Health inspection·May 14, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observations, staff interview and medical record review, the facility failed to maintain a dignified dining experience for one of thirty-four sampled residents (#20), during two of four days observed (5/11/2021, and 5/12/2021). Staff were observed not providing timely meal set up and eating assistance, stood up and behind the resident while assisting with eating, and stopped the meal feeding assistance several times to reposition a resident. Findings included: On 5/11/2021 at 11:58 a.m. the first floor dining room was observed for the lunch meal observation. There were six tables each table with a plastic see through partition to ensure resident social distancing while eating. There were seven residents in the room, seated in their wheelchairs or Broada reclining chairs and awaiting their meal service. At 12:01 p.m. staff brought in a tray cart and three employees began to serve and set up trays. At 12:02 p.m. a table was served with two residents. Resident #20, while seated in a reclining Broada chair was provided with her meal and placed in front of her and with the lid still on. A Staff member left the area to assist passing out the rest of the trays. At 12:03 p.m. staff served each resident and set up their meal for them. However, Resident #20 was still observed with her meal in front of her and with the lid on and also she was observed reclined back in her Broada chair. Two of the three employees left the room. One Certified Nursing Assistant (CNA), Employee A stood at the doorway and watched the room. Finally at 12:15 p.m. employee A walked up to Resident #20 and sat down next to her and removed the lid of the tray and assisted with feeding her. This happened after the resident sat with her meal in front of her with the lid on for thirteen minutes. The Aide, employee A took forkful of food and brought it up to Resident #20's mouth. Resident #20 accepted the bites of food that were brought to her mouth. At 12:18 p.m. employee A stood up, walked back behind the resident and repositioned her up, while seated in the Broada chair. The chair evidently reclined back very slowly, while she was assisting Resident #20 with her meal. At 12:21 p.m. the Aide employee A again stood up and walked back to the back of the Broada chair and had to reposition the chair that slowly reclined back. Resident #20 had to stop eating for a couple of minutes. Page 1 of 17 105603 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 12:24 p.m. the Aide employee A again had to stop assisting the resident with eating to get up and reposition the chair from a reclined position to a seated upright position. The Aide now had to stop assisting the resident with eating three times now and each time did not explain to Resident #20 what she was doing. The resident was visibly accepting bites of food when the Aide did assist. Employee A was asked about the reclined Broada chair that kept slowly falling back. She said that she normally assists Resident #20 with her meals and that the chair was not broken before. She asked another employee who passed by the dining room to get therapy. The Rehab Director, employee B came into the room and employee A told her the chair kept falling back very slowly. The Rehab Director, employee B proceeded to walk behind the resident and pulled the chair up abruptly and without warning the resident or telling her what she was doing. After being repositioned, employee A sat down again and assisted Resident #20 with her meal. On 5/12/2021 at 7:20 a.m. the first floor dining room was observed with six tables and with plastic see through partitions to separate residents and to promote social distancing. There were twelve residents seated at these six tables. There were three staff in the room to include two aides and one Registered Nurse. At 7:35 a.m. the meal cart was brought into the room. The staff started passing meal trays to residents in the room immediately. Employee A was observed to grab a tray from the cart and placed it on a table in front of a Resident #20. The tray lid was left on and employee A walked away to assist other residents with their meal set up. Fourteen minutes later at 7:49 a.m. employee A then came to Resident #20 and sat down and began to assist her with eating. Resident #20's table mate was observed already eating her meal at 7:36 a.m. Once employee A attempted to assist Resident #20 with eating, she accepted the bites of food that were brought to her mouth. Resident #20 is not able to be interviewed related to her care and services due to her impaired cognition. Interview with employee A was asked why she had left Resident #20 with her meal tray in front of her with the lid on for a long period of time. She revealed it's hard to have to serve and set up meals for others in the room and assist Resident #20 with her meal at the same time. Employee A was asked why she would serve the tray and leave it with the lid on. She said she had to do that because all residents at the same table had to be served the same time. However, she confirmed she had just left the tray with the lid on, while the table mate had already started eating. Employee A confirmed Resident #20 needed both cueing and eating assistance with her meals. On 5/14/2021 at 11:30 a.m. an interview with the Rehabilitation Director, employee B revealed that she was called by staff on 5/11/2021 during the lunch meal service because resident #20, while seated in her Broada chair, kept falling back slowly. She said it was brought to her attention that the Broada chair may have been slipping back. She confirmed she came in the room and she and employee A both tried to move the chair up and down and then used the brake handles and it seemed to be working fine after that. The Rehabilitation Director was asked if she and employee A notified the resident and let her know what they were doing prior to moving and repositioning her. She said that she did not remember but that they should always explain positioning procedures prior to doing it. She also confirmed that resident #20 was eating during the time they repositioned her. On 5/14/2021 at 1:00 p.m. an interview with the Director of Nursing revealed that it is a Standard of Practice for staff to serve and set up resident meals in rooms and dining room in a timely manner and that residents, to include Resident #20 were assisted with cueing and eating assistance during 105603 Page 2 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the same time as table mates. She confirmed that trays are not to be passed and placed on the table and left with the lid on for long periods of time. The Nursing Home Administrator was interviewed on 5/14/2021 at 2:30 p.m. She confirmed that residents while dining in the dining rooms are to be served and set up fully with their meals and are not to be left with the lid on and not assisted for long periods of time. She also confirmed that when staff are repositioning residents while seated in their chairs, staff are to talk with them and let them know what they are doing before they reposition. The Administrator also revealed that staff should not be stopping with eating assistance a number of times during the meal service. