Health inspection·June 14, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, interview and record review, the facility failed to maintain a safe and homelike environment free of pest for 1 of 2 halls observered (north hall). Residents Affected - Some The findings include: On 6/12/23 at approximately 2:11 PM, an interview was conducted at the nursing station with staff member D, Certified Nursing Assistant (CNA). During the interview multiple large, brown, cockroaches were noted scurrying about the nursing station floor. At this time the CNA stated that there has been an issue with roaches in the nursing station that has been getting worse. On 6/12/23 at approximately 2:39 PM, an interview was conducted with the Unit Manager who stated that there is an ongoing issue with roaches on the North side of the building. They come and spray about once a month but it is getting worse. On 6/13/23 at approximately 9:55 AM an interview was conducted with a family member of resident #11 who reported the resident had been here for about 5 months and came for skilled nursing care to get her strength back. She reported that she and the resident had observed roaches in her room she is not sure if the facility is spraying or not. On 6/13/23 at approximately 11:18 AM, an interview was conducted with the Resident Council President who reported during the meetings there had been complaints about cold food and that rooms were not getting cleaned. She stated the facility does respond to their concerns, however the issue with roaches is an ongoing issue. On 6/14/23 at approximately 9:00 AM, an interview was conducted with the pest control services provider for the facility who stated that the facility had an active and current contract with them and had amended their contract in June 2021 to allow for twice monthly services due to ongoing roach issues. The pest control company reported that they sprayed the facility twice in June on the 1st and again on the 13th where they sprayed the north wing for American cockroaches and did a preventative treatment in the kitchen. A review was conducted of the pest control licenses for fumigation, general household pest and rodent control, lawn and ornamental, termite and other WDO control revealed the license had been issued on March 1, 2022 and expired on February 28, 2023. Page 1 of 16 105634 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

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 staff interviews, clinical record reviews, and review of facility investigation, the facility failed to submit federal immediate report for 1 or 3 residents sampled for abuse (Resident #8). The facility failed to report an injury of unknown source and a transfer of the same resident to the hospital for a right femoral fracture that occurred while the resident was in the facility. The findings include: A review was conducted of the medical record for resident #8 which revealed that on 2/20/23 resident #8 complained of right hip pain, an x-ray was ordered and revealed an acute right intertrochanteric fracture with possible involvement of the femoral neck. The resident was transferred to the emergency room on 2/20/23. A review of the hospital records revealed a Diagnostic Imaging report for a CT Scan of the head dated 2/20/23 at 21:29 (9:29 PM), Impression: Right Occipital skull fracture, no cervical spine fracture, and states the clinical indication: Head trauma, mod severe, Impression: right occipital bone fracture is seen without displacement. No acute infarct mass effect or intracranial hemorrhage. This report also identified findings There is an acute right intertrochanteric fracture with possible involvement of the femoral neck as well. No lytic process is seen. Impression Acute right intertrochanteric fracture with likely involvement of the right femoral neck. A reexamination/reevaluation completed on 2/20/23 at 10:28 PM, under assessment/plan states acute right intertrochanteric hip fracture, right occipital skull fracture, UTI (urinary tract infection). A review of the history and physical dated 2/21/23 at 3:46 PM revealed [AGE] year old female present to the ER from her living facility complaining of hip pain. Diagnosed with right hip fracture and occipital bone fracture. The history of present illness for a consultation dated 2/21/23 at 11:13 AM, stated [AGE] year old female admitted to the hospital. She has an extensive medical history and is not a great historian. Unclear if she had a fall and/or loss of consciousness, but she was complaining of hip pain and was found to have a hip fracture and CT head demonstrated a right occipital skull fracture. The assessment and plan for this consultation stated, [AGE] year old female with right hip fracture and nondisplaced right occipital skull fracture without intracranial hemorrhage is a poor historian but denies a fall. It is difficult to assess the timing or when actually she had this fracture. Regardless this is a nondisplaced skull fracture without intracranial hemorrhage there is nothing neurosurgical to do. This will heal on its own over the next 4 to 8 weeks. A review of the Unit Manager's witness statement dated 2/21/23, revealed that she had worked with resident #8 on 2/18/23, and documented, Resident was fine and doing good. No complaints of any hip pain. The statement goes on to state that she worked on 2/20/23 and at approximately 1:00 PM the resident started to scream in pain when I ask her what was wrong she said her hip hurt and she rub the right leg. The statement states that the Unit Manager asked the Certified Nursing Assistant (CNA) if the resident had been complaining on Sunday about leg pain. The CNA said (resident #8) was complaining when she put her to bed and she notified the nurse (staff member F, Licensed Practical Nurse) and she said resident was fine. The UM goes on to state that she ordered an xray and called the medical director with the results of an acute femoral right fracture. The statement goes on to state that she called the resident's husband who told her that he had been with the resident on Sunday and she had not complained of pain. A review of an undated witness statement for staff member H, CNA, revealed she was working in another room on 2/19/23 with another resident right before dinner and she and the resident she was 105634 Page 2 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assisting heard resident #8 scream out not to loud but loud enough for me to hear it, and some male resident was