Health inspection·August 17, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure prompt efforts were taken to resolve a grievance for one (Resident #12) of one resident reviewed on the facility's grievance process. Findings included: A review of the facility's Grievance Log dated June 2023 showed an entry for Resident #12 dated 06/14/23. The entry showed Resident #12's grievance was about Resident deliveries. The column on the grievance form titled,disposition of grievance was left blank. A review of Resident #12's Grievance Form dated 06/14/23 showed Resident indicted a package was delivered in February and Resident did not receive package. Order was tracked and package was shown to be delivered. This was a wrist blood pressure cuff. The grievance follow up showed, Resident re-ordered a wrist blood pressure cuff back in [DATE]. We cannot reimburse resident, however we could have re-ordered the cuff. During an interview on 08/17/23 at 9:50 a.m., Staff Q Social Service Director (SSD) stated Resident #12's grievance started back in February 2023. Staff Q stated the grievance remained un-resolved in June 2023 when she took over as grievance officer. In June 2023, Staff Q followed up with Resident #12's missing property but informed Resident #12 there was nothing the facility could do as the facility did not replace resident's missing property so, Resident #12 chose to re-order the blood pressure again. Staff Q stated the grievance remained unresolved as there was nothing the facility could do for Resident #12. During an interview on 08/17/23 at 10:00 a.m., Resident #12 stated she had ordered a blood pressure cuff in February 2023 but never got it. Resident #12 stated the package tracker said the package was delivered to the facility. Resident #12 stated when she asked for the package the facility stated the package was missing. Resident #12 stated in June 2023, [Staff Q] discussed the missing blood pressure cuff with me but told me I would need to reorder my blood pressure cuff as the facility did not replace missing items. During an interview on 08/17/23 at 11:00 a.m., the Director of Nursing (DON) stated the facility did replace missing items for residents. The Staff Q was a fairly new employee and would need to be educated on the facility's policy and procedures for missing resident items. The DON stated Resident #12 would be reimbursed, and the SSD would be educated prior to the survey team leaving the facility today. Page 1 of 6 105634 105634 08/17/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/17/23 at 11:05 a.m., the Regional Nurse Consultant (RNC) stated that facility policy and procedure was to reimburse residents for missing items and it was the expectation that the missing item should have been replaced when it was reviewed by Staff Q, SSD in June 2023. During an interview on 08/17/23 at 3:56 p.m., the Regional Director of Operations stated resident reimbursement is on a case by base basis but if the facility lost or destroyed a resident's belonging then it was expected that the facility be responsibility to replace the item. Review of the facility's policy Resident and Family Grievances revised date 08/14/2023 stated, 10 Procedure: d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. 12. The facility will make prompt effort to resolve grievances. Review of the facility's policy Resident Personal Belongings revised date 08/14/2023 stated, 2. The facility will support the resident's right to use personal possessions to promote a homelike environment and maintain their independence. 7. The facility will exercise reasonable care for the protection of the resident's property from loss and theft. 105634 Page 2 of 6 105634 08/17/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the resident activities program for three (Residents #14,#15, and #16) of 21 sampled residents was directed by a qualified activities professional. Residents Affected - Few An interview was conducted at 10:01 a.m. on 8/17/23, with the activities director who stated she had worked at the facility for several years as a Certified Nursing Assistant (CNA) and was promoted to activities director approximately three months ago. She confirmed she had not taken an approved training course and that the last administrator was supposed to help her sign up for the required training, but did not do so before he left. She stated she participated in resident care plan meetings and documented in the resident records. Record review of the attendance logs for the sampled Residents ( #14, #15, and #16), confirmed she directed resident group and one on one activities; and documented participation at group and one on one activities. Record review of the care plans for the sampled Residents (#14, #15,and #16) confirmed she participated in the activities care plan meetings with updates and activity assessments. An interview with the regional nursing consultant on 8/17/2023 at 1:00 p.m., confirmed the activities director was not qualified and that they would put a plan in place to make sure she became qualified as soon as possible. 