Health inspection·November 3, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record reviews, interviews, and facility policy and procedure review, the facility failed to notify the resident, the resident's representative, and the office of the Long-Term Care Ombudsman of the resident's transfer and the reasons for the transfer in writing for one (Resident #1) of three residents reviewed for hospitalization. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on 9/16/23. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. Resident #1's medical record revealed that he had his wife designated as his primary emergency contact and responsible party. A review of the resident's nursing progress notes revealed that on 9/20/23 at 2:09 pm, Employee E, Registered Nurse (RN)/Unit Manager (UM) was summoned by the therapist who was performing exercises in the resident's room. Resident #1 was unable to perform his exercises due to bleeding sores all over his body. Upon assessment, the resident's upper thigh had more wounds and they were profusely bleeding. Resident #1 complained of itching and kept scratching his sores. He was using napkins to stop the bleeding site. The resident was not following instructions and kept picking the sores. The doctor was made aware and ordered the resident sent to the hospital for evaluation and proper management. The wife was notified and became upset. She refused for the husband to go to the referred hospital because they had had a bad experience, and they did not receive good service in the past. The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medical Director were notified and decided to send the resident to the hospital from where he was admitted to the facility. The note indicated, At this time, we are not able to meet the resident's needs. He requires more monitoring and proper management. (Copy obtained) The DON was interviewed on 10/12/23 at 5:27 pm who stated she contacted the hospital discharge planner. She confirmed Resident #1 physically left the faciity on 9/20/2023. She stated the facility contacted the hospital to advise them they could not meet the resident's needs because of the bleeding, and it was then the hospital advised the facility that the resident was being admitted . The DON stated the facility also notified the resident's wife of the discharge. She was asked to provide a copy of the discharge summary or discharge forms. Page 1 of 9 105645 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/12/23 at 5:46 pm, the DON and Social Services Director (SSD) returned with a blank Nursing Home requested. The purpose of the form was explained to staff. The SSD stated they would need to contact medical records. On 10/12/23 at 6:01 pm, the DON stated they were not able to locate a discharge summary or Nursing was not readmitted to the facility and stated they were unsure of his current location. She confirmed he should have received the form and stated there isn't a separate policy to address hospital transfers. A phone interview was conducted with Resident #1's wife on 11/3/23 at 10:06 am. She stated the facility informed her that her husband was being transferred to the hospital for treatment on 9/20/23. She was not aware that they were not allowing him to return until she received a call from the hospital the following day. She stated she never received a phone call or any paperwork from the facility regarding a bed-hold or discharge. She stated the hospital informed her that the facility refused to accept the resident back because he was HIV positive and bleeding profusely from his wounds. She stated the resident had MRSA which left him with the sores on his body. However, he does not have HIV and should have been allowed to return to the facility for wound care. The wife stated the resident was discharged home from the hospital after the facility continuously refused to accept him back. She stated no one from the facility has contacted her regarding the resident's status nor had she received anything from them since he was discharged . On 11/3/23 at 10:36 am, a phone interview was conducted with the Ombudsman. She stated as of today, she has not received a notice of discharge for Resident #1 from the facility. She added that she has made attempts to make herself available to the facility for transfer and discharge training. Review of the facility's policy for Notice of Transfer and Discharge (policy BC ADM-005) effective 6/13 and last review/update on 6/23 revealed: Purpose: To develop a process to notify a Guest/Resident about a Notice of a Transfer and or Discharge from facility. a. The transfer is necessary for the Guest/Resident's welfare and the Guest/Resident/Elder's needs cannot be met in the facility; 2. The Guest/Resident and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the Guest/Resident is being transferred or discharged ; d. The name, address, and telephone number of the state long-term care ombudsman; A resident has the right to request an ombudsman to review the notice. If the resident request notice to be reviewed by the local ombudsman the facility will transmit the request to review within 24 hours to the local district office. In emergency discharge situation a request for ombudsman review will be 105645 Page 2 of 9 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0623 transmitted to the ombudsman by telephone or in person. (Copy obtained) Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105645 Page 3 of 9 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on record reviews, interviews, and facility policy and procedure review, the facility failed to provide written information prior to hospital transfer that notified the resident/resident representative of the facility's bed hold policy for one (Resident #1) of three residents reviewed for hospital transfer. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on 9/16/23. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. Resident #1's medical record revealed that he had designated his wife as his primary emergency contact and responsible party. A discharge minimum data set (MDS) assessment with a reference date of 9/20/23, indicated unplanned discharge, return anticipated. Cognitive skills for decision making: moderately impaired. The activities of daily living (ADL) section revealed Resident #1 required supervision with bed mobility, transfers, locomotion on/off the unit, walking in the room/corridor, toilet use and personal hygiene. Resident was coded No for risk of pressure ulcers/injuries and unhealed pressure ulcers/injuries. The brief interview for mental status (BIMS) was not assessed. (Copy obtained) Resident #1 was care planned on 9/17/23 with focuses on bleeding due to use of anti-coagulants, impaired skin, HIV infection, and decreased ADL self-performance. Goals included reduced risk for signs and or symptoms of abnormal bleeding and no skin breakdown/impairment by next review date. Interventions included medications as ordered, report to MD any signs/symptoms of abnormal bleeding, turning and repositioning during care rounds, and weekly skin sweeps and monitor. (Copy obtained) A review of the resident's nursing progress notes revealed that on 9/20/23 at 2:09 pm, Employee E, Registered Nurse (RN)/Unit Manager (UM) was summoned by the therapist who was performing exercises in the patient's room. Resident #1 was unable to perform his exercises due to bleeding sores all over his body. Upon assessment, the resident's upper thigh had more wounds and they were profusely bleeding. The resident complained of itching and kept scratching his sores. He was using napkins to stop the bleeding site. The resident was not following instructions and kept picking the sores. The doctor was made aware and ordered the resident sent to the hospital for evaluation and proper management. The wife was notified and became upset. She refused for the husband to go to the referred hospital because they had had a bad experience, and they did not receive good service in the past. The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medical Director were notified and decided to send the resident to the hospital from which he was admitted to the facility. The note indicated, At this time, we are not able to meet the resident's needs. He requires more monitoring and proper management. (Copy obtained) A phone interview was conducted with Resident #1's wife on 11/3/23 at 10:06 am. She stated the facility informed her that her husband was being transferred to the hospital for treatment on 9/20/23. She was not aware that they were not allowing him to return until she received a call from the 105645 Page 4 of 9 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital the following day. She stated she never received a phone call or any paperwork from the facility regarding a bed-hold or discharge. She stated the hospital informed her that the facility refused to accept the resident back because he was HIV positive and bleeding profusely from his wounds. She stated the resident had MRSA which left him with the sores on his body. However, he does not have HIV and should have been allowed to return to the facility for wound care. The wife stated the resident was discharged home after the facility continuously refused to accept him back. She stated no one from the facility has contacted her regarding the resident's status nor had she received anything from them since he was discharged . Further review of Resident #1's record revealed there was no bed hold notice provided to the resident or representative notifying them of the facility's bed hold policy, the duration the bed would be held in his absence, or any daily room rate should the resident/representative choose to hold a bed while hospitalized . An interview was conducted with Employee G, the Business Office Manager (BOM) on 11/3/23 at 12:13 pm, who stated the resident was not contacted regarding a bed hold for his transfer on 9/20/23. The BOM stated she was not sure why the bed hold was not done. She stated typically when a resident goes out to the hospital, the business office will contact the resident or their family and follow up with admissions to see if the resident will be returning to facility. She again stated she was not sure why the resident was not contacted about a bed hold. She stated the business office, or the nurse manager will usually communicate with the patient or responsible party. The BOM stated the bed-hold can be signed upon admission; however, the business office may still follow-up with residents when they go out to the hospital. She again confirmed there was no bed-hold for Resident #1 and that it would have been appropriate for him to receive the bed-hold upon being transferred to the hospital. During an interview with the Administrator on 11/3/23 at 1:49 pm, he stated the resident wasn't allowed to return due to his excessive bleeding. He stated he and the DON spoke to the discharge planner at the hospital regarding their concerns. He felt the hospital did not accurately assess the resident and instead were inappropriately attempting to send him back to the facility. He felt the hospital needed to see the resident's bleeding. He acknowledged the facility refused to accept the resident back. He stated under normal circumstances Resident #1 would have been allowed to return; however, due to the excessive bleeding, they felt it was not safe for him to return to the facility. The administrator stated he was not sure if a bed hold was issued. He stated that would have come from the business office. Review of the facility's policy on bed holds which is included in all admissions packet revealed: K. Bed Holds. You may need to be absent from the Skilled Nursing Facility