sitting there, I'm thinking in front of her door talking to her telling her to stop trying to stand up. The CNA went on to document that she heard resident #8 say, I heard my leg crack. She further documents that at approximately 7:30 PM, two CNAs went to put the resident in bed and I heard her scream really loud that time so I walked down to the room and the CNA said she complaining about her leg hurting that it was difficult to put her to bed She goes on to write that the nurse came down to the room at which time she left the room, I walked away to finish put my other resident to bed cause I figured the nurse was there she will see what the problem was. Three residents were interviewed by the facility using a printed document that had questions relating to resident #8, the answers to the questions were transcribe by an unidentified staff member, all were unsigned and all were dated 2/22/23. Resident #9, stated that resident #8 was screaming in pain on & off. Sunday (2/19/23) not sure when friend was here and stated yelling around 6-8. Not sure where she was in her room in bed or in chair. Didn't see her only hear her yelling. Resident #6, stated Saw pt stand up hold railing. He heard a pop. He heard her say (not legible) she went to lay down. Resident #10 stated Her husband was rude to (resident) and angry he asked her for her bag he placed in drawer week before she said she didn't know. He said what do you know, and you don't even know what day it is. Sunday after husband left, she was in pain still light outside not sure of time. She was okay before she went out with husband her husband brought her in w/c (wheelchair) left her in room kissed her and left. He was yelling at her before they left the room. On 6/13/23 at approximately 2:13 PM an interview was conducted with the Administrator who stated that there was no evidence that resident #8 had fallen in the facility therefore he did not report the hip fracture to the regulatory agency. He stated that he assisted in the investigation, and it was determined that the resident had not fallen and that a resident had heard a pop when she was trying to stand up. He did not mention the skull fracture. On 6/13/23 at approximately 1:44 PM, an interview was conducted with the Unit Manager regarding resident #8 fractures. She was asked about the skull fracture she stated there had not been two fractures that it was only the resident's right hip. When shown the hospital record that identified two fractures one in the right hip and the other being the right occipital skull fracture, she stated that the skull fracture was old and from before the resident was admitted . On 6/14/23 at approximately 8:40 AM a telephone interview was conducted with the spouse of resident #8 during which he restated that the facility told him no one saw anything and they do not know how she injured her hip. She just started to complain of pain. He further reported that prior to this she had no history of head injuries or skull fractures. On 6/14/23 at approximately 10:01 AM an interview was conducted with the Medical Director who stated that in his opinion the resident's skull fracture was old because there were no obvious signs of trauma, but he confirmed that he had not seen the resident after her fall and did not assess her. He reported that the facility reported this information too him today and that he had not read the hospital record. He reported that the Administrator provided him with a verbal report this morning (6/14/23) of what was in the hospital record, saying that he was told the record said, age undetermined and that there was no obvious trauma. He stated that he was not aware that the record did not specifically say this, that the facility had interpreted the results. He was asked if the skull fracture could be an injury of unknown origin he stated, I can see how you could interpret this as an injury of unknown origin because we do not know how it happened. 105634 Page 3 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0609 Level of Harm - Minimal harm or potential for actual harm 6/13/23 at approximately 1:44 PM, a follow up interview was conducted with the Unit Manager regarding resident #8 fractures. She was asked about the skull fracture she stated there had not been two fractures that it was only the resident's right hip. When shown the hospital record that identified two fractures one in the right hip and the other being the right occipital skull fracture, she stated that the skull fracture was old and from before the resident was admitted . Residents Affected - Few On 6/14/23 at approximately 10:22 AM an interview was conducted with the Regional Operations Director and the current Administrator who reported that the record clearly shows that the skull fracture was old because there were no obvious signs of trauma. When asked to show where in the record this was, the Regional Operations Director pointed to the Assessment/Plan portion of the Consultations report from the hospital record. The Regional Operations Director verbalized age undetermined while running his right index finger over the words on the paper. When asked to specifically point out the words age undetermined he stated that it did not say those words, but they were implied. When asked if these injuries had been reported to the regulatory agency he stated that they had not because they did not see them as reportable events and even if they had been they had 15 days to investigate. He further stated that during those 15 days they determined the resident had not fallen and therefore did not need to report anything. He was asked if an injury of unknown origin or the transfer of a resident to a higher level of care with a bone fracture would require an immediate report to the agency he stated no because they have 15 days to investigate. A record review was conducted for resident #8 which revealed she was admitted to the facility on [DATE] with diagnoses of Warnicke's encephalopathy, hypertension, hypothyroidism, COPD and a history of TIA. Her Brief Interview for Mental Status (BIMS) was noted to be a 9 indicating moderately impaired cognition, on the last updated MDS dated [DATE]. Wernicke's encephalopathy is a degenerative brain disorder caused by the lack of vitamin B1, symptoms included confusion, loss of mental activity, loss of muscle coordination and vision changes. Review of the resident's plan of care included risk for falls and fall related injuries related to cognitive loss/decline, impaired mobility. A review of the Adverse Event Reporting Policy dated 11/2020 and revised 1/2022 states that an, Adverse Event - An event over which facility personnel could have exercised control and which is associated in whole or in part with the facility's intervention, rather than the condition for which such intervention occurred, and which results in one of the following outcomes: item 4. Fracture or dislocation of bones or joints and item 7. Any condition that required the transfer of the resident, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the resident's condition prior to the adverse incident. The policy goes on to state The facility will conduct a complete and thorough investigations to identify if an even meets the definition of an adverse event. 