Health inspection·January 26, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to reasonably accommodate the needs for one resident (#5) related to not placing the call light within the resident's reach of six residents sampled for environmental concerns. Residents Affected - Few Findings included: On 01/23/23 at 9:32 a.m. Resident #5 was heard calling from her room stating, Can you help me? Put this call light where I can reach it. Resident #5 was observed sitting in her wheelchair facing towards the foot of her bed. The call light was observed clipped to the head of the bed out of her reach. Staff K, Certified Nursing Assistant (CNA) came into Resident #5's room and moved the call light from the head of the bed to the foot of her bed and within her reach. Review of Resident #5's admission Record revealed she was re-admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included but were not limited to hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left non-dominant side, polyneuropathy, contracture, left wrist, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, lack of coordination, and pain. Review of Resident #5's Minimum Data Set (MDS) Section C, Cognitive Patterns, dated 12/30/2022, revealed a Brief Interview for Mental Status (BIMS) score of 13 out 15, indicating the resident was cognitively intact. An additional observation was conducted on 01/24/23 at 10:12 a.m. of Resident #5 sitting next to her bed in a wheelchair facing towards the foot of the bed. The call light was observed clipped by the pillow at the head of the bed. The resident stated, Can you hand me my call bell? I can't reach it. Then at 10:14 a.m. Staff J, Licensed Practical Nurse (LPN) came into the room and clipped the resident's call light onto the bed next to the resident and asked the resident if she could reach it. The resident demonstrated she could reach the call light and thanked the nurse. An interview was conducted on 01/26/23 at 12:48 p.m. with the Director of Nursing (DON) who indicated Resident #5 was able to use her call light. She also stated the resident was able to self-propel around her room. Another interview with the DON was conducted on 1/26/23 at 01:36 p.m. and she stated the facility does not have a policy related to call lights. Page 1 of 18 105603 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, the facility failed to ensure a care planned intervention related to having the bed positioned in the lowest position was implemented for one resident (#3) of forty-two sampled residents for three days (1/23/2023, 1/24/2023, and 1/26/2023) of four days observed. Findings included: On 1/23/2023 during a tour of the facility at approximately 10:45 a.m., Resident #3 was observed in her room lying in bed. Resident #3 was lying on a specialized mattress with raised bolsters to assist with fall prevention. The bed was elevated approximately three feet above its lowest position. The bed adjustment remote was placed on the foot of the bed and no staff were present in or around the resident's room. On 1/23/2023 at 2:00 p.m. Resident #3 was again observed in her room with the bed elevated approximately three feet from the lowest position with the remote at the foot of the bed. An attempt to interview the resident about her bed positioning indicated she was not able to answer questions related to her care and service. When asked about the bed remote on her bed she said, I don't know what that is. She was asked if she can move the bed on her own with the remote and she replied, I might be able to. On 1/24/2023 at 9:11 a.m. Resident #3 was observed in her room in bed. The bed was observed in a medium/high position with the top of the mattress elevated approximately three feet up from the floor. The bed remote was within her reach. On 1/25/2023 at 7:08 a.m. Staff B, Certified Nursing Assistant (CNA) was observed by Resident #3's room. He was interviewed about Resident #3's bed positioning, and Staff B replied, She (Resident #3) usually hangs her feet and leg off the side of the bed and she has not had any recent falls, I believe. Staff C, CNA stopped by the area and was interviewed along with Staff B. Staff B confirmed Resident #3 was on his assignment today and has had her many times before. Staff B and C did not know how the bed should be positioned for Resident #3 and indicated Resident #3 can adjust her bed on her own and they keep the remote for the bed within her reach. They were asked if Resident #3 was at risk for falls and they both indicated they believed that she was. On 1/26/2023 at 7:30 a.m. Resident #3 was observed in her room resting comfortable with the bed elevated and the top of the mattress was approximately three feet up off the floor. On 1/26/2023 at 8:12 a.m. Resident #3 was observed from the hall through the open door of her room using the bed remote to move the bed up and down several times. Resident #3 stopped the bed in a mid-high position where the top of the mattress was approximately three feet up off the floor. Both of the resident's feet were hanging off the left side of the bed mattress. Review of Resident #3's admission Record revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, hemiplegia, and contracture to the left hand. Review of the Minimum Data Set (MDS) Annual Assessment, dated 11/14/2022, revealed the following: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 3 out of 15, 105603 Page 2 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicating severe cognitive impairment. Section G - Functional Status indicated the resident required extensive assistance