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE]. Review of the advance directives revealed she had a Power of Attorney (POA) in place. Review of the diagnosis sheet revealed a diagnosis to include but not limited to Dementia. Review of the record contained an Incapacity statement signed and dated 10/18/2019 by the Physician. Review of the most current Minimum Data Set (MDS) Quarterly assessment, dated 3/7/2021 revealed: (Cognition/Brief Interview Mental Status BIMS score 00-15, which indicated resident #20 was deemed not interviewable); (Activities of Daily Living ADL - Eating was Extensive assistance with one person assist). The Nursing Home Administrator provided the Resident Dignity & Personal Privacy policy and procedure dated with last revision on 4/4/2019 for review. The policy indicated, Policy: The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Under the Fundamental Information section, revealed: Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth. Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Under the Procedure section of the policy, #1 revealed: Care for residents in a manner that maintains dignity and individuality with inclusion of residents in conversation. 105603 Page 3 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

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 review of resident medical records, the Medical Examiner's (ME) report, and facility policies/procedures and interviews with the Staffing Agency Administrator, Nursing Home Administrator (NHA), the Director of Nursing (DON), Regional Nurse Consultant (RNC), nursing staff members, the facility Medical Director, and Resident #71's family member the facility failed to correctly report an allegation of neglect for one (Resident #71) of thirty-four sampled residents. Findings included: Review of an Immediate Federal Report, #104360, filed by the facility on [DATE] revealed the reporting person was the Administrator, regarding Resident #71, the alleged perpetrator was Staff U, CNA (Certified Nursing Assistant), the date and time of the incident was [DATE] at 3:21 p.m., type of incident was listed as Neglect, and the resident's representative, Law Enforcement and the Abuse Registry had all been notified. The Description of the Incident was Resident #71 was observed on the floor by CNA, the Facility's Immediate Response was Resident was sent out to the hospital for evaluation. Immediate investigation started. Review of a Five Day Federal report, #104360, revealed the reporting person was the Administrator, regarding Resident #71, the alleged perpetrator was Staff U, CNA (Certified Nursing Assistant), the date and time of the incident was [DATE] at 3:21 p.m., type of incident was listed as Neglect, and the resident's representative, Law Enforcement and the Abuse Registry had all been notified. The Description of the Incident was Resident #71 was observed on the floor by CNA, the Facility's Immediate Response was Resident was sent out to the hospital for evaluation. Immediate investigation started. The Investigative findings showed the facility reviewed the resident's record and the resident does not ambulate nor move independently in bed and has had no prior falls. Staff U, CNA's statement in the report showed she was providing care to Resident #71, and during the provision of care she needed to get additional supplies. The CNA left the resident on her side since the resident was continuing to have a BM. As the CNA came out of the bathroom she witnessed the resident moving, then observed her legs hanging off the left side of the bed, before she could reach the resident she rolled off the side of the bed to the floor. The CNA immediately got the nurse. The responding nurse confirms she observed Resident #71 on the floor next to the bed; she exhibited signs of discomfort when attempting to mover her lower extremities. The resident was kept comfortable on the floor until 911 arrived; MD notified and resident transferred to the hospital for further evaluation. Although the facility did not suspect abuse or neglect, it was determined after thorough investigation (including but not limited to interviews, observations and record reviews as indicated) that the allegation is not substantiated; there was no intent to cause harm. The facility also evaluated for crimes against the elderly and determined that no crime occurred. The facility indicated on the report Resident #71 was sent out for evaluation and would not be returning to the facility. The report did not indicate that Resident #71 had any fractures or that Resident #71 had died. A review of the discharge summary from the hospital dated [DATE] at 8:58 p.m. for Resident #71 revealed a hospital course note: [AGE] year-old with history of severe dementia (bedridden), atrial fibrillation (no anticoagulants), who was a trauma alert via ground Emergency Medical Services (EMS) on [DATE] after a fall from her bed at Assisted Living Facility. Patient was found to have bilateral femur fractures, pubic ramus fracture, lumbar compression fracture, and a type 2 odontoid fracture of indeterminate age. Orthopedics and Neurosurgery were consulted after trauma evaluation. However, 105603 Page 4 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patient was hemodynamically unstable with mean arterial pressure (MAP) <65 requiring Intravenous Fluids (IVF). Initially, plans were to take patient to operating room after medical optimization. Patient remained slightly hypotensive, and hemoglobin dropped from 10.7 to 8.6 within 3 hours of initial labs. 2 units packed red blood cells (PRBC) ordered. Discussion was had at length with the patient's daughter. Patient was made Do Not Resuscitate (DNR). After further discussion with the Doctor, the daughter expressed interest in hospice. Hospice consult placed and patient's daughter spoke with them regarding the transition of the patient from the hospital into hospice care. Patient discharged to hospice at this time. A review of the Medical Examiner Report dated [DATE] for Resident #71, case number 21-00408 revealed the following summary and opinion: The decedent was a [AGE] year-old woman who was in her usual state at her long-term care facility on February 20, 2021, when she had a fall from bed. At that time, she was noted to have deformities of her lower extremities and accompanying pain. She was taken to the hospital, where initial evaluation included x-rays that confirmed bilateral femoral fractures. She remained in her severely demented state and was admitted for further evaluation and care. Of note, her past medical history included osteopenia and osteoarthritis, hypertension, atrial fibrillation, and heart disease. She underwent additional evaluation including multiple computerized tomographic scans (CT scans) that also identified fractures of the right pubic ramus and symphysis. An additional sacral fracture was noted. Spinal compression fractures were also identified, however these were felt to be chronic. Finally, an additional fracture of the odontoid process (upper cervical fracture) was also noted; however, it was found to be age indeterminate, and it is not clear if that was a pre-existent injury, and whether or not it had any impact on her current status. No operative intervention was performed, and she was transferred to the hospice center shortly thereafter. She subsequently expired on February 22, roughly two days following the initial fall. While it is not clear whether or not the spinal and odontoid fractures were acute and contributory to her rapid decline and death, clearly the pelvic and femoral fractures played a prominent role in her clinical course. Additionally, her underlying comorbidities, especially the dementia and hypertensive cardiovascular disease that included atrial fibrillation, also played a significant role. Finally, her advanced age certainly impacted her ability to overcome these injuries. Accordingly, it is my opinion that, based on all of the above information, gleaned from review of medical records and other investigative sources, that the cause of death is sequelae of blunt impact injuries including femoral and pelvic fractures. Contributory causes include dementia, hypertensive cardiovascular disease, and advance age. Because the events were set in motion by an apparent accidental fall, the manner of death is best certified as accident. A review of the facility medical record for Resident #71 revealed an admission date of [DATE] and diagnoses including dementia, adult failure to thrive, atrial fibrillation, hypertension, pseudobulbar affect, gastrostomy tube, lack of coordination, dysphagia, cognitive communication deficit and generalized muscle weakness. A review of the physician order summary indicated Resident #71 was to be provided full resuscitation efforts in the event of a code situation. A review of the Quarterly Minimum Data Set (MDS) assessment completed on [DATE] revealed in section C, the Brief Interview of Mental Status (BIMS) was unable to be conducted due to the resident being rarely/never understood. Section G, functional status, revealed Resident #71 was totally dependent on two persons physical assist for bed mobility and transfers. Section H, bladder, and bowel revealed Resident #71 was always incontinent of bowel and bladder. Section J, health conditions, revealed 105603 Page 5 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #71 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months, nor had any falls since admission/entry or reentry prior to the assessment. A review of the nursing progress notes revealed a note dated [DATE] at 6:04 p.m. written by Staff T, Licensed Practical Nurse (LPN) as follows: Called to room [ROOM NUMBER] by CNA related to resident fall. Found resident flat on her back beside her bed, her head was against two feet of the intravenous pole. Pole was moved, pillow placed under resident's head and resident assessed for injury. Her eyes were open; however, she was not tracking my voice. She was nonverbal. Vital signs taken, 160/80-100-18-97.7. Was able to range upper extremities without eliciting pain. However, resident grabbed both right and left legs, and moaned when I attempted to touch lower extremities. Did not range lower extremities due to this reason. Left lower extremity appeared externally rotated. Resident covered with blanket and left on the floor, with CNA. Call placed to Doctor, call placed to 911 operator, call placed to daughter, and daughter was updated. Emergency Medical Technicians (EMT's) to facility by 3:05 p.m. and resident out via 911 at 3:15 p.m. Second call placed to daughter to update her regarding being sent to the hospital. Doctor returned call and updated regarding resident status. On [DATE] at 1:24 p.m. an interview was conducted with the Staffing Agency Administrator for whom Staff U, Agency Certified Nursing Assistant (CNA) was employed. The Administrator stated she had taken a statement from Staff U, CNA after the incident on [DATE] at the facility. She stated Staff U was placed on a leave from working until an investigation from the facility was completed. The Administrator stated the facility NHA called her on [DATE] to tell her the incident had been unsubstantiated, however, the facility did not want Staff U, CNA to return to the facility for work again. She indicated she was not aware of any other agencies that investigated the incident or their findings. She stated the employee was back on the schedule and working. On [DATE] at 3:47 p.m. a telephone interview was conducted with Staff U, agency CNA. Staff U stated she thought all the investigations were already done because she was told by the agency she works for, everything was cleared. Staff U stated on the day of the incident she went to go and clean up Resident #71 and the resident continued to have more bowel movement. She stated she left the resident lying on her left side in the bed facing the window and the resident fell out of the bed. She stated the resident's bed was next to the door. Staff U stated she took about 10 steps to the bathroom to get more supplies. She stated when she turned around the resident's legs were hanging over the side