105634 Page 4 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to investigate an injury of unknown source for 1 of 3 residents reviewed for abuse. Resident #8 was found to have an occipital skull fracture while being treated in the emergency room for a right hip fracture obtained in the facility. The facility's investigation failed to include the resident's skull fracture. Residents Affected - Few The findings include: On 6/12/23 at approximately 110 PM an interview was conducted with the spouse of resident #8 who stated the resident broke her hip while at the facility. He stated the facility told him that no one saw anything, and they do not know how she injured her hip. He stated they reported to him that she just started to complaint about pain in her hip, so they did an x-ray and found a fracture. She had surgery and returned to the facility sometime in February. A review of the resident's electronic medical record revealed a nursing note dated 2/20/23 at 16:09 (4:09 PM) documented by the Unit Manager, resident complaining of right hip pains mobile xray ordered. A follow up progress note dated 2/20/23 at 18:30 (6:30 PM) xray result came back right femoral acute fracture Doctor (name) was notified the statement includes that the resident's spouse was also notified. At 20:14 (8:14 PM) a narrative note revealed that the hospital called wanted to know when did she fall. I explained to them that we have no report of any fall. I let them know that resident is very confused and doesn't remember things resident was in bed sleep for majority of the day shift and when she woke up she was complaining of right hip pain x-ray was ordered and completed and resident was sent to ER (Emergency Room). There is no documentation in the record prior the 2/20/23 regarding the resident complaining of hip pain. A record review was conducted for resident #8 which revealed she was admitted to the facility on [DATE] with diagnoses of Warnicke's encephalopathy, hypertension, hypothyroidism, COPD and a history of TIA. Her Brief Interview for Mental Status (BIMS) was noted to be a 9 indicating moderately impaired cognition, on the last updated MDS dated [DATE]. Wernicke's encephalopathy is a degenerative brain disorder caused by the lack of vitamin B1, symptoms included confusion, loss of mental activity, loss of muscle coordination and vision changes. Review of the resident's plan of care included risk for falls and fall related injuries related to cognitive loss/decline, impaired mobility. A review of the Unit Manager's witness statement dated 2/21/23, revealed that she had worked with resident #8 on 2/18/23, and documented, Resident was fine and doing good. No complaints of any hip pain. The statement goes on to state that she worked on 2/20/23 and at approximately 1:00 PM the resident started to scream in pain when I ask her what was wrong she said her hip hurt and she rub the right leg. The statement states that the Unit Manager asked the Certified Nursing Assistant (CNA) if the resident had been complaining on Sunday about leg pain. The CNA said (resident #8) was complaining when she put her to bed and she notified the nurse (staff member F, Licensed Practical Nurse) and she said resident was fine. The UM goes on to state that she ordered an xray and called the medical director with the results of an acute femoral right fracture. The statement goes on to state that she called the resident's husband who told her that he had been with the resident on Sunday and she had not complained of pain. A review of an undated witness statement for staff member H, CNA, revealed she was working in another room on 2/19/23 with another resident right before dinner and she and the resident she was 105634 Page 5 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assisting heard resident #8 scream out not to loud but loud enough for me to hear it, and some male resident was sitting there, I'm thinking in front of her door talking to her telling her to stop trying to stand up. The CNA went on to document that she heard resident #8 say, I heard my leg crack. She further documents that at approximately 7:30 PM, two CNAs went to put the resident in bed and I heard her scream really loud that time so I walked down to the room and the CNA said she complaining about her leg hurting that it was difficult to put her to bed She goes on to write that the nurse came down to the room at which time she left the room, I walked away to finish put my other resident to bed cause I figured the nurse was there she will see what the problem was. Three residents were interviewed by the facility using a printed documented that had questions relating to resident #8, the answers to the questions were transcribe by an unidentified staff member, all were unsigned and all were dated 2/22/23. Resident #9, stated that resident #8 was screaming in pain on & off. Sunday (2/19/23) not sure when friend was here and stated yelling around 6-8. Not sure where she was in her room in bed or in chair. Didn't see her only hear her yelling. Resident #6, stated Saw pt stand up hold railing. He heard a pop. He heard her say (not legible) she went to lay down. Resident #10 stated Her husband was rude to (resident) and angry he asked her for her bag he placed in drawer week before she said she didn't know. He said what do you know, and you don't even know what day it is. Sunday after husband left, she was in pain still light outside not sure of time. She was okay before she went out with husband her husband brought her in w/c (wheelchair) left her in room kissed her and left. He was yelling at her before they left the room. A review of the hospital records for resident #8 revealed a Diagnostic Imaging report for a CT