with Activities of Daily Living (ADLs) to include bed mobility. Review of the current care plans with the next review date of 2/1/2023 included the following areas: - Falls related to impaired mobility (High Risk) an identified interventions to include but not limited to: Bed in low position while in bed. - Has alteration in neurological status related to CVA (Cerebrovascular Accident) with left sided hemiparesis with interventions in place. - Has impaired cognitive function/impaired thought process r/t dementia an identified interventions to include cue, reorient and supervise as needed. The current care plans were silent related to Resident #3 utilizing the bed remote. On 1/26/2023 at 8:55 a.m. an interview with the second floor unit nurse Staff D Licensed Practical Nurse (LPN), who was assigned to Resident #3 during the 7-3 shift on 1/24/2023, 1/25/2023, and 1/26/2023, and confirmed she knows the resident well. Staff D stated Resident #3 was a fall risk and her bed should be in the lowest position. Staff D was unable to confirm if the resident should have the bed remote to self-adjust her bed position. Staff D confirmed Resident #3 was lying in bed and it was not in its lowest position and that she should be in bed with the bed in a lower position. Staff D stated she would check the orders and care plan and that she did not know if the floor CNAs were aware Resident #3 was care planned to be in a low bed position when in bed. On 1/26/2023 at 9:15 a.m. an interview with the second floor Unit Manager Staff A, Registered Nurse (RN) stated she knows Resident #3 and her care expectations. She was not sure if Resident #3 should be in a low bed when in bed but would check the orders. Staff A reviewed the medical record and confirmed that when in bed, Resident #3 should always have the bed in the lowest position. She did not have any documentation to support implementation of this care planned intervention, nor did she know if her floor staff were knowledgeable to follow this care planned intervention. Staff A confirmed Resident #3 has not had a recent fall but she was at risk for falls. Staff A was also not aware Resident #3 was moving the bed from low to high and high to low positions by using the bed remote herself. She confirmed residents at risk for falls should have the bed in a low position. If the resident has cognitive deficits, the bed remote control should not be available to them. Review of the policy titled, Comprehensive Person-Centered Care Plans, effective date 10/24/2022, revealed: The center will develop a comprehensive person-centered care plan for each resident that is individualized and includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Comprehensive care plan will be consistent with resident goals and right to be informed and participate in his/her treatment. 105603 Page 3 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0656 Additionally, under the Fundamental Information Section the policy documented: Level of Harm - Minimal harm or potential for actual harm A comprehensive care plan will be: Residents Affected - Few iii. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as changes in the resident's care and treatment occur. Any member of the interdisciplinary team may enter the updates to the comprehensive care plan under the guidance of a registered nurse who is responsible for the resident. The comprehensive plan of care should include the following: - Reflect current standards of professional practice .; - Be periodically reviewed and revised by the interdisciplinary team as change in the resident's care and treatment occur. Additionally, under the Procedure section the policy documented: - .Communicate care plan changes on an ongoing basis to all members of the interdisciplinary team. - Re-evaluate and modify care plans: As needed to reflect changes in care, service and treatment. 105603 Page 4 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to ensure care plans were revised to reflect the current care status for two residents (#66 and #3) of forty-two sampled residents, related to Activities of Daily Living (ADLs) for eating assistance (#66), and impaired mobility and contracture management (#3). Findings included: 1. On 1/23/2023 at 12:30 p.m. Resident #66 was observed in her room and lying on her side on top of the bed eating her lunch meal. Her lunch meal tray was on the bedside table which was positioned slightly above head level and she was observed feeding herself with no problems. She appeared slow to eat but comfortable and able to feed herself. No staff were present in the room from 12:30 p.m. to 1:08 p.m. when a staff member came to remove the lunch tray. On 1/24/2023 at 7:45 a.m. Resident #66 was observed resting comfortably in bed with her eyes closed and the lights off. Further observation at 7:56 a.m. revealed Staff B, Certified Nursing Assistant (CNA) bringing the resident's breakfast tray to her room. Prior to him going in the room, Staff B was asked to present the meal ticket and food items for observation. The meal ticket indicated Controlled Carbohydrate (CCHO) diet, mechanical texture, thin liquids. Resident #66 received two waffles and one container of syrup, mechanical meat, scrambled eggs, bowl of hot cereal/oatmeal, carton of whole milk, cup of water, and a cup of orange juice. Staff B stated that Resident #66 eats on her own with some set up and very little cueing. He set the tray on the bedside table, woke the resident, then took the lids off and left the room. Resident #66 was still resting in bed with eyes closed at 8:17 a.m. and had