Health inspection·November 3, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #20's admission record revealed the resident was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident #20's medical records revealed the resident had a fall with injury on 10/3/2023. Resident #20 returned to the facility following a temporary absence for hospitalization on 10/9/2023 with a new diagnosis of fracture of left radius. Review of Resident #20's Minimum Data Set showed the resident's next assessment reference date of 10/16/2023 that was 18 days overdue. During an interview on 11/3/2023 at approximately 7:45 AM, the Director of Nursing stated, My expectation is that upon return to the facility, the assessment should be completed within 14 days. Review of the facility policy and procedure titled Resident Assessment Instrument (RAI) last reviewed on 3/30/2023 reads, Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capabilities and assist staff to identify problems for care plan development. Based on record review and interview, the facility failed to complete a minimum data set assessment in a timely manner for 1 of 5 residents reviewed for respiratory services, Resident #231, and 1 of 4 residents reviewed for accidents, Resident #20. Findings include: 1. Review of Resident #231's admission record showed the resident was admitted to the facility on [DATE]. Review of Resident #231's minimum data set assessments on 11/1/2023 showed the resident's Admission/Medicare 5 Day comprehensive assessment had a status of In Progress. During an interview on 11/1/2023 at 1:01 PM, the Minimum Data Set Coordinator stated Resident #231's Admission/Medicare 5 Day comprehensive assessment was due on 10/25/2023 and confirmed that it was not completed in a timely manner. Page 1 of 18 105652 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0641 Ensure each resident receives an accurate assessment. 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 interview, the facility failed to ensure the assessments accurately reflected the resident's status at the time of assessment for 2 of 2 residents reviewed for hospice services, Residents #27 and #41, and 1 of 4 residents reviewed for discharge, Resident #179. Residents Affected - Few Findings include: 1. Review of Hospice Medicare Revocation Statement signed by Resident #27 showed the resident had revoked the hospice election on 11/23/2022 to seek aggressive treatment. Review of Resident #27's Minimum Data Set (MDS) dated [DATE] showed hospice care while a resident under Section O. Special Treatment, Procedures, and Programs. During an interview on 11/3/2023 at approximately 7:45 AM, the Director of Nursing stated Resident #27 should not be coded as hospice. Review of the facility policy and procedure titled Resident Assessment Instrument (RAI) last reviewed on 3/30/2023 reads, Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capabilities and assist staff to identify problems for care plan development. Procedure . 4. Assessments are also completed for residents who have experienced a Significant Change. Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition . A significant change in status MOS [Sic.] is required when a resident elects, and revokes the hospice benefit, and if decline or improvement from baseline in 2 or more areas of the residence functional status. 2. Review of Resident #179's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including presence of unspecified artificial knee joint, hypertension, difficulty in walking, and gastro-esophageal reflux disease. Review of Resident #179's Discharge Planning Review dated 10/2/2023 showed the resident was discharged to private residence. Review of Resident #179's Minimum Data Set Assessment Discharge Return Not Anticipated dated 10/2/2023 showed the resident had been discharged to a short-term general hospital (acute hospital) under Section A2100. During an interview on 11/1/2023 at 10:42 AM, the Social Services Director stated, [Resident #179's Name] discharged home with her husband with home health. I arranged for home health services. I documented her discharge in the discharge summary. During an interview on 11/1/2023 at 11:06 AM, the MDS Coordinator confirmed the discharge assessment showed Resident #179 was discharged to an acute hospital. 105652 Page 2 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0641 Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #41's physician order dated 7/28/2023 reads, May Consult [Hospice's name] Hospice Care. Review of Resident #41's medical records revealed an RN-Initial Comprehensive Assessment for hospice completed on 7/28/2023. Residents Affected - Few Review of Resident's #41's Significant Change MDS dated [DATE] showed no hospice care while a resident identified under Section O. Special Treatment, Procedures, and Programs. During an interview on 11/1/2023 at 10:37 AM, the Director of Nursing stated, [Resident #41's name] is receiving hospice services and should have been coded. During an interview on 11/1/2023 at 10:52 AM, the MDS Coordinator stated, [Resident #41's name] is not coded for hospice services. We will correct it. Review of the facility policy and procedure titled Resident Assessment with the last review date of 3/30/2023 reads, Intent: It is the policy of the facility to provide care and services related to Resident Assessment/Instrument and Process in accordance to State and Federal regulation. Procedure: This policy will include . 