of the bed and the legs brought the resident down and she fell to the floor. Staff U stated the resident landed on her hip and was curled up on her side. She stated she called for help and people came into the room. She did not recall who came into the room. She indicated Staff T, LPN came into the room to assess the resident. She stated 911 was called and they took the resident to the hospital. She stated she had been a certified nursing assistant for two years and had been working in the facility as an agency staff member for the previous two months. She stated she was working doubles for them to help with staffing. She stated it was the first time she had a fall with a resident. Staff U revealed she had no orientation to the facility when she first started working there. She stated she was just learning by dealing with the resident because you do not get any real report. She stated the facility had a lot of agency staff so there was no one who really knew the residents. She stated she was really upset because she was helping the facility by working a lot and she believed they were trying to throw her under the bus. She stated she had not worked at the facility since the time of the incident. She became emotional on the phone and stated she found out later on what happened to the resident. On [DATE] at 4:11 p.m. a telephone interview was conducted with Staff T, LPN. Staff T, LPN stated she was the nurse on duty at the time of the fall for Resident #71. She stated she remembered she had 105603 Page 6 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few just finished up a medication administration and she was restocking her medication cart. She remembered the incident occurred toward the end of the day shift. Staff T, LPN stated Staff U, CNA came running up to her and asked her to come quick because a resident had fallen. Staff T stated she asked Staff U who had fallen? Staff U explained Resident #71 had fallen and Staff T, LPN stated she was in shock because Resident #71 was immobile, and she could not understand how the resident would fall. Staff T, LPN stated Resident #71 was not able to move herself around in a bed at all. Staff T stated she knew the resident well and had been working with Resident #71 for about 8 months. Staff T stated Resident #71 was and had always been an assist of two and one person should never have been performing incontinence care. She stated Staff U, CNA told her she had just left the resident to go into the bathroom to find some rags. Staff T, LPN stated later Staff U tried to say the resident jumped out to the bed but that was not what she had stated to her. Staff T stated she went to the room and found the bed at hip level and the patient on the floor on her back between the two beds. Staff T stated the resident's head was on the foot of the IV pole. She stated she moved the pole and put a pillow under her head. She stated she knew the resident was hurt badly. Staff T stated the resident was in pain and did not want her to touch her at all. Staff T stated she knew both of the resident's legs were in bad shape because they appeared rotated. She stated she put a blanket on the resident and asked other staff members to go get her blood pressure cuff. Staff T stated she had the aides stay with the resident and she called 911 and got all paperwork ready. Staff T, LPN stated she told Staff U, CNA to stick around so she could get her statement down about the incident but when she looked for her, after the resident had been taken to the hospital, Staff U had already left the building. Staff T, LPN stated they tried to contact Staff U but could not. She stated Staff U had left a statement saying the resident jumped out of the bed but that was not true. Staff T, LPN was emotional on the phone and crying during the interview. She stated the incident with Resident #71 was the reason she decided to leave the facility. She just did not feel like residents were safe there. Staff T, LPN stated she found out from other staff members that Resident #71 was taken into hospice care because her family was told she could not survive the surgery. She later found out the resident died. Staff T, LPN stated she wrote a statement about everything she was telling the surveyor. Staff T, LPN stated she believed Staff U, CNA absolutely knew she had done something she should not have done. She stated she felt at the very least the aide should have rolled the resident to her back and lowered the bed before she walked away from the resident. Staff T, LPN stated the procedures are nursing 101 for resident safety. On [DATE] at 9:52 a.m. an interview was conducted with Staff Y, CNA. Staff Y stated she knew Resident #71 very well. She stated she was present on the day of [DATE] when the resident fell. She stated she ran into the room and she saw Resident #71 on her back on the floor between the two beds in the room. Staff Y stated when she entered the room the bed was in the highest position. She stated Staff U, CNA told her she was providing care to the resident and she had her rolled on her left side away from her facing the other bed. She stated Staff U told her she was trying to change her and while she was doing that the resident across the hall and the roommate were both yelling at her to help them. She stated Staff U told her the roommate needed her to turn down the air in the room because her arm was cold and insisted, she do it right away. She stated Staff U told her she left Resident #71 turned on the left side with the bed in the current position and went to turn down the air in the room when the resident fell off the bed. Staff Y, CNA stated the resident was not able to move on her own but if you left her on the side and her legs flopped over the bed that would be all it took for her to fall. She stated she did not understand why you would roll the resident away from you in the first place. She stated you always roll them toward you for safety. She 105603 Page 7 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Staff U said the resident hit the floor the moment she left her. Staff Y stated Resident #71 never moved, so if the resident had been placed on her back and the bed lowered, she would not have been able to roll off the bed. Staff Y, CNA indicated she had given the exact statement to the Administrator at the time of the incident. Staff Y stated Staff U was so upset after the incident she left the building before anyone could take her statement and they needed to call