not consumed any of her meal. Then at 8:27 a.m. Staff B, CNA stated the resident was pushing the tray away after cueing twice by him and another CNA. He said they would wait a bit longer and try again before removing the tray and stated there are times when she does not eat in the morning even after cued. Staff B reiterated that Resident #66 is able to eat on her own and does not require any eating assistance or any physical assistance with eating devices. Staff B was observed checking on Resident #66 three times to cue her to eat from 7:56 a.m. to 8:44 a.m. Staff were not observed providing meal assistance and by 8:44 a.m. Resident #66 consumed 0% of her meal. On 1/24/2023 at 12:45 p.m., after the lunch meal, Resident #66's tray was observed with 50 - 75% of her meal consumed. Staff C, CNA was interviewed and confirmed the amount of the meal that consumed was 50-75%. Review of the Resident #66's admission Record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the diagnosis sheet revealed diagnoses to include: sequelae cerebrovascular disease, muscle weakness, , hypertension, dysphagia, and dementia. Review of the Minimum Data Set (MDS), dated [DATE], revealed in Section G - Functional Status for ADLs for Eating as extensive assistance with one person assistance. The Nutrition Assessment, dated 10/27/2022, showed Section 11. Ability to feed was self checked as Dependent on staff with all meals. Review of the current care plans, with the next review date of 2/13/2023, included the following 105603 Page 5 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0657 Focus areas: Level of Harm - Minimal harm or potential for actual harm - [Resident #66] has an ADL self-care performance deficit r/t (related to) impaired mobility, initiated on 10/19/22, and with interventions in place to include but not limited to: EATING = 1 Person Assistance. Residents Affected - Some - [Resident #66] is at risk for decreased nutritional status & dehydration r/t dementia, UTI (urinary tract infection), hx ABT (history of antibiotics), behaviors, weight fluctuations with cellulitis, edema, weeping of LE (lower extremities), therapeutic diet, varied PO (oral) intake, confusion, requires strong encouragement to eat, resistant to care and refuses medications at times .H/o (History of) significant weight fluctuations. Recent hospitalization for suspected CVA (cerebral vascular accident), returned with weakness and swallowing difficulties. Triggering for wt (weight) loss . Varying meal intakes, needs encouragement with meals, dysphagia. Mech (mechanical) soft diet with soft bread products. Intake mostly 25-50% . Interventions included but not limited to: Assist with meals as needed, Diet as ordered, Encourage resident to eat meals in the dining room as able, as tolerated. On 1/24/2023 at 7:38 a.m. Resident #66 was observed in her room awake with the room light on and lying in bed. Then at 7:44 a.m. Staff T, Social Services Director (SSD) was observed bringing Resident #66 her meal tray and placed it on the table. He and Staff B, CNA tried to elevate the head of the bed for the resident so she would be more comfortable eating and in a better eating position. Resident #66 cursed at both Staff B, CNA and Staff T, SSD and told them to leave her flat. They explained she needed to be in a better position and she refused. The breakfast tray was set up. She cursed at them and the two staff members decided to leave the room to let her calm down. Resident #66 was then observed at 7:46 a.m. flat in bed laying on her right side facing the bedside table on the side of her bed. She was reaching for the food with a fork and appeared able to get bites of food on her own. Resident #66 was able to drink from her milk carton without difficulty. On 1/24/2023 between 7:57 a.m. and 8:04 a.m. Staff C, CNA and Staff A, Registered Nurse (RN) were observed to assist Resident #66's roommate with their meal and not Resident #66. On 1/24/2023 at 8:20 a.m. Resident #66 was interviewed and said she had no concerns with her breakfast meal. She consumed over 75% of her meal and most of her liquids. She was asked if she could eat comfortably and use the fork to get food and she replied, I can do it, ok. Staff C, CNA was interviewed at 8:28 a.m. on 1/24/2023. Staff C said the resident can eat on her own and usually consumes around 50 - 75% of her meal. She rarely refuses breakfast or lunch but sometimes refuses dinner. Staff C explained the resident had a recent hospitalization and required eating assistance when she was readmitted . She has gotten better and is now able to eat on her own without any staff assistance. Review of the CNA ADL Flow/Task sheet for the month of 1/2023 revealed most meals were consumed independently without assistance. There were nine meals out of twenty nine meals that required supervision oversight. There was one day marked as dependent on staff with eating. Review of a dietary progress note, dated 1/24/2023, at 10:37 a.m. documented - Resident has been stabilized with weights. There was no noting with relation to what type of eating assistance the resident required or if the resident needed assistance at all. On 1/26/2023 at 10:08 a.m. an interview with the Registered Dietician Tech revealed Resident #66 105603 Page 6 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was being monitored for weight loss and eating activities. She revealed when the resident returned from the hospital sometime in 10/2022, she required a lot of eating assistance from staff and has been getting better. To her knowledge she no longer required eating