temporarily for hospitalization or therapeutic leave. You may request that we hold your bed during this time. This is known as a bed hold. You shall be given notice of the bed hold option at the time of admission and upon hospitalization or therapeutic leave. (Copy obtained) Review of the facility's policy for Bed Holds and Notice Acknowledgement (policy BC ADM-001) effective 6/23 and last review/update on 7/23 revealed: Policy: Facility will follow Florida Policy on Bed Holds and Notice Acknowledgement. D. Facility Bed Hold Policy - The facility will reserve the bed of a resident who has been transferred to a hospital or who otherwise leaves the facility with the expectation of returning in the near 105645 Page 5 of 9 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few future, as long as payment is made in advance to reserve the bed in accordance with the facility's bed hold charge. The resident/responsible party agrees that in the event of such temporary leave from the facility the facility shall reserve the bed until such time that the advance payment ceases to cover the bed hold or the facility is notified by the resident/responsible party that the bed should no longer be reserved. The facility will similarly reserve the bed, as long as payment is made in advance in anticipation of pending admission. The facility bed hold charge is FULL Price per day. (Copy obtained) . 105645 Page 6 of 9 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to permit a resident to return after a transfer to the hospital for one (Resident #1) of three residents reviewed for transfer/discharge. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on 9/16/23. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. A telephone interview was conducted with the hospital discharge planner on 10/12/23 at 10:26 am regarding Resident #1. She stated the resident was previously sent to the hospital on 9/18/23 and returned to the facility the same day. Resident #1 returned to the hospital emergency department on 9/20/23 at approximately 3:30 pm for observation. The resident was there less than 30 minutes when the doctor said he was stable and that there was no medical reason for him to remain at the hospital. She said when they contacted the facility's Director of Admissions and Administrator, they declined to accept the resident back. She stated neither could provide a clear reason why they wouldn't readmit the resident. She stated the hospital made attempts to find a long-term acute care center for the resident, but he didn't qualify for admission. As a result, the resident remained at the hospital until the doctor ordered him to be discharged home with home health. Resident #1's medical record revealed that he had designated his wife as his primary emergency contact and responsible party. A discharge minimum data set (MDS) assessment with a reference date of 9/20/23, indicated unplanned discharge, return anticipated. Cognitive skills for decision making: moderately impaired. The activities of daily living (ADL) section revealed Resident #1 required supervision with bed mobility, transfers, locomotion on/off the unit, walking in the room/corridor, toilet use and personal hygiene. Resident was coded No for risk of pressure ulcers/injuries and unhealed pressure ulcers/injuries. The brief interview for mental status (BIMS) was not assessed. (Copy obtained) Resident #1 was care planned on 9/17/23 with focuses on bleeding due to use of anti-coagulants, impaired skin, HIV infection, and decreased ADL self-performance. Goals included reduced risk for signs and or symptoms of abnormal bleeding and no skin breakdown/impairment by next review date. Interventions included medications as ordered, report to MD any signs/symptoms of abnormal bleeding, turning and repositioning during care rounds, and weekly skin sweeps and monitor. (Copy obtained) A review of the resident's nursing progress notes revealed that on 9/20/23 at 2:09 pm, Employee E, Registered Nurse (RN)/Unit Manager (UM) was summoned by the therapist who was performing exercises in the resident's room. Resident #1 was unable to perform his exercises due to bleeding sores all over his body. Upon assessment the resident's upper thigh had more wounds and they were profusely bleeding. The resident complained of itching and kept scratching his sores. He was using napkins to stop the bleeding site. The resident was not following instructions and kept picking the sores. The doctor was made aware and ordered the resident sent to the hospital for evaluation and proper management. 105645 Page 7 of 9 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The wife was notified and became upset. She refused for the husband to go to the referred hospital because they had had a bad experience, and they did not receive good service in the past. The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medical Director were notified and decided to send the resident to the hospital from where he was admitted to the facility. The note indicated, At this time, we are not able to meet the resident's needs. He requires more monitoring and proper management. (Copy obtained) An interview was conducted with Employee E, RN/UM on 10/12/23 at 4:06 pm. She confirmed Resident #1 was sent to the hospital on 9/20/23. She stated it was his second time going to the hospital after being admitted on [DATE]. He was sent to the hospital on 9/18/2023 for excessive bleeding and returned to the facility that same day. However, he wasn't readmitted after the hospitalization on 9/20/2023 because the facility could not meet his needs due to the profuse bleeding. She stated the hospital didn't treat the resident and every time they would touch him, he would bleed. The resident was confused and was picking at his skin and the facility was worried about infections. She stated there was no discharge paperwork