105634 Page 3 of 6 105634 08/17/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to complete a neurochecks assessment and accurate skin assessments for one (Resident #12) of three residents reviewed for falls. Residents Affected - Few Findings included: An observation on 08/17/23 at 10:00 a.m., revealed Resident #12 was sitting in bed and had bruising on her right arm. (Photographic Evidence Obtained) During an interview on 08/17/23 at 10:00 a.m., Resident #12 stated she fell a couple nights ago. She stated she got up to go to the bathroom and fell. She stated staff came in and helped her off the floor. Resident #12 stated no one assessed her arm after her fall. She said her bruised arm was sore but her butt where she fell hurt more than her arm. A review of the facility's fall log for [DATE] showed Resident #12 had an unwitnessed fall on 08/14/23 at 6:06 a.m. A review of Resident #12's medical record showed she was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of native coronary artery with unstable angina pectoris, lack of coordination, muscle weakness, difficulty walking and repeated falls. The facesheet showed Resident #12 was her own responsible party. The care plan, initiated on 1/27/23, showed Resident #12 was at risk for falls and fall related to injury related to difficulty walking, history of halls and impaired mobility. The interventions included: Anticipate needs, provide prompt assistance, Encourage [Resident #12] to wear nonskid socks when getting out of bed and ambulating, Ensure call light is within use and encourage use for assist with standing/transferring and ambulation, Keep frequently used items within reach and Needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach. Further review of Resident 12's medical record showed a Post Fall Evaluation dated 08/15/23 that showed, Resident #12 had an unwitnessed fall on 08/14/23 at 2:30 a.m. The evaluation showed Resident #12 slipped while going to the bathroom. Resident #12 was wearing slipper and non-skid socks. neurochecks were initiated. There was no change of condition evaluation available for Resident #12's 08/14/23 fall and no physician orders available addressing Resident #12's right arm injury. Review of Resident #12's Neuro Check Assessment Form with start date 08/14/23 showed neurochecks are to be completed with the following timeline: - every 15 minutes for one hour - every 30 minutes for one hour - every one hour for four hours - every four hours for 24 hours - every shift until 72 hours after fall. 105634 Page 4 of 6 105634 08/17/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #12 had three of four 15 minute checks completed during the first hour. Resident #12 had one of two 30 minute checks completed during the second hour. Resident #12 had three of four one hour checks during the next four hours. A column dated 08/14/23 at 2:45 p.m. was left blank with no Neuro checks check completed. Review of the 72 Hour Monitoring forms revealed there were four skin assessments conducted after Resident #12's fall on 08/14/23. The four assessments showed: - 72 Hour Monitoring dated 08/17/23 at 6:36 a.m. showed no new altered skin alterations. - 72 Hour Monitoring dated 08/16/23 at 10:29 p.m. showed no new altered skin alterations. - 72 Hour Monitoring dated 08/16/23 at 1:37 p.m. showed no new altered skin alterations. - 72 Hour Monitoring dated 08/15/23 at 10:47 a.m. showed no new altered skin alterations. During an interview on 08/17/23 at 1:26 p.m., Staff P, Unit Manager (UM) stated Resident #12's Neuro Check Assessment Form with start date 08/14/23 was not completed accurately. Staff P stated Resident #12's Neuro Check Assessment Form was incomplete with blank spaces and she would expect the nurses to follow the timeline directions located in the top left of the Neuro Check Assessment Form when completing which was also inaccurate. During an interview on 08/17/23 at 1:36 p.m., the Regional Nurse Consultant (RNC) stated she would expect the neurochecks frequency to match the timeline listed on the top left of the neurochecks form. The RNC reviewed Resident #12's Neuro Check Assessment Form with a start date of 08/14/23 and confirmed neurochecks were not competed accurately. RNC reviewed Resident #12's 72 Hour Monitoring Assessments and confirmed the assessments were inaccurate as Resident #12 had bruising on her right arm. RNC stated she would expect to see a change of condition evaluation after a resident falls but there was no change of condition form completed in the medical record after Resident #12's fall on 08/14/23. During an additional interview on 08/17/23 at 3:13 p.m., Staff P stated every nurses station had a Resident fall guideline for the nurses. Staff P stated fall guidelines were titled, Falls Education What to do with every fall. and was used by the facility as a guidelines on the necessary tasks nurses needed to complete after a Resident falls. Review of Falls Education What to do with every fall. not dated showed: * Head to toe assessment * eInteract Change of Condition evaluation *Risk Management report *Treatment for any injury on the TAR *Intervention for fall *Neuro checks for 72 hours 105634 Page 5 of 6 105634 08/17/2023 Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756

F 0684 * Pass on in report Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled, Fall Prevention Program revised date 04/2023 showed, 7. When any resident experiences a fall, the facility will: Residents Affected - Few a. Assess the resident b. Initiate neuro checks if resident hits head and/or fall is unwitnessed. c. Complete an incident report d. Notify physician and family e. Review the resident's care plan and update as indicated. f. Document all assessment and actions g. Complete a fall investigation which may include obtaining statement from the resident and/or witnesses. 105634 Page 6 of 6