assistance and was able to eat on her own with very little to no supervision. On 1/26/2023 at 10:50 a.m. an interview with the Care Plan/Minimum Data Set (MDS) coordinators Staff E, Licensed Practical Nurse (LPN) and Staff F, LPN was conducted. Staff E and F confirmed the MDS assessment and care plan currently reflect Resident #66 required one person assistance with meals and that she had progressively gotten better since her last hospitalization and readmission on [DATE]. They stated there had not been any information from the nurses and aides indicating what the resident's eating assistance needs were. Staff E and F confirmed they had not reviewed the CNA ADL Flow Sheets . Staff E and F reviewed the ADL Flow Sheets for the past two months and confirmed Resident #66 improved with eating and would be more at the supervision with set up only, rather than extensive assistance. They further confirmed the care plan should have been revised to reflect the resident was/is able to eat on her own since at least 12/2022. Staff E said eating assistance with one person assistance was interpreted as a staff member was to be in the room and physically assisting the resident with eating, and with staff handling the eating utensils. She revealed - Resident #66's care plan should have been revised around 12/2022 to reflect no longer needing any type of physical assistance. 2. On 1/23/2023 at 10:45 a.m. Resident #3 was observed in her room lying in bed and her bare feet were exposed out from the covers. During the interview Resident #3 was only able to answer some simple yes and no questions and unable to answer questions related to her care and services. On 1/24/2023 at 9:11 a.m. Resident #3 was observed in her room, in bed with her feet bare and free from foam boots/splints. On 1/24/2023 at 2:30 p.m. Resident #3 was observed in the dining room attending a group activity. Resident #3 was observed seated in her [specialized] chair. She was observed wearing non-skid socks with her feet propped up on both foot pedals and not wearing foam boots/splints. On 1/25/2023 at 7:00 a.m. Resident #3 was observed in her room and lying in bed half under the covers with her lower body exposed and with her right leg hanging off the side of the bed with both feet bare and without any type of foam boots and/or splints. Then at 7:08 a.m. Staff B, CNA was asked if the resident wore any type of splints or foam boots while in bed and he replied, I don't believe so, I have not seen her with any on. On 1/25/2023 at 9:30 a.m. Resident #3 was observed in her room seated in her [specialized chair], and both of her feet were positioned on the chair foot pedals with both feet only in white and blue non-skid socks. The resident was not observed with foam boots/splints on. Her room was observed free from any type of foam boots/splints. On 1/25/2023 at 10:20 a.m. the resident was observed participating in a group activity in the first floor activities/dining room. The resident was observed seated in her [specialized]chair and both of her feet were observed positioned on the chair foot pedals in white and blue non-skid socks. There was no evidence of the resident wearing any type of splints/boots on either of her feet. On 1/25/2023 at 1:02 p.m. Resident #3 was being assisted back to her room and was observed still without foam boots on. 105603 Page 7 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/26/2023 at 7:30 a.m. Resident #3 was observed in her room, lying flat in bed, under the covers with her legs and feet exposed. The resident was observed with bare feet and not wearing foam boots. Review of the admission Record revealed Resident #3 was admitted to the facility on [DATE] Review of the diagnosis sheet revealed diagnoses to include but not limited to: dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and muscle weakness. Review of the Annual Minimum Data Set (MDS) assessment, dated 11/14/2022, revealed the following: Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe impairment; Section G - Functional Status showed for Activities of Daily Living (ADLs) for Bed Mobility as extensive assist with two person assist, Personal Hygiene as extensive assistance with one person assist, has impaired function on one side upper extremity, and impairment one side lower extremity. Review of the current care plans, with the next review date of 2/1/2023 revealed the following Focus areas: - Left upper extremity contracture, specifically to wrist, digits, and elbow, with interventions in place to include: Straighten and bend left digits x 15 repetitions. Straighten and bend left wrist x15 repetitions. Straighten and bend left elbow x 15 repetitions. Turn palm up and down x 15 repetitions. - ADL self-care performance deficit r/t impaired mobility with interventions in place to include: May use [specialized] lift with 2 person assist with transfers, . Foam boots while in bed and in chair. A restorative care assessment was conducted on 1/7/2022. The assessment revealed: Problem was LUE (left upper extremity) Contracture/decreased ROM (range of motion). The goals included: Decrease risk for further contracture, reduce pain, facilitate proper positioning. The approaches included: Provide gentle passive range of motion to all joints to left arm with focus on returning forearm and wrist to neutral position. The restorative assessment indicated to provide approaches at least three times a week. No other restorative notes since the 1/7/2022 assessment were present in the medical record. There was no documented evidence within the resident's medical record for