Scan of the head dated 2/20/23 at 21:29 (9:29 PM), Impression: Right Occipital skull fracture, no cervical spine fracture, and states the clinical indication: Head trauma, mod severe, Impression: right occipital bone fracture is seen without displacement. No acute infarct mass effect or intracranial hemorrhage. This report also identified findings There is an acute right intertrochanteric fracture with possible involvement of the femoral neck as well. No lytic process is seen. Impression Acute right intertrochanteric fracture with likely involvement of the right femoral neck. Review of the Emergency Department Documents I spoke with a nurse at the facility named (unit manager) who advised me that she worked on Saturday (2/18/23) and the patient did not have any complaints. Today (2/20/23) the patient complained of right sided hip pain so an x-ray was done which showed a fracture. However, there were no reported falls, patient was never found on the ground. She reports that the patient is at her baseline mental status. Further review of the document revealed a rationale for a CT Scan of the head as X-ray here also shows an acute right intertrochanteric fracture. Head CT was performed due to the unclear details of her fall. This showed an occipital fracture. I discussed this with the PA on -call for neurosurgery. They advised the patient would be appropriate for the floor given she is at her baseline mental status, does not seem to have any acute symptoms related to this and there is no associated intracranial hemorrhage. A reexamination/reevaluation completed on 2/20/23 at 10:28 PM, under assessment/plan states acute right intertrochanteric hip fracture, right occipital skull fracture, UTI (urinary tract infection). A review of the history and physical dated 2/21/23 at 3:46 PM revealed [AGE] year old female present to the ER from her living facility complaining of hip pain. Diagnosed with right hip fracture and occipital bone fracture. The history of present illness for a consultation dated 2/21/23 at 11:13 AM, stated [AGE] year old female admitted to the hospital. She has an extensive medical history and is not a great historian. Unclear if she had a fall and/or loss of consciousness, but she was complaining of hip pain and was found to have a hip fracture and CT head demonstrated a right occipital skull fracture. The assessment and plan for this consultation stated, [AGE] year old female with 105634 Page 6 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few right hip fracture and nondisplaced right occipital skull fracture without intracranial hemorrhage is a poor historian but denies a fall. It is difficult to assess the timing or when actually she had this fracture. Regardless this is a nondisplaced skull fracture without intracranial hemorrhage there is nothing neurosurgical to do. This will heal on its own over the next 4 to 8 weeks. On 6/13/23 at approximately 12:26 PM an interview was conducted with staff member E, CNA, who reported she was on leave from the facility at this time. She stated she worked with resident #8 as a CNA on 2/19/23 and remembered the resident complaining about her leg hurting. She reported she let the nurse know who told her that she was already aware. She stated she was not aware of the resident falling or of anything popping. She stated there was no way to tell when or how the resident got hurt because the resident is very forgetful and confused all the time. She stated that she worked the two or three days after this and no one asked her what happened or asked her to write a witness statement. She clarified that no one in the facility talked to her about this incident until today (6/13/23) when the facility called to tell her the state would be calling her. On 6/13/23 at approximately 12:31 PM an interview was conducted with staff member F, an agency Licensed Practical Nurse (LPN), she does not remember working with this resident but does remember working that day because the facility never paid her and she had not worked there since. She stated she was not contacted by the facility regarding resident #8 until today (6/13/23). She stated she was not asked what happened that day nor was she asked to give a witness statement. On 6/13/23 at approximately 1:44 PM, a follow up interview was conducted with the Unit Manager regarding resident #8 fractures. She was asked about the skull fracture she stated there had not been two fractures that it was only the resident's right hip. When shown the hospital record that identified two fractures one in the right hip and the other being the occipital skull fracture, she stated that the skull fracture was old and from before the resident was admitted . On 6/13/23 at approximately 2:13 PM an interview was conducted with the Administrator who stated that there was no evidence that resident #8 had fallen in the facility therefore he did not report the hip fracture to the regulatory agency. He stated that he assisted in the investigation, and it was determined that the resident had not fallen and that a resident had heard a pop when she was trying to stand up. He did not mention the skull fracture. On 6/13/23 at approximately 2:51 PM an interview was conducted with the Director of Nursing during which she stated that in the event of a patient injury the facility would contact the clinical adviser and if she was not in the facility she would come in immediately. She would conduct an investigation and interview anyone who previously cared for the patient, to include housekeeping, CNAs, but especially the nurse who was taking care of the resident. She stated that she would not usually get a statement from a resident unless they were directly involved but prefers getting information from staff. On 6/14/23 at approximately 8:40 AM a follow-up interview via telephone was conducted with the spouse of resident #8 during which he restated that the facility told him no one saw anything and they do not know how she injured her hip. She just started to complain of pain. He further reported that prior to this she had no history of head injuries or skull fractures. On 6/14/23 at approximately 9:55 AM an interview was conducted with the Regional Nurse Consultant who stated that the resident did not have a fall in the facility and the records show that the resident denied a fall but stated the resident was confused at all times and is not a good historian She 105634 Page 7 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few offered that staff