Health inspection·August 24, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to assess and obtain wound care orders for one (#12) of two residents reviewed for wound care. Residents Affected - Few Findings included: On 8/24/24 at 9:51 a.m., Resident #12 was observed sitting in a wheelchair inside the second floor activity room across from the nursing station. The observation revealed a tan-colored 4 x 4 shiny plastic-looking border dressing near the resident's right elbow. The dressing was undated with an approximate quarter-sized area of discoloration staining the near-center of the dressing. The resident's speech was non-sensical. An interview and observation of Resident #12's dressing was conducted with Staff A, Licensed Practical Nurse (LPN) on 8/24/24 at 9:57 a.m. Staff A stated when an area of (disrupted) skin integrity was observed, the area was assessed, a head-to-toe assessment was completed, and a physician order was obtained for treatment. The staff member viewed Resident #12's right elbow dressing and reported seeing the area also that morning. Staff A confirmed the dressing should be dated, there should be a physician order for the dressing, and an assessment of the area should have been done. Review of Resident #12's medical record, including progress notes, Interdisciplinary Team (IDT) Quick View notes, and Wound/Skin notes did not reveal an assessment or note was completed regarding the cause of the resident's right elbow injury. The record did not reveal a treatment order had been obtained from the physician (prior to the observation) or the resident's responsible party was notified of the injury. The record showed on 8/17/24 at 7:55 p.m., Resident #12's skin was intact. A IDT note dated 8/20/24 at 8:11 p.m. revealed the resident was status/post (s/p) fall with no delayed injuries. An interview was conducted with the Director of Nursing (DON) on 8/24/24 at 3:44 a.m. The DON stated when a skin issue was noted, staff were to obtain a physician order and let management know so they could investigate the cause and circumstances. The DON confirmed not knowing about Resident #12's skin injury. Review of the policy - Wound Care, dated October 2010, revealed The purpose of this procedure guidelines for the care of wounds to promote healing. The preparation instructed staff to 1. Verify that there is a physician's order for this procedure. The procedure portion of the policy included instructions for staff to 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. The policy showed the following documentation should be recorded in the resident's medical record: Page 1 of 5 105616 105616 08/24/2024 Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716

F 0684 1. Level of Harm - Minimal harm or potential for actual harm Wound care provided. 2. Residents Affected - Few The date and shift the wound care was provided. 3. The name and title of the individual performing the wound care. 4. Any change in the resident's condition. 5. Assessment data (i.e. Wound bed color, size, drainage, etc.) Obtained when inspecting the wound. 6. How the resident tolerated the procedure. 7. Problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment and the reason(s) why. 9. The signature and title of the person recording the data. 105616 Page 2 of 5 105616 08/24/2024 Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure laboratory testing was obtained per physician orders for one (#12) of two residents sampled. Residents Affected - Few Findings included: On 8/24/24 at 9:51 a.m., Resident #12 was observed in the second floor activity room with other residents and a television was playing. The resident's speech was non-sensical. On 8/24/24 at 9:57 a.m., Staff A, Licensed Practical Nurse (LPN), confirmed the resident's identity. The resident appeared to be a frail elderly resident, clean and appropriately dressed. Review of Resident #12's medical record revealed the resident was admitted on [DATE] and 11/22/22. The record included the diagnoses: Adult failure to thrive, unspecified stage 3 chronic kidney disease, unspecified anemia, unspecified vitamin deficiency, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #12's active physician orders, dated August 2024, revealed an order written and to start on 1/18/23 for a Complete Blood Count (CBC)/Comprehensive Metabolic Panel (CMP)/Ammonia level every (Q) 4 months. The laboratory testing should have been scheduled during the months of January, May, and September, according to the calendar cycle of every 4 months per the physician order. Review of Resident #12's Laboratory results and Treatment Administration Records (TAR) from January 2023 to August 2024 revealed the following: - 1/19/23: CMP/CBC/Ammonia level, signed on 1/20/23. - 5/18/23: The TAR revealed a CBC/CMP/Ammonia level was to be drawn on Thursday 5/18/23 and did not show it had been completed/administered. Review of the resident's electronic record did not reveal any laboratory results for May 2023 and the facility did not provide as requested. - 9/5/23 laboratory results revealed a CMP and CBC had been drawn without an Ammonia level. The September 2023 TAR revealed a CBC/CMP/Ammonia level had been drawn on Friday 9/15/23. Review of the laboratory results located in the electronic record did not reveal any results dated 9/15/23 and the facility did not provide those results as requested. - 1/8/24: Laboratory documentation show Vitamin D and parathyroid hormone (PTH) results were pending, and the facility had received Potassium and CBC results. - 1/13/24: The TAR revealed a CBC/CMP/Ammonia level had been drawn on 1/13/24. Review of the resident's medical record did not reveal those results and the facility did not provide the results for 1/13/24. - 5/12/24: The TAR did not show a CBC/CMP/Ammonia level had been drawn on Sunday 5/12/24. The facility did not provide any laboratory results from May 2024. Review of Resident #12's progress notes revealed the following: 105616 Page 3 of 5 105616 08/24/2024 Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716

F 0770 - 5/18/23: no progress note from 5/18/23 showing the reason laboratory testing had not been completed. Level of Harm - Minimal harm or potential for actual harm - 9/15/23: no progress note from 9/15/23 showing the reason laboratory testing had not been completed. Residents Affected - Few - Follow up Cardiology provider note, dated 6/14/24, revealed laboratory results reviewed were dated 1/8/24, No new labs to review. During an interview on 8/24/24 at 3:44 p.m., the Director of Nursing (DON) stated the night shift nurses put in the laboratory requests, the order pops up for them and they were supposed to have them done and print out the results. A review of Resident #12's May TAR revealed the order for laboratory testing had been scheduled for the 7:00 p.m.-7:00 a.m. shift, she stated the lab vendor came to the facility at 4:30 a.m. and saw the issue, if the order pops up at 7 a.m. the vendor was gone. During a follow up interview on 8/24/24 at 4:48 p.m., the DON said nurses compared the lab log and the results that came through, the nurses and Unit Manager were responsible for the laboratory results. The nurses reached out to the physician's (if necessary). The nurses had to print out the results so they could be scanned into the record. The physician's were able to access the laboratory and radiology systems. Review of the policy - Lab and Diagnostic Test Results: Physician Role and Follow Up, dated September 2017, revealed The facility shall use a systematic process for obtaining and reviewing lab and diagnostic test results and reporting to the physicians. Physicians shall address lab test results appropriately and in a timely manner. The Outcomes review showed Clinically significant test results will be reviewed and acted upon appropriately and in a timely manner. The procedure section of the policy included the following: 1. the physician will identify an order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 4. A nurse will review all results. - If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 8. A nurse will try to determine whether the test was done: 105616 Page 4 of 5 105616 08/24/2024 Brighton Bay Center for Rehabilitation and Healing 10501 Roosevelt Blvd N Saint Petersburg, FL 33716

F 0770 a. As a routine screen or follow up; Level of Harm - Minimal harm or potential for actual harm b. To assess a condition change or recent onset of signs and symptoms; or c. To monitor a serum medication level. Residents Affected - Few - The reason for getting a test often affects the urgency of reporting and acting upon the result. 105616 Page 5 of 5