Health inspection·June 27, 2023

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 record review and interview, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime. This practice involved 1 out of 5 sampled residents (Resident #4). There were 111 residents residing in the facility at the time of the survey. The findings included: During an interview on 6/27/23 at 9:45AM with the Nursing Home Administrator (NHA) it was reported, I started working at this facility on 10/31/22, the former NHA, Staff E was here and the former Director of Nursing (DON) Staff D oversaw the investigation. From my recollection, Resident #4 was alleging that her pain medication was not given to her, an investigation started the nurse involved was called to the facility for investigation. I advised the former NHA, Staff E to report the incident to AHCA (Agency for Health Care Administration). The incident occurred on 10/27/22 and it was reported on 11/1/22 to AHCA, DCF (Department of Children and Family) and the Police Department. The nurse involved License was also reported to the nursing board. The nurse involved was suspended and later resigned from the facility. The resident was able to receive her scheduled pain medications from what we had in stock at the facility. The five-day investigation concluded no physical harm, pain or mental anguish was done to the resident. The complaint allegation of misappropriation of resident property was substantiated, the nurse was terminated and then he resigned. I am aware that the report should have been filed within two (2) hours of the alleged incident. Review of the medical records for Resident #4 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Aftercare following Joint replacement and Presence of left artificial knee joint. Resident #4 was discharged on 11/02/2022. Review of the Physician's Orders Sheet for October 2022 revealed, Resident #4 had orders that included but were not limited to: 10/23/22-10/28/22-Oxycodone HCL (Hydrochloride) tablet 5 Milligrams (MG)-Give 1 tablet by mouth every 4 hours as needed for pain. 10/28/22-11/2/22-Tylenol with codeine #3 tablet 300-30MG-Give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident # 4's Discharge Return not anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 13 on a 0-15 scale, indicating the resident is cognitively intact. Section J for Health conditions documented, the resident received scheduled pain medications in the last 5 days. Section N for Medications documented, the resident received antidepressants, and antibiotics in the last 7 days. Record review of Resident # 4's Care Plans Dated 10/24/2022 revealed: The resident is at risk for Page 1 of 2 105641 105641 06/27/2023 Nspire Healthcare Kendall 9400 SW 137th Avenue Kendall, FL 33186

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pain related to arthritis, left total Knee Replacement. Interventions included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Monitor and document the side effects. Provide the resident with assurance that pain is time limited. Review of the discharge summary progress note for Resident #4 dated 11/02/2022 timestamped 13:53 documented, Patient went home with son, vital signs were stable, patient was alert, Certified Nursing Assistant assisted patient to the vehicle. Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation revision date 11/16/2022 states: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrence of resident abuse. Misappropriation of resident property is the deliberate misplacement, exploitation or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent. Employee Misappropriation includes but is not limited to: o Diversion of resident's medication(s), including, but not limited to, controlled substances for staff use or personal gain. Reporting/Response Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with state law. 105641 Page 2 of 2