heard a pop and that is why they feel it was not a fall. She went on to state the skull fracture was old, age undetermined because there were no obvious signs of trauma. When asked why the emergency room would have done a CT Scan of the resident's head if she had been complaining of hip pain she stated that it was routine that the ER will do a full body CT scan for hip pain. On 6/14/23 at approximately 10:01 AM an interview was conducted with the Medical Director who stated that in his opinion the resident's skull fracture was old because there were no obvious signs of trauma, but he confirmed that he had not see the resident after her fall and did not assess her. He reported that the facility reported this information too him today and that he had not read the hospital record. He reported that the Administrator provided him with a verbal report this morning (6/14/23) of what was in the hospital record, saying that he was told the record said, age undetermined and that there was no obvious trauma. He stated that he was not aware that the record did not specifically say this, that the facility had interpreted the results. He was asked if the skull fracture could be an injury of unknown origin he stated, I can see how you could interpret this as an injury of unknown origin because we do not know how it happened. On 6/14/23 at approximately 10:22 AM an interview was conducted with the Regional Director of Operations and the current Administrator who reported that the record clearly shows that the skull fracture was old because there were no obvious signs of trauma. When asked to show where in the record this was, the Regional Director of Operations pointed to the Assessment/Plan portion of the Consultations report from the hospital record. The Regional Director of Operations verbalized age undetermined while running his right index finger over the words on the paper. When asked to specifically point out the words age undetermined he stated that it did not say those words, but they were implied. He stated again that there were no obvious signs of trauma. At this time, he was asked to point to the area on his own head where he believed the occipital portion of the skull was, he raised his right hand and using his right index finger he made half circle around his right eye. When told this was not correct that the occipital potion of the skull was at the back of the head, he raised his left arm and placed his hand on the back of his head. He confirmed that the hair on the back of the head could cover signs of trauma. On 6/14/23 at approximately 11:33 AM an interview was conducted with the Business Office Manager who reported that she does not have copies of abuse training for any employee who started prior to her starting her position in January 2023. This would include the two staff members working with Resident #8 on 2/19/23 (staff members E & F). She said she had not been able to find any reports from the previous Business Office Manager and feels they were lost or in a box that is somewhere in the building but she has given up trying to find them and started new with anyone who has been hired since she started. She was able to pull up the schedule for staff member E, CNA, for the days after the issue with resident #8 which revealed she was working in the building for two days fallowing the concern. On 6/14/23 at approximately 2:05 PM a follow-up interview was conducted with the current administrator in the presence of the newly hired Administrator. The current administrator was asked about the investigation of resident #8s skull fracture. He reported that he had not actually obtained the witness statements that it was either the Director of Nursing or the pervious administrator. He agreed that the two staff members who had been assigned to work with resident #8 on 2/19/23 when the resident was noted to scream out in pain, should have been interviewed. He reported at the time of this incident he had just started at the facility as an assistant administrator. He also verified that that there should have been a progress note written when the resident complained of pain or had reported hearing a popping sound in her hip, he again verified that there was no documentation regarding this 105634 Page 8 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the resident's medical record. He stated that the investigation into the hip fracture began on 2/20/23 and took until the 23rd or the 24th to complete. He verified that he had not reported this to the regulatory agency because it was not a reportable event. When asked what his definition was of an injury of unknown origin, he reported that an injury of unknown origin is identified if there is an injury that you cannot figure out how it happened or what caused it. The interviews with residents and staff are what made us (the facility) determine it was a pop that caused the resident's hip injury. When asked if the skull fracture could have been an injury of unknown origin, he responded that they became aware of the skull fracture after the CT scan but that the administrative team determined that the skull fracture was old, and the age could not be determined because there was no trauma. He offered that You could argue that this was a fall, but we (the Administration) determined that this was from her repositioning in her wheelchair and that there was no evidence of a fall because the skull fracture was old. He verified that the words age undetermined were not written anywhere in the hospital record and stated that he believes it was an interpretation of the wording by the previous administrator. A review of the Adverse Event Reporting Policy dated 11/2020 and revised 1/2022 states that an, Adverse Event - An event over which facility personnel could have exercised control and which is associated in whole or in part with the facility's intervention, rather than the condition for which such intervention occurred, and which results in one of the following outcomes: item 4. Fracture or dislocation of bones or joints and item 7. Any condition that required the transfer of the resident, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the resident's condition prior to the adverse incident. The policy goes on to state The facility will conduct a complete and thorough investigations to identify if an even meets the definition of an adverse event. A review of the Incidents and Accidents policy dated 11/2020 and reviewed on 10/01/22 states that It is the policy of this facility