her back to get it from her. Staff Y stated at the time of the incident Resident #71 was in a lot of pain. She stated although she could not verbalize it when she looked at her on the floor, she could see her eyes wide open, and you could tell she was in pain. On [DATE] at 10:39 a.m. an interview was conducted with Resident #56. A review of the MDS assessment dated [DATE] for Resident #56 revealed a BIMS score of 15, indicating intact cognition. The resident indicated she was the roommate of Resident #71 at the time of the incident on [DATE]. Resident #56 stated the incident was burned into the brain. Resident #56 stated she pushed the call light to be changed and Staff U, CNA came in to answer the light. She stated Staff U told her she was going to take care of Resident #71 first and Resident #56 agreed. Resident #56 stated she used to be a certified nursing assistant herself. Resident #56 explained Staff U, CNA was taking care of resident #71 and she went into the bathroom. She stated Staff U was standing in the bathroom and she heard a loud noise. She stated things were flying all over the room. She stated she looked over and the curtain was closed but she could see Resident #71 lying on the floor. Resident #56 stated Staff U came out of the bathroom screaming NO! Resident #56 stated she told her it was too late, and Resident #71 was going to die now. She stated Staff Y, CNA came into the room and said, her leg is broken. Resident #56 stated she told Staff Y that Staff U had done it. Resident #56 was adamant that Staff U, CNA was 100% at fault. She stated Resident #71 was always very quiet and was not necessarily able to speak loudly for herself. She stated What I saw and heard is permanently stained in my brain. My story has never changed. On [DATE] at 9:31 a.m. a telephone interview was conducted with Resident #71's daughter. She indicated she was the Power of Attorney (POA) for Resident #71. The daughter stated just a few days before the fall she was speaking with all of the therapy staff about her mother. She stated the therapy staff had indicated her mother was looking better and they were seeing improvement. She stated she had hopes that maybe she could visit and take her mother outside in a wheelchair or on an outing. The daughter was emotional on the phone and stated she understood her mother was ill and was [AGE] years old, but the conversation she had with therapy really gave her some hope. She stated on [DATE] she received a phone call from the nurse on duty who told her that her mother fell out of the bed and the girl who was cleaning her up had left her to go get something and when she turned back around her mother had fallen on the floor. She indicated 911 was called and the facility sent her mother to the hospital. She stated she was told that her mother had both femurs broken and due to her condition, the doctors were debating putting her on a respirator and possibly needed to do surgery right away. The daughter stated she was told by the doctors that due to the seriousness of the injuries they were not sure her mother would survive the surgery. The daughter stated she was then told her mother also had a break in her neck. The daughter stated after consultation with the medical team, she decided to place her mother in hospice care rather than take the risk of surgery and put her mother through all the pain and suffering. She stated her mother was transferred to the Hospice House and passed away the next day. The daughter indicated an autopsy had been completed for Resident #71. She stated the ME indicated her mother died as a result of the injuries she sustained during the fall. Again, the daughter reiterated how hopeful she was after speaking with the therapist just days before the fall. She stated she was so upset over all this and felt as though she had been robbed of more time with her mother. She asked, Why would 105603 Page 8 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few anyone walk away and leave my mother unattended when she was in the condition she was in? She stated she hoped no other family ever has to go through this type of loss because it was not necessary. On [DATE] at 4:40 p.m. an interview was conducted with the Medical Director for the facility. Multiple attempts had been made to reach the Primary Care Physician with no success. The Medical Director stated he did not treat the resident, but he had been a part of discussions at the time of the resident's fall with the previous NHA. He stated they sat down and talked about the need to educate the staff on the care that lead to the incident. He stated the staff needed to be educated to avoid these types of falls and they came up with an education and training plan. He stated his recall was that this was an Agency staff member, and he would expect them to send the facility more qualified staff. He stated he did notify the Primary Care Physician right away to let him know the circumstances. He stated he believed this is unfortunate for any resident to have injuries. The Medical Director stated they have a very fragile population that is living longer and longer, and expectations are getting higher. He stated we are in a national crisis with nursing. He stated there needs to be training of staff and leadership that has hands on training with all aides and nurses. He believes training needs to be continuous and staff need to check in on residents more often to provide safety. When asked what he thought could be done differently in the facility he stated he thought management had to have accountability to the entire staff and beef up the middle management in the facility. He stated maybe they should have a 24-hour Assistant Director of Nursing to roam the facility and keep an eye on what the staff is doing. He stated the facility needed to get people in to generate good help. On [DATE] at 2:46 p.m. an interview was conducted with the NHA, DON, and RNC to review the investigation involving the incident on [DATE] with Resident #71. The NHA stated the investigation was done by the previous Administrator. She stated all agencies were notified as required and the local police department was contacted. The reason for the report was listed as neglect. The DON at the time was also involved in the investigation. The NHA indicated a review of the [NAME], care plan, and medical record for Resident #71 was completed. She stated the care plan and the [NAME] both indicated total assist but did not list by how