the months of 1/2023 and 12/2022 of Resident #3 receiving left upper extremity contracture exercise maintenance. There were no sections in the Medication/Treatment Administration Records during 1/2023 and 12/2022 revealing any type of left upper extremity contracture exercise maintenance. On 1/26/2023 at 8:55 a.m. an interview was conducted with Staff D, LPN, who cared for the resident on the 7:00 a.m. to 3:00 p.m. shift for the dates of 1/24/2023, 1/25/2023, and 1/26/2023. She stated she knows the resident well and she was aware the resident has foam boots to wear while in bed and in her chair. She said that it was typically the responsibility of the wound care nurse to don and doff the boots daily. Staff D stated the wound care nurse, as of about one week prior to this interview, no longer works at the facility and that may be the reason why the resident has not had the foam boots applied. 105603 Page 8 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/26/2023 at 9:15 a.m. in an interview Staff A, Registered Nurse (RN) Second Floor Unit Manager stated she knows Resident #3 and her care expectations. She was not sure if the resident had been wearing foam boots while in bed but would follow up and review the chart. After reviewing the chart and care plan she confirmed the resident has interventions for foam boots while in bed and in chair. Staff A confirmed the wound care nurse would have been initially responsible for evaluating all residents in the building for foam boots and other pressure relieving devices. Staff A stated it was the responsibility of the certified nursing assistants to don and doff the pressure relieving devices, including foam boots. Staff A was unaware if the resident had care plan interventions for the left hand wrist exercises for the contracture. She reviewed the medical chart and identified a care plan problem area for the left hand contracture with interventions for multiple left hand/wrist exercises. Staff A stated the restorative program would conduct the wrist exercises, but the resident was no longer receiving restorative nursing care. Staff A could not produce documentation to show the hand/wrist exercises were offered, conducted or refused. She said there was no real way to monitor in the chart whether the exercises were effective or not, or if were completed daily. A follow up interview with the Second Floor Unit Manager Staff A, RN on 1/26/2023 at 9:52 a.m. revealed she spoke with both the care plan team and the restorative nursing staff. She said the foam boots were resolved but it was not documented or removed from the care plan interventions. She also confirmed that during her conversation with the restorative nurse the left hand exercises were resolved and should have been removed from the care plan. On 1/26/2023 at 10:50 a.m. an interview with the Care Plan/MDS coordinators Staff E, LPN and Staff F, LPN was conducted. Staff E indicated Resident #3 has not used the boots in a long time, she used them when she was seen by the restorative nursing program. Staff E and F both agreed this intervention should have been revised or removed from the care plan back in 11/2022. Both staff members stated since the resident no longer receives restorative nursing the left hand/wrist exercises should have been removed at the last care plan conference in 11/2022. Review of the Comprehensive Person-Centered Care Plans policy, dated 10/24/2022 , revealed: The Policy section as: The center will develop a comprehensive person-centered care plan for each resident that is individualized and includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Comprehensive care plan will be consistent with resident goals and right to be informed and participate in his/her treatment. Under the Fundamental Information Section the policy documented: A comprehensive care plan will be: iii. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as changes in the resident's care and treatment occur. Any member of the interdisciplinary team may enter the updates to the comprehensive care plan 105603 Page 9 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0657 under the guidance of a registered nurse who is responsible for the resident. Level of Harm - Minimal harm or potential for actual harm The comprehensive plan of care should include the following: - Reflect current standards of professional practice .; Residents Affected - Some - Be periodically reviewed and revised by the interdisciplinary team as change in the resident's care and treatment occur. Additionally, under the Procedure section the policy documented: - .Communicate care plan changes on an ongoing basis to all members of the interdisciplinary team. - Re-evaluate and modify care plans: As needed to reflect changes in care, service and treatment. 