for staff to report, investigate and review any accident or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The policy defines an accident as refers to any unexpected or unintentional incident which results or may results in injury or illness to a resident. The purpose of the incident reporting can include conducting a root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance performance Improvement (QAPI) to avoid further occurrences. Incidents that rise to the level of abuse, misappropriation or neglect will be managed and reported timely to the facility Risk Manager, Administrator and/or Director of Nursing and in accordance with state and federal regulations. Included on the list of incidents/accidents that require an incident report include Alleged abuse and falls. Documentation should include the date, time nature of the incident, locations, initial findings, immediate interventions, notifications and orders obtained for follow-up interventions. The facility was asked for a policy regarding injury of unknown origins however this was not provided by the end of the survey on 6/14/23 at approximately 2:59 PM. 105634 Page 9 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

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. Based on interview and record review, the facility failed to ensure interdisciplinary team involvement in the development and review of the comprehensive plan of care for 3 of 3 residents reviewed. (Residents #2, #8 and #11). The findings include: On 6/12/23 at approximately 1:10 PM an interview was conducted with the spouse of resident #8 during which he stated that the resident had been in the facility for about 10 months, and he had not been told what services his wife was receiving especially related to therapy. He stated he received a letter from the facility shortly after she was admitted about attending a care plan meeting but has not received one since. He stated that he was not able to attend this meeting due to living so far from the facility and was not given the option to attend via conference call. On 6/13/23 at approximately 9:55 AM an interview was conducted with the daughter of resident #11 during which she stated that the facility does not have care plan meetings and that she has not been invited to attend any since her mother was admitted in January. On 6/13/23 at approximately 12:51 PM an interview was conducted with the MDS coordinator. She stated that families are called to let them know there is a care plan meeting and are given the date and the time of the meeting. She reported the facility does not send letters to the families just attempts to call them. She stated that she is behind in putting the care plan notices into the computer. She provided the Quarterly Care Plan Meeting Minutes for 3 residents. She stated these were all that she had and that the staff members listed are the only ones who have attended the meetings. Documentation revealed: -Resident #11 had a Quarterly care plan meeting on 4/26/23. The team members in attendance were the MDS coordinator and staff member J, a certified nursing assistant (CNA). -Resident #2 had a Quarterly Care plan meeting on 3/29/23. The team members in attendance were the MDS Coordinator and staff member K, whose title is agency staff. -Resident #8 had a Quarterly Care plan meeting on 4/19/23. The team members in attendance were the MDS Coordinator and staff member K, agency staff. On 6/13/23 at approximately 12:31 PM an interview was conducted with the Social Services Director who stated that she started her job in May and has not attended a care plan meeting. On 6/14/23 at approximately 1:28 PM an interview was conducted with the Director of Nursing who stated that care plan meetings are scheduled by the MDS coordinator and therapy. She stated that she is not always able to go. She reported that families should be notified of the meetings via letter and via telephone, and if not able to attend offered to call in via conference call. These communications should be documented in the electronic medical record. A review of the Comprehensive Care Plans policy dated 11/2020 and revised on 7/27/22 states that the comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to the attending physician, a registered nurse who responsibility for the resident, the nurse 105634 Page 10 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0657 Level of Harm - Minimal harm or potential for actual harm aide with responsibility for the resident, a member of the food and nutrition services staff, the resident and the resident representative other appropriate staff or professionals in disciplines as determined by the resident's needs or requested by the residents. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Residents Affected - Some 105634 Page 11 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure staff follow appropriate isolation precautions during the provision of resident care for 1 of 3 sampled residents on transmission-based precautions. (Resident #6). This has the potential to affect all residents in the facility who receive care by facility staff and who come in contact with the resident as he propels himself through the facility. Residents Affected - Some The findings include: On 6/12/23 at approximately 11:15 AM an observation was made of resident #6. On the door of his room was observed a sign that stated STOP Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. An isolation kit was noted hanging from the top of the door that included blue disposable isolation gowns, blue foot covers and three boxes of gloves. A machinal lift was blocking the doorway. Two certified nursing assistants (CNAs) were observed assisting the resident in his wheelchair, applying the leg rests to the chair and cleaning up around the room. The resident was observed to have the mechanical lift sling under him. The two CNAs, staff members C and D, were not noted to being wearing any personal protective equipment (PPE). During the observation a housekeeper was observed to enter the room and replace the alcohol-based hand sanitizer on the wall, he also did not donn PPE before entering the room and was not observed to perform hand hygiene. The CNAs exited the room pushing the mechanical lift against the wall across from the room. At no time was either CNA observed to perform hand hygiene or sanitize the mechanical lift. On 6/12/23 at approximately 11:21 AM an interview was conducted with resident #6 during which he stated