many staff members. The report indicated the staff had followed the plan of care and the incident was not substantiated. The NHA stated they completed staff interviews with Staff U, agency CNA and Staff T, LPN who were involved in the incident. She indicated interviews with Staff Y, CNA, who responded to assist, and Resident #71's roommate were also conducted. She stated the interviews revealed Staff U, CNA was providing incontinence care at the bedside and the resident had an additional bowel movement, so Staff U, CNA determined she needed additional supplies. The NHA stated Staff U positioned the resident in the middle of the bed but kept her on the left side. The NHA stated when Staff U came out of the bathroom the resident had her legs off the bed and the resident fell to the ground before the aide could get to the resident. The NHA stated according to the report Staff Y, CNA arrived after hearing a call for help and stayed with Resident #71 while Staff U ran to get the nurse. The NHA stated Staff T, LPN came to the room and assessed the resident and immediately contacted the physician. The nurse called 911 and Resident #71 was sent to the hospital. The NHA stated they had no contact with the hospital and did not have any hospital records to review at the time of the investigation that she could determine from looking at the reports. A review of the facility policy entitled Abuse and Neglect Prohibition with a revised date of [DATE] indicated the following: Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Fundamental Information: Definitions 105603 Page 9 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Identification: 2 The facility Quality Assessment and Assurance Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect, or misappropriation of resident property to determine the direction of the investigation/interventions, through analysis of systems, audits, and reports. Investigation: 1 The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state and federal law. 3 The facility will report reportable investigation findings 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 will be taken. Protection: 2 The facility will make referrals to the appropriate state agencies as necessary, to ensure the protection for the resident or resident's property. Reporting and Response: 1 The facility will report all allegations and substantiated occurrences of abuse, neglect, and misappropriation of property to the state/federal agency and law enforcement officials as designated by state/federal law. 2 The facility will report to the corporate office in accordance with reporting procedures via risk guide. 3 The facility will report any occurrences of abuse by registered or certified staff or the State Board as required by state law. 4 Policies and facility procedures will be analyzed and modified as necessary by the Quality Assurance Committee so as to meet the full intent of the law. A review of the facility job description for Administrator with a revised date of [DATE] indicated the following: Summary: The incumbent is responsible for the overall management of the facility. Plans, develops, directs, monitors, and supports all operational, administrative, clinical, human resources, customer service, and fiscal activities for the facility's programs and services. Essential duties and responsibilities Serves as the Risk Manager of the center 105603 Page 10 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0609 Level of Harm - Minimal harm or potential for actual harm Ensures the quality and appropriateness of resident/patient care meets or exceeds company and regulatory standards. Makes sure facility is a safe, clean, comfortable, and appealing environment for residents, patients, visitors, and staff in accordance with company guidelines. Residents Affected - Few Ensures all required records are maintained and submitted, as appropriate, in an accurate and timely manner. Completes required forms and documents in accordance with company policy and state and/or federal regulations. Manages all aspects of state or federal government survey processes. 105603 Page 11 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review and staff interviews, the facility failed to ensure upon resident discharge from the facility, staff provided complete discharge notices to three of thirty-four sampled residents (#72, #121, and #33) and failed to send notice of discharge to the Ombudsman's office. Findings included: 1. On [DATE] review of resident #72's closed medical record revealed he had originally been admitted to the facility on [DATE]. Review of the progress notes dated [DATE] revealed Resident #72 was admitted with a fracture and for aftercare. Review of the Hospital discharge summary (Form 3008), dated [DATE] revealed resident was alert and oriented x 3. Review of the advance directives revealed resident #72 was his own responsible party and decision maker. Review of progress notes dated [DATE] revealed Resident #72 was discharged and sent to the Hospital. Review of a progress note dated [DATE] 17:00 (5:00 p.m.) Late entry revealed, Nurse observed the resident leaning against the bathroom wall on his right side. The nurse and the CNA lowered the resident to the floor to begin CPR (Cardio pulmonary Resuscitation), and 911 was called staff members continued CPR until EMS (Emergency Medical Services) and firefighters took over CPR. EMS was able to obtain a pulse on the resident and the resident was transferred to Hospital with EMS. Resident was last seen alert and oriented x 3 with no complaints by staff around 16:30. Further review of the closed medical record and electronic record revealed Resident #72 did not return from hospital. On [DATE] the Social Services Director provided the Discharge Notice for review. The form Agency For Health Care Administration Nursing Home Transfer and Discharge Notice indicated the following information: Name of Resident #72, Name of Resident #72's family member and address, Date of Notice given - [DATE], Date Effective - [DATE], Reason for Discharge - Your needs could not be met in the facility, Explanation - Change of Condition. The second page of the Discharge notice was blank, there was no indication of who the notice was presented by, received by, given to and there was no indication that the Discharge Notice was sent to the Local Long Term Care Ombudsman Council. 