introduction Ideally, the code team should consist of health care workers trained in advanced cardiac life support (ACLS), although health care workers trained in basic life support (BLS). Implementation An ACLS trained nurse acts as the code leader until the practitioner arrives. Meanwhile, another code team member should document events and treatment. Documentation Documentation associated with code management involves adding to the code form the events and interventions in as much detail as possible, including: whether someone witnessed the arrest or that no one witnessed it time of the arrest time CPR began time the code team arrived and their names total resuscitation time number of defibrillations 105599 Page 9 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0678 times they were performed Level of Harm - Minimal harm or potential for actual harm energy dose patient's cardiac rhythm before and after defibrillation Residents Affected - Some presence or absence of a pulse procedures o time of the procedure o patient's tolerance of the procedure time of death pronounced The policy provided by the facility Emergency Management dated 06/2021 revealed the following: Purpose: To provide guidelines for documentation after the provision of emergency services to a resident. To establish a process defining roles and responsibilities of caregivers involved in the care of a resident in an emergent situation. Documentation of Emergency Services Provided: Document the following in a progress note after a resident emergency event: o Resident status o Time medical emergency was identified, and type of emergency care initiated o Evaluation of resident's level of consciousness, circulation, airway and breathing o Verification of resident's code status o 105599 Page 10 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0678 Occurrence and time the CPR was started, if applicable Level of Harm - Minimal harm or potential for actual harm o Time and person contacting EMS Residents Affected - Some o Step by step description of care provided: initiation of CPR (if applicable), AED use (If applicable), vital sign check and results, suctioning (if applicable) o Physician notification, response received, orders obtained o Family notification, response received o EMS arrival and transfer of care o Time and resident status upon transfer from community o Any additional applicable information Emergency Response Guidelines: Documentation of actions taken, notifications made, and other relevant information identified is documented in progress notes by the licensed nurse. 105599 Page 11 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 perform adequate assessments for worsening pressure ulcers for one of three sampled residents (#2). Residents Affected - Few Findings included: Resident #2 was admitted on [DATE] and discharged on 03/30/2023. Review of the admission showed diagnoses included but were not limited to wedge compression fracture of the third lumbar vertebrae, dementia, hypertension, weakness, neuromuscular dysfunction of the bladder, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 6 or severe impairment. Section G showed she required extensive assistance of two for bed mobility and transfers. She had a stage I pressure ulcer and 1 venous and arterial ulcers. Record review of the physician orders showed: Prosource 30 ml (milliliters) daily for a supplement; House shake twice a day; wound care appointment on 03/27/23; Left dorsal foot care: cleanse with normal saline, apply Prisma collagen, cover with foam dressing every Monday, Wednesday and Friday as of 03/29 Left ischial wound care: apply Dakin's wet to dry dressing daily as of 03/27 Right heel wound care: cleanse with normal saline, apply Santyl ointment to wound bed, apply wet to dry gauze dressing daily as of 03/27 Left lower buttock / gluteal fold wound care: apply Dakin's wet to dry dressing daily as of 03/27 Resident to stay in bed on air loss pressure mattress as of 03/27 Reposition resident side to side as of 03/27 Prevalon boots on at all times as of 03/27 Do not place resident in wheelchair as of 03/27 Place resident on back for meals and medication administration. Then reposition pt [patient] on her side for offloading purposes as of 03/27 Doxycline hyclate 100 mg (milligrams) every 12 hours for cellulitis of right ankle for 7 days as of 03/21 Record review of the Progress notes showed: On 02/21/23, a stage II wound to the sacrum area. It was 1.0 x 0.5 cm (centimeters) with scant drainage, pink surrounding tissue, and wound bed. Treatment was in place. Resident had an air mattress. 105599 Page 12 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0686 Boots were worn while in bed. She was receiving protein shakes and prosource. Level of Harm - Minimal harm or potential for actual harm On 03/01 Weekly Wound Rounds performed: stage II ulcer to the sacrum 1.5 cm x 0.5 cm, 70% slough and 30% granulation. Pressure Ulcer Healing Chart (Push) score of 7. The right heel wound showed a deep tissue injury (DTI) measuring 2.2 cm x 1.0 cm. The wound bed has 90% slough and 10% granulation. The surrounding tissue was macerated. Had a Push score of 9. Residents Affected - Few On 03/01 the treatment was changed to the right heel. Cleanse with normal saline and apply triple antibiotic ointment and cover. On 03/06, the treatment to the right heel was changed to medi-honey. On 03/08, Weekly Wound Rounds performed: Stage II to sacrum of 1.0 cm x 0.5 cm. Push score was 4. Right heel DTI 2.0 cm x 1.5 cm. The wound had 75% granulation and 25% slough. Maceration was present. The Push score was 10. On 03/15, Weekly Wound Rounds performed: Sacrum 1.5 cm x 1.5 cm. PUSH score of 7. Right heel DTI 2.0 cm x 1.5 cm. Copious amount of drainage from wound bed with 75% granulation and 25% slough. Maceration present. A Push score of 13. On 03/20 a wound appointment was scheduled for 03/27 with the Wound Care Center. On 03/21, the provider was made aware of redness to the right ankle and odor to open area on heel. New orders for wound culture and Doxycycline 100 every 12 x 7 days. On 03/22 Weekly Wound Rounds performed: Sacrum area 6.5 cm x 2.5 cm copious amounts of drainage. The wound bed was 100% granulation and pink and surrounding tissue. The Push score was 14. Right heel DTI measuring 3.0 x 3.0 with copious amount of drainage from the wound bed with 50% granulation and 50% slough. Maceration present. The Push score was 13. On 03/27 received all new orders from the wound care center. On 03/29 Weekly Wound Rounds performed: Sacrum measure 6.2 cm x 3 cm x 1.8 cm with 75% necrosis and 25% slough to wound bed. Moderate amount of drainage. Push score of 15. Pressure wound to the right heel 1.3 cm x 1.2 cm, with scant amount of exudate and with 50% slough and 50% necrosis. Push