that he had been in the facility for approximately 7 months and that he had c-diff (Clostridioides difficile). He stated that staff were fairly good at putting on PPE and offered they did it approximately 85% of the time. He stated the CNAs were helping him get up for the day and had used the lift to get him out of bed, he verified that the CNAs did not have on gowns or gloves but stated that they never touched him just got him out of bed. He stated the facility cannot keep him in his room and he is free to go where he wants, he is not a prisoner. At the end of the observation the surveyor attempted to find a trash bin to discard PPE and the resident went to his bathroom and removed a small trash can with paper towels and other debris stating just throw it in here there there was no discarded PPE noted in the trash bin and no other container noted in the room for discarded PPE. According to the Centers for Disease Control and Prevention (CDC) C. diff is a highly contagious bacterium (germ) that causes diarrhea and colitis (an inflammation of the colon). C.diff is infections and can be life-threatening. The CDC Recommendations for the healthcare setting is to use contact precautions for patients with known or suspected c-diff; wear gloves and a gown when entering a c-diff patient's room and during care. There is no single method of hand hygiene that will eliminate all c-diff spores using gloves to prevent hand contamination remains the cornerstone of preventing c-dff transmission via the bad of healthcare personnel. Dedicate or perform cleaning and disinfecting of any shared medical equipment between patients. Implement an environmental cleaning and disinfection strategy by ensuring adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. 105634 Page 12 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 Retrieved on 6/13/23 from https://www.cdc.gov/cdiff/clinicians/resources.html Level of Harm - Minimal harm or potential for actual harm On 6/12/23 at approximately 1:25 PM an interview was conducted with staff member C, CNA, who had been observed without PPE while caring for resident #6. She reported the resident had been on isolation for about two weeks for C-diff. She stated that they only have to put on PPE when they have physical contact with the resident. She stated that hand sanitizer or soap was okay to use when sanitizing your hands. Residents Affected - Some On 6/12/23 at approximately 1:40 PM an observation was made of Resident #6 who was resting in his wheelchair in the smoking area talking with other residents and the CNA who was monitoring the smoking porch. He was observed to hand the CNA a round container of tobacco at which time he stated that he had to give it to her (the CNA) because he was not allowed to keep it in his room. He was not wearing PPE. The CNA was observed to put the container of tobacco into the cart with other residents' cigarettes and lighters. The CNA was not wearing gloves and did not perform hand hygiene. On 6/12/23 at approximately 2:11 PM an interview was conducted with staff member D, CNA, who was observed earlier in the day providing care to resident #6 without PPE. She stated, we did not know he was on isolation and offered that the resident roams around the facility, so no one knows he is on isolation. She offered that the nurses usually let them know when someone is on isolation but she did not know. She also stated that she only put the feet on the resident's wheelchair and did not touch the resident so she really did not need to have on PPE. On 6/12/23 at approximately 2:39 PM an interview was conducted with the unit manager who reported that the isolation crates on the doors should alert staff when a resident is on isolation. She stated that resident #6 is on isolation for c-dff is total care and staff should be donning PPE, to include gowns, gloves and booties (shoe covers) before they enter his room. She said if staff just have a quick question they can stand at the doorway and ask a question but if they enter the room, they must donn PPE. She offered that he is a smoker and that she had notified the big bosses that he was going to the smoke area. She reported the c-diff was contained so it is okay for him to go outside to smoke. It is not spread by coughing or sneezing, but he should not share a room, he is in a private room. She stated that they remind him he is on isolation. He hates to be inside all the time, so he goes outside to the smoke porch. He is incontinent and total care. He chews tobacco he has a can of dip that they keep locked up in the bin on the smoke porch. He can do his own dip and handles the container himself. She stated that she had been told about the two CNAs not wearing PPE this morning and has started in-services with staff. She stated, they should have known and verified the lift was used for more than one resident and should have been cleaned after use. On 6/12/23 at approximately 3:40 PM an interview was conducted with the Administrator who presented a Performance Improvement Plan (PIP) dated for today (6/12/23) for infection control/isolation. He stated that he was not sure if the resident had been provided education on how to keep other resident's safe from exposure to C-diff but would get the Director of Nursing (DON). He stated that the resident does not wish to stay in his room and likes to go outside to chew tobacco during smoking times. He stated that he has encouraged the resident to stay in his room but feels he cannot force him. 6/12/23 at approximately 3:59 PM, an interview was conducted with the DON and the Administrator during which the DON stated that they recommend the resident stay in his room but it is difficult to keep him there. He is alert and oriented, but he is not compliant with the policy and procedures. The DON verified that there is no education documented in his electronic medical record but they have talked to him about protecting other residents. He was readmitted to the facility on [DATE] and 105634 Page 13 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 returned positive for c-diff. She stated all education had been verbal. Level of Harm - Minimal harm or potential for actual harm 6/12/23 at approximately 4:20 PM a follow-up interview was conducted with resident #6 in the presence of the Administrator, who was observed in his wheelchair talking in the doorway of another resident's room. He stated that he had not been offered any education on c-diff by the facility, they had just told him