105603 Page 10 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure communication between the facility and dialysis centers consistent with professional standards of practice for ensuring ongoing assessment and oversight of the resident before, during, and after dialysis treatments for three residents (#6, #97, and #90) out of three sampled residents. Residents Affected - Some Findings included: 1. Interview was conducted with Resident #90 on 01/23/2023 at 11:31 a.m. She confirmed she received hemodialysis treatment at a community provider three days per week. She stated she was not aware of any communication forms sent between the facility and the provider. On 01/25/2023 at 2:32 p.m. the resident was interviewed and confirmed she had been to the dialysis center for treatment that day. Review of Resident #90's medical record was conducted. The admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis. The Minimum Data Set (MDS) dated [DATE] revealed a Brief interview for Mental Status (BIMS) score of 15 which meant the resident was cognitively intact. Physician orders for January 2023 revealed dialysis treatment three times per week. The care plan revealed a focus area for dialysis and interventions that included Send dialysis communication form with resident and be sure to retrieve information from resident on return initiated 01/05/2023. An interview was conducted with Staff D, Licensed Practical Nurse (LPN) on 01/25/2023 at 12:43 p.m. She revealed a blank paper form titled, Dialysis Communication and stated the form was used for every dialysis appointment for the facility residents. She stated the facility nurse was responsible for completing the top portion of the form and sending it to the dialysis center either with the resident in paper form or via fax. Staff D stated the dialysis center was responsible to complete the bottom portion of the form and return it either with the resident in paper form or via fax. Staff D stated completed forms were filed in each resident's medical chart at the nurses' station on their unit. Review of Resident #90's medical chart on her unit was reviewed on 01/25/2023 and no dialysis communication forms were found. An interview was conducted with Staff G, LPN on 01/25/2023 1:40 p.m. She confirmed she was Resident #90's assigned nurse that day/shift and she had been assigned to her on 01/24/2023 as well. Regarding the process for communication with the dialysis centers for pre/during/post treatment clinical information, she stated she wasn't too familiar with what the facility's process was currently. She stated that in the recent past the facility wasn't allowed to have dialysis binders with communication forms or send binders or paper communication forms to the dialysis centers because of COVID (coronavirus disease), and so the process was for the nurse to complete the top portion of the communication form and fax it to the dialysis center, but that the center didn't send anything back. She stated when a resident returned from dialysis treatment the process was to take their vitals and generally assess them and ideally write a dialysis note. Staff G stated she thought the facility was getting back to the dialysis binder system now but wasn't sure. She stated when they had the binder system in the past it worked well. 105603 Page 11 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with Staff A, Registered Nurse (RN) Unit Manager (UM) for Resident #90's unit on 01/25/2023 at 2:33 p.m. Regarding facility process related to dialysis communication forms she said, I may need to check to give you information on the process. She stated she didn't know for certain what the process was. The blank dialysis communication form that had been provided by Staff D, LPN was revealed to Staff A, RN and she stated, we don't use those forms. Staff A stated, usually when they (residents) come back from dialysis the center faxes a form and then the nurse puts it in the chart, we don't have the nurses fill anything out to send with the resident. Staff A reviewed Resident #90's medical chart at the nurses' station and confirmed there were no dialysis communication forms in the chart and confirmed that was where that information should be filed. Staff A followed up on 01/25/2023 at 5:10 p.m. and reported the following: no paper communication forms were used because the dialysis centers weren't accepting them, no information was sent from the facility to the dialysis provider regarding the residents on their treatment days, the dialysis centers faxed a communication report to the facility after the resident completed their treatment and the nurse was expected to collect it and read it, if the dialysis center did not fax a form then the nurse or the UM was supposed to call the center and request it. Staff A stated there were no reports from the dialysis center for Resident #90 and she had called them after previous interview and requested them and they were to fax them to the facility that day. Form CMS-802 (Centers for Medicare and Medicaid Services) completed by the facility was reviewed and two additional residents receiving dialysis treatment were selected for review: Resident # 6 and Resident #97. 2. Review of Resident #97's medical record was conducted. The admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis. Physician orders for January 2023 revealed dialysis treatment three times per week. The care plan revealed a focus area for dialysis with interventions that included, send dialysis communication form with resident and be sure to retrieve information from resident on return, initiated 01/11/2023. The medical chart on the resident's unit was reviewed on 01/25/2023 at 5:00 p.m. and no dialysis communication forms were found. 