score of 9. Pressure wound to left dorsal foot measures 1.0 cm x 1. cm with no drainage. Push score of 5. Pressure wound to left ischium 2.2 cm x 3 cm x 2.9 cm with 50 % slough and 50% granulation, with moderate amount of exudate and a PUSH score of 12. She was seen by the wound care center. Impaired mobility and incontinence which may contribute to further skin breakdown. On an air mattress and is repositioned side to side except for meals and meds. Not up in wheelchair. Record review of the care plans showed resident had a pressure ulcer to sacrum area related to immobility. Interventions included administering treatment per physician orders, pressure redistributing support surface and repositioning during ADLs. Right heel pressure area care plan related to diabetes, impaired mobility, vascular disease. Interventions included administering treatment per physician orders, elevating heels as able, pressure reducing surface on bed /wheelchair, use pillow and /or positioning devices as needed. Right ankle wound care plan showed interventions included treatment per physician orders, elevate heels as able, follow up care with physician as ordered, report evidence of infection to physician as needed. Resident had pressure ulcers on left dorsal foot. 105599 Page 13 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interventions included administering treatment per physician orders and pressure redistributing support surface. Resident had a pressure ulcer to left ischium care plan. Interventions include administer treatment per physician orders, daily body audit, dietary consult, incontinence management, pressure redistributing support surface, repositioning during ADLs, skin barrier. An interview on 05/01/23 at 12:04 p.m. with Staff H, Registered Nurse (RN) and Staff F, RN, both Unit Managers. They stated that Resident #2 had a pressure ulcer discovered on 02/21. On 03/01 they stated they changed the wound care order due to slough being present. Staff H and Staff F stated they used the wound care guidelines provided by corporate and then reported to the ARNP regarding the resident's wound, wound orders and change in wound care orders. The resident was on protein and wore boots. Staff F, RN stated that she was not a wound care nurse and documented it to the best of her ability. Staff F stated the coccyx wound did get worse and she did not increase the staging. They stated that they did know the pressure ulcers were getting worse and the family knew it was getting worse. That was why they got an order to see a wound care doctor at the wound care clinic (WCC). The resident needed to be seen by a wound care doctor. She was seen by the WCC due to the facility not having a wound care doctor in-house. They stated that they did not have a big enough census to have a wound care nurse according to corporate. Staff H stated that she had called the WCC about the Prism order. Staff H stated that she only called about the dressings, she did not go and look at the wounds. They stated that the dorsal wound was discovered on 03/22. The nurses should have described the dorsal wound between 03/22 and the wound care center visit of 03/27. It should have been documented in the notes. They confirmed that the left dorsal wound was described on 3/29 in the PUSH report. Staff F and Staff H stated that there was no communication found regarding the increase in size of the coccyx wound from 03/15 and 03/22 in the progress notes. When it was noted that the resident's PUSH number went up, and it was not getting better and getting worse, she was sent to the WCC. They based the treatment of the wounds on the protocols they were provided from corporate. Dakin's was not on the wound protocol; it was not an option for them to use on the resident. They both stated that they had no formal wound care training, just following the protocols. The resident was on an antibiotic. Interview on 05/03/23 at 12:36 p.m. with the Director of Nursing (DON) regarding wound care. She stated that upon admission they do two skin assessments. The Unit Managers (UM) are notified of any new wounds coming in. The UM goes in and measures the wounds. They are the only ones who do measurements, so the wounds will not be off. If the UMs feel the need to send the residents out to WCC they will get an order. If the resident was admitted with a stage 2 or above pressure ulcer, they will get an order to send out for evaluation. If the pressure ulcer was acquired in the facility and was not getting any better, they will send them out for wound evaluation. She stated that about a month ago they had a wound manufacturing company come in and give an in-service for about 2 hours. She stated that they did have a wound care nurse but removed her from the position. The UMs are monitoring the wounds, doing wound rounds, and measurements. She stated that they just hired a new wound nurse to replace the old one. The wound nurse will perform the wound care Monday through Friday and the floor nurses will on the weekends. If the wound gets worse, they are to let the UMs know and contact the MD and see the wound. They are to get an order for the WCC as needed. She stated that they do not have a wound care doctor here. The DON stated that the UMs nor the wound care nurse are certified. We have staging material that can describe it and the WCC will stage the wound. The nurse should have let the UM know about an increase in wound size. The DON verified there was no documentation that the nurses had let the UMs know there was an increase in wound size for Resident #2 between 03/15 and 03/22. There was a lack of documentation. There should have been documentation. Record review of the facility's, 105599 Page 14 of 15 105599 05/03/2023 Hillside Health and Rehabilitation Center 38220 Henry Dr Zephyrhills, FL 33540

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Skin Quick Reference, dated 02/2022 showed documenting skin: on admission / readmission -document history and risk. Second skin check within 24 hours of admission on the progress note. New pressure injury develops after admission document on incident report, Braden, PUSH took, Pressure ulcer UDs, progress note, treatment orders, eTAR, care plan. New skin alterations develop after admission document on incident report, skin alteration record, treatment orders, eTAR, care plan. Weekly wound Rounds document on PUSH tool, Pressure Ulcer Weekly Note, eTAR, care plan. Role of the Nurse: complete documentation requirements as above. Components of wound Evaluation: location, wound etiology, measurements, state, wound bed, wound edges/border, per-wound appearance, tunneling, undermining, exudate, signs/symptoms of infection, pain, odor, wound status, signs /symptoms of healing, response to treatment, goal of care. 105599 Page 15 of 15