he should stay in his room. Her verified again that the CNAs did not wear PPE while transferring him using the mechanical list this morning but again stated they never touched him during the transfer. He voiced concern that the CNAs were written up for not using PPE and stated he does not touch anyone when his is outside his room and never high-[NAME] anyone just does elbow bumps which he demonstrated with the Administrator as they bumped their elbows together, both were wearing short sleeve shirts, their elbows made contact. They both stated they do this all the time most every time they pass in the hallway. The resident said he likes going to the smoke area and can't stay in his room he'd go crazy staying in there all time. He stated he educated himself on google about c-diff and that the staff have not talked to him about it outside of the need to stay in his room. Residents Affected - Some 6/13/23 at approximately 11:38 AM an interview was conducted with staff member G, CNA, who was observe monitoring the smoking porch and assisting resident #6 with his chewing tobacco. She stated that she hands the resident his can of tobacco to the resident and he gets out his own tobacco. After he is finished she placed it back into the drawer. She does not clean the can or sanitize her hands because he is not providing care. There is no observation of cleaning supplies or alcohol based hand sanitizer noted on the smoke porch. On 6/14/23 at approximately 1:44 PM a follow up interview was conducted with the Unit Manager who stated that training on isolation is done in orientation via the infection control portion of the training. She stated she had put up the isolation crate on Friday so between Friday and Monday someone took it down. She offered that soap and water is preferred because it kills everything, but alcohol-based hand sanitizer can be used if you just touch his tray or the doorknob in his room. She stated that you should preform hand hygiene when you exit his room but to use soap and water you would have to walk through his room after you wash your hands because the bathroom is toward the back and that is where the sink is. A review of the medical record for resident #6 revealed he was readmitted to the facility on [DATE] with a stage 4 pressure ulcer, amputation of two or more left toes, COPD, PVD, asthma and diverticulitis. The admitting 3008 identifies C-diff contact bleach. Contract Isolation was initiated on 5/30/23. Review of the last quarterly MDS revealed he is frequently incontinent of bowel and bladder and requires one person physical assist with toilet use and personal hygiene. BIMS is 15. Review of the plan of care indicated the resident is on contact isolation for c-diff. interventions include encourage food clean hygiene techniques to avoid cross contamination, especially hand washing before meals and after bowel movement observe facility policies for infection control. Contact isolation every shift for c-diff until 6/29/23. A review of the Transmission-based (Isolation) Precautions policy dated 11/2022 and revised May 2023 states that contact precautions refer to measures that are intended to prevent transmission of infections agents which are spread by direct or indirect contract with the resident or their resident's environment. Contact precautions include c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the residents' environment. D. Donning personal protective equipment (PPR) upon room entry and discarding before exiting the room is done to contain pathogens especially those that have been implicated I transmission through environments contamination (i.e VRE, c. 105634 Page 14 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0880 difficile . The policy states that clostridioides difficile, formerly clostridium difficile requires contact isolation for the duration of the illness and states that hand hygiene will soap and water. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 105634 Page 15 of 16 105634 06/14/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0943 Level of Harm - Minimal harm or potential for actual harm Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on record review and interview, the facility failed to ensure that staff were provided with abuse education at least annually for 7 of 8 staff members reviewed. (Staff Members C, D, E, F, M, N, and O) Residents Affected - Some The findings include: On 6/13/23 at approximately 1:27 PM, an interview was conducted with the Business Office Manager (BOM) who stated she started with the facility in January 2023. She stated that she ensures that all staff are on the employee roster and maintains the employee files to include education files. At this time she was given a list of employees with the request to provide the dates they had received training on abuse. These employees were employee C, certified nursing assistant (CNA) with a date of hire of 11/01/19; employee D, CNA, with a date of hire of 6/9/22; employee E, CNA, date of hire 8/31/22; employee M, Contractor with a date of hire of 9/12/22; employee N, Registered Nurse with a date of hire of 7/11/22 and employee O, Maintenance with a date of hire of 5/11/22. The request included employee F, Licensed Practical Nurse (LPN) date of hire not available and the Unit Manager. On 6/14/23 at approximately 11:33 AM, an interview was conducted with the BOM who reported that she does not have copies of abuse training for any employee who started prior to her starting her position in January 2023. She said she had not been able to find any reports from the previous Business Office Manager and feels they were lost or in a box that is somewhere in the building, but she has given up trying to find them and started new with anyone who has been hired since she started. On 6/14/23 at approximately 1:28 PM, the Director of Nursing (DON) who stated that she did in-services with staff on abuse and kept the sign-in sheets in a binder in her office. She stated that employee F, LPN was an agency nurse. At this time, she accessed an electronic employee file from the staffing agency the facility utilized for nursing staff. Staff member F's name appeared on the screen, but abuse training was not listed as being provided. The DON then stated that she was sure the staff member had received abuse training and she would review her binders for the nurse's name. By the time of survey exit abuse training related to staff member F, had not been provided by the DON. 105634 Page 16 of 16