2. Review of Resident #121's closed medical record revealed she was readmitted to the facility on [DATE] and discharged on [DATE] with no return to the facility. Review of the advance directives revealed the resident had a Health Care Proxy in place. Review of the nurse progress notes dated [DATE] 20:00 revealed, Resident has abnormal arterial Doppler related lower extremities. Notified Physician and stated to send to the emergency room for observation. Notified Power of Attorney. Interview on [DATE] at 9:50 a.m. with the Social Service Director revealed he did not have any evidence of the Discharge Notice related to the resident's discharge to the hospital on [DATE]. He further confirmed that he has no evidence that the Local Long Term Ombudsman Council was notified of the discharge either. He further confirmed the discharge was not planned and the resident did not return to the facility. Resident #121 could not be interviewed related to her discharge from the facility. 105603 Page 12 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0623 Form 3120-0002 (Discharge Notice) revealed the following: Level of Harm - Minimal harm or potential for actual harm Date Notice was given: [DATE] Residents Affected - Few Effective Date: [DATE] Resident transferring from Nursing Facility to Hospital Reason for Discharge or Transfer: Your needs cannot be met at this facility. Explanation: Resident sent out to the hospital for pain in hip. The date as to when the Discharge Notice was given to the Local Long Term Care Ombudsman Council was not completed party. (photographic evidence obtained) During an interview conducted on [DATE] at 9:25 am, the Social Services Director confirmed that Resident Service Director stated, I found out that the fax number to the Ombudsman was incorrect, so now we are sending it to the correct number. On [DATE] at 9:25 a.m. an interview was conducted with the Social Service Director (SSD), employed at the facility since 10/2021, who provided evidence and documentation on how he provides residents and or representatives with Discharge Notices. He revealed that the notices are filled out by himself and then given to either the resident upon leaving the facility or will send them to the resident or representatives address of record. The SSD confirmed that the second page of the discharge notice was not signed by either the nursing home administrator or the physician or his/her designee for residents #72 and #70. He provided other examples that showed the Administrator/Designee, the Physician/Designee never signed the notice, nor was there evidence to show the Ombudsman office was sent the notice. The SSD revealed he believed that once the notice is sent to the representative or resident, they sign and send the notice back to the facility, he would then have the Administrator and Physician sign and then send the completed document to the local Ombudsman and for facility records. Interview on [DATE] at 3:00 p.m. with the Nursing Home Administrator, employee S verified that all discharge notices need to be completely filled out and with Administrator/Designee and Physician/Designee signature prior to giving and or sending out to the resident and or his/her representative. She confirmed that practice that the notices are sent to the resident and representative to sign and then send back to have the Administrator and Physician sign, was not correct. The Nursing Home Administrator, employee S then provided the Transfer & Discharge policy and procedure for review. The policy was last revised on [DATE]. Review of the policy under Purpose, revealed: The transfer and discharge process is designated to provide a safe and orderly transfer or 105603 Page 13 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0623 discharge from the facility. Level of Harm - Minimal harm or potential for actual harm The Discharge planning process revealed: The facility will develop and implement discharge planning process that focuses on the resident's discharge goals and preparing residents to be active partners in post-discharge care, effective transition of the resident from SNF to post-SNF care, and the reduction of factors leading to preventable readmissions. Residents Affected - Few The Discharge section of the policy revealed: Moving the resident to a non-institutional setting such as home, or discharge without expectations of return. The Discharge section, #1 revealed: The interdisciplinary team will involve the resident and resident representative in the development of the discharge plan and communicate to the resident and resident representative of the final plan encompassing the residents goals to the extent possible. Under the Unplanned Hospital Transfer section, #4, revealed: The facility will complete the Resident Transfer Form and provide a copy of the form for transfer and retain a copy of the transfer form for the clinical record. #5 revealed: Notify the family or responsible party of the pending transfer, and the reasons for the move. #7 revealed: Write discharge note to include: ( c ) Name of provider who provided orders/and or was notified of transfer, (d) Name of resident representative who was notified of the transfer. 105603 Page 14 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review the facility did not ensure appropriate labeling of three opened insulin pens of seven insulin pens in one medication cart (medication cart #1) of four medication carts on one of four nursing units (unit one). Findings included: On [DATE] at 12:45 PM an observation was conducted on unit one during the medication storage inspection of medication cart one with Staff F, LPN (licensed practical nurse). There were two insulin aspart pens and one Novolog insulin pen that were opened and did not have open dates labeled on them. Each pen had a bright orange sticker marked with open date: indicating they should be labeled with an open date. Staff F, LPN confirmed they had not been labeled with an open date, Staff F, LPN said the regional nurse had just been in checking the medication cart. The label on the Novolog pen indicated it had to be discarded twenty-eight days after opening. The insulin aspart labels indicated they needed to be discarded twenty-eight days after opening. On [DATE] at 2:22 PM an interview was conducted with the DON (director of nursing). The DON said the insulin has to be labeled with the open date because they expire in a certain time frame after the open date, depending on the insulin type. On [DATE] at 4:20 PM a telephone interview was conducted with the consultant pharmacist. She said she likes the open date to be labeled on the package or vial. Without an open date we assume the insulin is expired. The only date on it would be the date dispensed. When it is taken out the refrigerator it should be dated. They expire within so many days after opening. The consultant pharmacist said she checked the medication carts last month. Review of the policy, Drug Labeling, dated [DATE], reflected the following findings: Purpose All drugs and biologicals must be properly labeled and legible at all times. Procedure 1. Individual prescription drug container labels must contain: (bullet 5) appropriate cautionary and/or accessory labels 9. Notify pharmacy of medications not properly labeled and remove from stock. 