3. Review of Resident #6's medical record was conducted. The admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, end stage renal disease, and dependence on renal dialysis. Physician orders for January 2023 revealed dialysis treatment three times per week. The care plan revealed a focus area for dialysis with interventions that included, send dialysis communication form with resident and be sure to retrieve information from resident on return initiated 06/01/2022. The medical chart on the resident's unit was reviewed on 01/25/2023 at 5:00 p.m. and no dialysis communication forms were found. An interview was conducted with Staff I, LPN on 01/25/2023 at 4:59 p.m. He confirmed he was the assigned nurse for Resident #6, had worked at the facility for one year, and routinely cared for residents who received dialysis treatment. Staff I stated he did not know anything about a dialysis communication form. He said because he worked 3:00 p.m. to 11:00 p.m. shift, generally residents had already returned from their dialysis treatments when he came on shift. He stated he had been instructed that the expectation when a resident returned from dialysis treatment was to check the dialysis port, take vitals, ensure no new orders, and write a progress note. Regarding how he would know if there were new orders he said, Sometimes they [the dialysis center] call. Staff I stated he was not aware of any expectation to call the center for report and stated he was not aware of anything/information that the facility was responsible to send with the resident or communicate to the dialysis center. 105603 Page 12 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with Staff O, RN, UM for Resident #6's and Resident #97's units on 01/25/2023 at 5:30 p.m. Regarding communication with dialysis centers she said, We don't send anything with the resident because of COVID. She stated the dialysis centers were supposed to send a form to the facility after dialysis treatment and said, They usually fax the communication form and the three to eleven nurse is supposed to put it in the resident's chart. Staff O stated the facility called the dialysis centers and requested the form if it wasn't sent and said, Usually I call because the fax comes to my attention. Regarding the purpose of communication between facility and dialysis centers, Staff O said, I know we always need the weight but I'm not sure honestly about it. An interview was conducted with the Director of Nursing (DON) on 01/26/2023 at 8:17 a.m. stated the expectation would be for facility nurses to complete the top portion of the form and send it with the resident to their dialysis appointment in the binder. She stated that system was being implemented as of today. The DON stated she had not been aware that the communication process wasn't happening with dialysis centers until it was brought to her attention. Review of facility policy titled, Dialysis, revised 06/23/2015, revealed a section titled, Continuity of Care and Communication: -Send Dialysis Communication Form (SHC 215-26) with resident for every treatment. -Coordinate care plans with dialysis clinic to assure continuity of care. 105603 Page 13 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed with three errors identified for three residents (#451, #13, and #203) of eight residents sampled constituting a 10.00% medication error rate. Residents Affected - Few Findings included: 1. A medication administration observation was conducted on 1/24/23 at 9:43 a.m. with Staff G Licensed Practical Nurse (LPN) for Resident #451. Staff G administered: -Amlodipine 10 milligram (MG) -Furosemide 20MG tablet -Aspirin 81MG tablet -Ferrous sulfate 325mg (65 Fe (iron)) MG tablet -2 tablets of Calcium Acetate 667 MG. At the time Staff G dispensed the Calcium Acetate medication, an observation was made of the Calcium Acetate order on the electronic medical record on 1/24/23 at 9:44 a.m. The medication was highlighted in red. Staff G, LPN indicated the medication order was red because it was late. Staff G confirmed it was scheduled to be given at 8:30 a.m. and confirmed it was over an hour after it was due. She confirmed the medication order showed the medication was to be given with meals and the resident needed it for medical management for kidney failure. Review of Resident #451's physician orders for January 2023 revealed, Calcium Acetate Oral Tablet 667MG (Calcium Acetate (Phosphate Binder)) Give 2 tablets by mouth with meals for CKD (chronic kidney disease), with a start date of1/22/23 and with no end date. Review of the Medication Administration Recorded (MAR) for January 2023 revealed Calcium Acetate Oral Tablet 667MG was scheduled at 8:30 a.m., 12:30 p.m., and 5:30 p.m. Review of Resident #451's Progress Notes from 1/1/23 to 1/26/23 was conducted and there was no evidence of the physician being notified of the late medication. 2. A medication administration observation was conducted on 1/25/23 at 11:15 a.m. with Staff D, LPN for Resident #203. Staff D obtained Resident #203's blood sugar with an accu-check machine which resulted in a blood sugar reading of 379. Staff D reviewed the physician's orders for the Lispro insulin sliding scale order and said the sliding scale only went as high as 350. Staff D stated, I am going to call the physician. Staff D called the physician and obtained an order to administer 8 units of Lispro insulin. On 1/25/23 at 11:28 a.m. Staff D stated, I feel like these pens never give the right amount of insulin with these needles. Staff D removed the Lispro KwikPen (insulin pen) from her medication cart, compared it to the physician orders, placed the needle on the tip of the insulin pen, and dialed the 105603 Page 14 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0759 Level of Harm - Minimal harm or potential for actual harm insulin pen to 8 units. She sanitized her hands, put on gloves, went into Resident 203's room, cleaned the resident's right lower quadrant of her abdomen with an alcohol wipe and administered the insulin medication. She then removed the needle, discarded the needle into the sharp's container, removed her gloves, sanitized her hands, went back out to her medication cart located outside of the resident's room, placed the medication back into the cart and documented the medication administration. Residents Affected - Few On 1/25/23 at 11:35 a.m. Staff D, LPN was interviewed, and she stated, We are not supposed to prime the needle because I don't think the pen will let you push it twice once you dial it to how many units they need. Staff D, LPN then dispensed Junamet 50-500mg (SITagliptin-metformin HCL) tablet to Resident #203. 