because the resident went out to the hospital. She confirmed the resident had not returned to the facility. An interview was conducted with the Social Services Director/Discharge Planner (SSD) on 10/12/23 at 5:07 pm, who was familiar with Resident #1. She stated he went out to the hospital twice, adding he went once and came back. Then he went back and was admitted . The SSD stated she had been out and did not see him for a full assessment. She stated if a resident is transferred to the hospital, it's anticipated that they will 3120-0002 and stated that the resident should have one on file. She then left the room to look for the form. An interview was conducted on 10/12/23 at 5:27 pm with the Director of Nursing (DON), who stated she contacted the hospital discharge planner. She confirmed Resident #1 physically left the faciity on 9/20/2023. She stated the facility contacted the hospital to advise them they could not meet the resident's needs because of the bleeding, and it was then the hospital advised the the facility that the resident was being admitted . The DON stated the facility also notified the resident's wife of the discharge. She was asked to provide a copy of the discharge summary or Nursing Home Transfer and Discharge Notice AHCA form 3120-0002. She stated the resident received the discharge forms. On 10/12/23 at 5:46 pm, the DON and SSD returned with a blank Nursing Home Transfer and Discharge the form was explained to staff. The SSD stated they would need to contact medical records. On 10/12/23 at 6:01pm, the DON stated they were not able to locate a discharge summary or Nursing was not readmitted to the facility and stated they were unsure of his current location. She confirmed he should have received the form and stated there isn't a separate policy to address hospital transfers. A phone interview was conducted with Resident #1's wife on 11/3/23 at 10:06 am. She stated the facility informed her that her husband was being transferred to the hospital for treatment on 9/20/23. She was not aware that they were not allowing him to return until she received a call from the hospital the following day. She stated she never received a phone call or any paperwork from the facility regarding a bed-hold or discharge. She stated the hospital informed her that the facility refused to accept the resident back because he was HIV positive and bleeding profusely from his wounds. She 105645 Page 8 of 9 105645 11/03/2023 Bartram Crossing 6209 Brooks Bartram Drive Jacksonville, FL 32258

F 0626 Level of Harm - Minimal harm or potential for actual harm stated the resident had MRSA which left him with the sores on his body. However, he does not have HIV and should have been allowed to return to the facility for wound care. The wife stated the resident was discharged home after the facility continuously refused to accept him back. She stated no one from the facility has contacted her regarding the resident's status nor had she received anything from them since he was discharged . Residents Affected - Few An interview was conducted with Employee G, the Business Office Manager (BOM) on 11/3/23 at 12:13 pm, who stated that Resident #1 was not contacted regarding a bed hold for his transfer on 9/20/23. She stated she was not sure why the bed hold was not done. She stated typically when a resident goes out to the hospital, the business office will contact the resident or their family and follow up with admissions to see if the resident will be returning to facility. The BOM again stated she was not sure why the resident was not contacted about a bed hold. She stated the business office, or the nurse manager will usually communicate with the patient or responsible party. She stated the bed-hold can be signed upon admission; however, the business office may still follow-up with residents when they go out to the hospital. She again confirmed there was no bed-hold for Resident #1 and that it would have been appropriate for him to receive the bed-hold upon being transferred to the hospital. During a follow up interview with the DON on 11/3/23 at 12:35 pm, she again confirmed that Resident #1 was sent to the hospital for treatment for excessive bleeding. She stated the resident needed a higher level of care for his wounds. She stated the facility felt the hospital needed to appropriately assess the resident's condition instead of returning him to the facility. She confirmed that the bed hold was not discussed again, adding the resident needed a higher level of care. She stated they asked the family to provide a private sitter for the resident, but they could not. She stated the facility also made attempts to provide a private sitter to keep the resident safe; however, they also were unsuccessful. She stated the resident needed one-to-one care and that the facility did not have the staff to support that. During an interview with the Administrator on 11/3/23 at 1:49 pm, he stated that Resident #1 wasn't allowed to return due to his excessive bleeding. He stated he and the DON spoke to the discharge planner at the hospital regarding their concerns. He felt the hospital did not accurately assess the resident and instead were inappropriately attempting to send him back to the facility. He stated they felt the hospital needed to see the resident's bleeding. The administrator acknowledged the facility refused to accept the resident back. He stated under normal circumstances he would have been allowed to return; however, due to the excessive bleeding, they felt it was not safe for him to return to the facility. He stated he was not sure if a bed hold was issued. He stated that would have come from the business office. Further record review revealed the facility failed to enter a bed hold during Resident #1's hospitalization. Per billing census, a stop billing was entered on 9/20/2023. . 105645 Page 9 of 9