105603 Page 15 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, and policy review the facility did not ensure food was served in a form the residents could tolerate and according their therapeutic diet orders for one (#60) of three residents receiving pureed diets without orders for mechanical soft snacks. Findings included: Resident #60 was admitted to the facility with a diagnosis of dysphagia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] reflected that a brief interview for mental status (BIMS) could not be completed because Resident #60 is rarely/never understood, indicating severe cognitive impairment. Review of Section K, swallowing/nutritional status, reflected that Resident #60 was on a mechanically altered diet. Review of the physician ' s orders in the medical record reflected a diet order dated 7/30/20 Regular diet, Pureed texture. Review of the CNA (certified nursing assistant) care instructions in the medical record reflected Diet as ordered Puree diet, current as of 5/13/21. Review of the dietary slip for Resident #60 reflected a regular puree diet. A review of the care plan revised on 8/2/20, revealed Resident #60 is at risk for decreased nutritional status and dehydration r/t (related to) enterocolitis d/t (due to) AFTT (adult failure to thrive), Afib, intracerebral hemorrhage, Alzheimer ' s disease, dementia, hypertension, gastrostomy status, osteoarthritis (OA), history of cancer, MDD (major depressive disorder), GERD (gastroesophageal reflux disorder), aphasia, anxiety, dependent on enteral feeds as sole source of nutrition support, advanced age, poor po (by mouth) intake, abnormal labs at admission. Interventions included diet as ordered Puree diet. A review of the speech therapy SLP (speech language pathology) evaluation and plan of treatment, dated 2/11/21 reflected a diagnosis of dysphagia, oropharyngeal phase. The clinical bedside assessment of swallowing reflected solids/foods assessed =pureed foods. On 5/13/21 at 12:52 PM an observation was conducted in the dining room on the first floor. Resident #60 was sitting in her wheel chair at a table with a lunch tray in front of her. The meal slip on the tray indicated Resident #60 was on a pureed diet. The lunch meal on her tray was pureed, however, there was a cookie on the tray also. The cookie was not mechanically altered in any way. The plate was covered with a napkin and her silverware indicating Resident #60 was finished eating. The cookie was visible from beneath the napkin on top of the dinner plate of the half eaten pureed meal. On 5/13/21 at 12:54 PM an interview was conducted with Staff G, RN (registered nurse). Staff G, RN said she was from another facility and was here helping out today. Staff G, RN said she doesn't know Resident #60, but a pureed diet does not get a cookie. They would get an alternate like a pudding. 105603 Page 16 of 17 105603 05/14/2021 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0805 Level of Harm - Minimal harm or potential for actual harm On 5/13/21 at 1:09 PM an interview was conducted with the CDM (certified dietary manager). He said he is present during the tray line service if the staff are behind. He was not present during the tray line today. Residents on pureed diets would receive a pureed cookie or pudding. He was asked if they pureed any cookies today and he said he didn't think so. The dessert was a sugar cookie. The dietary aid would puree the cookie in a blender with a little bit of milk. The CDM said usually two dietary aides will check the trays. Residents Affected - Few On 5/13/21 at 1:13 PM an interview was conducted with Staff K, dietary aid and Staff L, dietary aid. Staff K, dietary aid said she was on the tray line with Staff L, dietary aid today. Staff K said residents on pureed diets can have a magic cup, ice cream or pureed dessert. They don ' t get a cookie. Anyone on puree got ice cream or a magic cup. Staff L, dietary aid, is the double checker at the end. Staff K and Staff L both said they did not recall putting cookies on pureed trays. Staff L, dietary aide said she put either ice cream or magic cups on them. The CDM who was present during the interview, said the reason residents on pureed diets can't have a cookie is because they could choke. On 5/13/21 at 4:09 PM an interview was conducted with Staff P, CNA (certified nurse's assistant) who said she looks at the ticket to see if it's pureed, mechanical soft, or there any allergies. Sometimes the kitchen makes mistakes so you have to look at the ticket and make sure its right. On 5/13/21 at 4:40 PM an interview was conducted with Staff O, CNA. Staff O, CNA said you look on the meal ticket for the diet orders, consistency and allergies. If you see they served the wrong texture you would take the slip to dietary with the tray and get the proper texture. You would not serve the wrong consistency, you could choke them. On 5/14/21 at 8:59 AM in an interview with the NHA (nursing home administrator) she confirmed that Resident #60 does not get pleasure foods. On 5/14/21 at 12:29 PM an interview was conducted with the DON who confirmed resident #60 should not have been given a cookie. A review of the policy, Diet Formulary, revised 2/21/17, revealed the following: Purpose The facility provides each resident with a regular and therapeutic diet, as ordered by the physician. Procedure 4. The diet formulary available in the facility includes: c. Therapeutic diets-defined as any deviation form the regular diet. d. Mechanically altered diets-a mechanically altered diet is any diet with texture alterations. ii. Pureed is a dysphagia pureed level 1. All foods should be pureed to a pudding like consistency, including breads and bakery products. 105603 Page 17 of 17