3. A medication administration observation was conducted on 1/25/23 at 4:23 p.m. with Staff I, LPN for Resident #13. Staff I, LPN obtained Resident #13's blood sugar with an accu-check machine which resulted in a blood sugar reading of 241. Staff I removed the Novolog Flex Pen from the medication cart, compared it to the physician orders, placed the needle on the tip of the insulin pen, and dialed the insulin pen to 2 units. He then sanitized his hands, put on gloves, went into the resident's room, cleaned the resident's left upper arm with an alcohol wipe and administered the insulin medication. He then removed the needle, discarded the needle into the sharp's container, removed his gloves, sanitized his hands, went back out to his medication cart, located just outside the resident's door, placed the medication back into the cart and documented the medication administration. Immediately after he documented the medication administration and he stated, You don't need to prime the needle, you just put the needle on and it's ready to go. Review of Resident #13's physician orders for January 2023 revealed an order for Novolog solution 100unit/ML (milliliter) inject as per sliding scale if 200-250 = 2units .subcutaneous before meals and at bedtime for diabetes before bedtime. An interview was conducted with Staff G, LPN on 1/25/22 at 11:07 a.m. and she stated, When you have an insulin pen you place the needle onto the tip of the pen, dial it to the amount of units you want to administer, clean the area you are going to inject with an alcohol pad and push the pen onto the skin and slowly push the button to inject the insulin. You do not have to prime the pen I don't think, that would be news to me, and I would have to look that up. An interview was conducted on 1/26/23 at 9:48 a.m. with the Director of Nursing (DON), she indicated she would have to look up the policy and the process related to insulin pens and priming the needle prior to administration. She confirmed the calcium acetate should have been administered as ordered. On 01/26/23 at 11:03 a.m. an interview with the DON was conducted and she stated the facility's policy indicates to follow the manufacturer's guidelines related to insulin pens. According to NovoLog (insulin aspart) injection FlexPen Instructions For Use .Giving the airshot before each injection(Retrieved on 1/26/2023 from https://www.novo-pi.com/novolog.pdf) revealed: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: 105603 Page 15 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0759 E. Turn the dose selector to select 2 units (see diagram E). Level of Harm - Minimal harm or potential for actual harm F. Hold your NovoLog® FlexPen® with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge (see diagram F). Residents Affected - Few G. Keep the needle pointing upwards, press the push-button all the way in (see diagram G). The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. According to instructions titled, INSULIN LISPRO KWIKPEN - insulin lispro injection, solution instructions for use, (Retrieved on 1/26/2023 from https://uspl.lilly.com/lispro/lispro.html#ug1) revised on 2/2020, revealed: .Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle and repeat priming steps 6 to 8 Review of the facility's policy and procedure titled, Medication Pass Guidelines, revised on 4/25/2017, revealed: Purpose: 105603 Page 16 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0759 Level of Harm - Minimal harm or potential for actual harm To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systematically distribute medications to residents in accordance with state and federal guidelines. Residents Affected - Few Fundamental Information . Physician's Orders- Medications are administered in accordance with written orders of the attending physician . Procedure .7. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility . 105603 Page 17 of 18 105603 01/26/2023 Riviera Palms Rehabilitation Center 926 Haben Blvd Palmetto, FL 34221

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the correct medical diagnosis was documented in a resident's medical record. The failed practice was true for one resident (#32) of 42 sampled residents. Findings included: A record review of Resident #32's medical record showed a diagnosis of Post Traumatic Stress Disorder (PTSD) that was initiated on 10/26/21. The quarterly Minimum Data Set (MDS), dated [DATE], showed PTSD in Section I - Active Diagnoses. There was no care plan focus for PTSD. There was no completed PASRR Level II. During an interview on 01/26/23 at 9:00 a.m. the Nursing Home Administrator (NHA) stated that a PASRR Level II would be looked into as to whether one had been completed or not. In an additional interview on 01/26/23 at 9:25 a.m. the NHA stated that Resident #32 did not have PTSD and that the diagnosis of PTSD on the medical diagnosis page was in error. The NHA stated that no one knew how the diagnosis was placed in error on Resident #32's medical record and that [physician name] was not going to be happy because that error in diagnosis had been filtered into the doctor's notes as well. 105603 Page 18 of 18