7. Accuracy of Assessment. 105652 Page 3 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents with newly evident or possible serious mental disorder, intellectual disability or related condition were referred to the appropriate state designated authority for 3 of 4 residents reviewed for mood and behaviors, Residents #53, #95, #142. Findings include: 1. Review of Resident #142's admission record showed the resident was admitted on [DATE] and was diagnosed with brief psychotic disorder on 9/27/2022. Review of Resident #142's physician order dated 7/14/2023 reads, Valproic Acid (Depakote)**Sent to lab 7/14/2023 1:41 AM ET [Eastern Time] ** one time only related to autistic disorder, brief psychotic disorder. Review of Resident #142's physician order dated 8/30/2023 reads, Depakote Oral Tablet Delayed Release (Divalproex Sodium) give 750 mg [milligram] by mouth two times a day for mood disorder. Review (PASRR) dated 8/19/2022 showed no mental illness or suspected mental illness. Review of Resident #142's Annual MDS dated [DATE] showed psychotic disorder (other than schizophrenia) under Section I. Active Diagnoses. Review of Resident #142's care plan initiated on 10/5/2022 reads, Mood/ Behavior- The resident has a behavior problem- attention seeking behaviors r/t [related to] cognitive impairment due to autism/psychosis, resident also noted to void on floor rather than in bathroom, takes off soiled briefs and throws them on the floor. Curses and teases other residents. 2. Review of Resident #53's admission record showed the resident was admitted on [DATE] and was diagnosed with brief psychotic disorder on 2/1/2022. Review of Resident #53's Quarterly MDS dated [DATE] showed psychotic disorder (other than schizophrenia) under Section I. Active Diagnoses. Review of Resident #53's progress note dated 5/12/2023 reads, History of Present Illness: This is an [AGE] years old patient with past psychiatric history of depression, anxiety, dementia, insomnia and mood disorder. Prior to last visit, patient was suffering from sign and symptoms of mood disorder. Staff reported increased aggression and behaviors. Ordered Depakote and Depakote related labs. Review of Resident #53's care plan initiated on 11/1/2023 reads, Mood- The resident has a mood problem r/t depression, dementia, delusional disorder, brief psychotic disorder. Review (PASRR) dated 6/29/2016 showed depressive disorder. 3. Review of Resident #95's admission record showed the resident was admitted on [DATE] and was 105652 Page 4 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0644 diagnosed with brief psychotic disorder on 1/26/2022. Level of Harm - Minimal harm or potential for actual harm Review of Resident #95's Quarterly MDS dated [DATE] showed psychotic disorder (other than schizophrenia) under Section I. Active Diagnoses. Residents Affected - Some Review of Resident #95's Psychiatry Subsequent Note dated 5/26/2023 reads, Assessment and Plan: Pt [patient] is unstable requiring med [medication] changes: As per collected information and interview, it appears that patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying depressive disorder. The symptoms are occurring almost daily and causing severe distress. Review (PASRR) dated 9/10/2018 showed depressive disorder. During an interview on 11/2/2023 at 7:25 AM, the Director of Nursing stated, [Resident #53's name], [Resident #95's name], and [Resident #142's name] should have triggered for a review. I do not have that documentation. Review of the facility policy and procedure titled Resident Assessment with last review date of 3/30/2023 reads, Intent: It is the policy of the facility to provide care and services related to Resident Assessment/Instrument and Process in accordance to State and Federal regulation. Procedure: This policy will include . 9. Coordination of PASARR and Assessments. 10. PASARR Screening for MD [Mental Disorder] & ID [Intellectual Disability]. 105652 Page 5 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a person-centered care plan for 1 of 2 residents reviewed for hospice services, Resident #41, and 1 of 8 residents reviewed for nutrition, Resident #101. Findings include: 1. Review of Resident #41's physician order dated 9/29/2023 reads, [Hospice's name] Hospice. Review of Resident #41 progress notes dated 7/28/2023 reads, Consultation done on shift. [Hospice's name] consultation nurse stated that a nurse will be out to facility Monday and patient will be assigned a case manager at that time. Review of Resident #41's medical records revealed an RN-Initial Comprehensive Assessment for hospice completed on 7/28/2023. Review of Resident #41's care plan revealed no focus or interventions for hospice services. During an interview on 11/1/2023 at 10:37 AM, the Director of Nursing stated, Once hospice is recommended for a resident and the resident is signed up, we will include the services in the resident's care plan. [Resident #41's name] is receiving hospice services and should have been care planned. During an interview on 11/1/2023 at 10:52 AM, the MDS (Minimum Data Set) Coordinator stated, Resident is not care planned for hospice. We will correct it. 2. Review of Resident #101's physician order dated 7/24/2023 reads, Low Concentrated Sweets. Review of Resident #101's care plan initiated on 9/19/2023 reads, Focus: Dietary- The resident has nutritional problem or potential nutritional problem . Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight within (X)% of (specify baseline), no s/sx [signs and symptoms] of malnutrition, and consuming at least (X)% of at least (specify) meals daily through review date . Interventions: Device: Adaptive equipment as ordered. During an interview on 11/1/2023 at 9:55 AM, the Registered Dietician stated, I oversee the nutritional portion of the care plan. [Resident #101's name] care plan is not completed, and the resident does not use adaptive equipment. Review of the facility policy and procedure titled Person Centered Care Planning with the last review date of 3/30/2023 reads, An individualized comprehensive care plan will be person centered and must include measurable objectives and timetables that meet the resident's medical, nursing, mental, and psychosocial needs. The care plan will consider the whole person, taking into account each resident's unique qualities, abilities, interests, preferences, and needs. The facility's IDT [Interdisciplinary Team], in coordination with the resident, the resident's family or representative, develops and maintains this care plan in an effort to attain and /or maintain the highest level of function the resident may be expected to reach . Care plans are to be revised as changes in the resident's condition warrant or when there is a change in resident preference or choice of treatment. 105652 Page 6 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards for wound care for 1 of 3 residents reviewed for skin conditions, Resident #4. Residents Affected - Few Findings include: During an observation on 10/30/2023 at 10:35 AM, Resident #4 was sitting in her wheelchair with a dressing dated 10/25/2023 on her right forearm (photographic evidence obtained). During an interview on 10/30/2023 at 10:35 AM, Resident #4 stated, I have a skin tear on my arm. Review of Resident #4's physician order dated 10/13/2023 reads, Cleanse right forearm skin tear with NS [Normal Saline] apply TAO [triple-antibiotic ointment] with dry dressing. Monitor for s/s [signs/symptoms] of pain, infection, and or any concerns. Notify MD [Medical Doctor] as needed, in the evening for right forearm skin tear. During an interview on 11/1/2023 at 10:48 AM, the Director of Nursing stated, Staff is supposed to follow physician orders. Dressing should have been changed daily. Review of the facility policy and procedure titled Wound Care with the last review date of 3/30/2023 reads, Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 105652 Page 7 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on record review and interview, the facility failed to ensure residents received restorative services as recommended by the physical therapist to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents reviewed for activities of daily living, Resident #161. Findings include: Review of Resident #161's care plan initiated on 5/20/2023 revealed Resident #161 was a high risk for falls related to gait/balance problems with a history of pelvic fracture and unaware of safety needs. Fall prevention interventions included physical therapy evaluation and treatment as ordered or as needed. Review of Resident #161's physical therapy discharge summary for the dates of service of 6/17/2023 through 8/4/2023, reads, Discharge Recommendations and Status, Range of Motion Program Established/ Trained: Patient is currently able to move feet up and down, and tier is functional and with Restorative Nursing Program, patient will be able to move feet up and down and move legs up and down by performing the following Restorative Nursing interventions: allow resident to assist as possible, keep hands in position to maintain support of joint, complete each motion in a smooth, slow, rhythmic motion, encourage resident to assist with the ROM [Range of Motion] and passive ROM. Prognosis . Good with consistent staff follow-through. During an interview on 11/1/2023 at 9:58 AM, the Director of Rehabilitation stated Resident #161 had received physical therapy services from 6/1/2023 until 8/4/2023; Resident #161 had been discharged from physical therapy to the facility restorative program to work on bed mobility and transfers; and Resident #161's restorative program was to include active and passive range of motion including upper and lower body range of motion, bed mobility, rolling and sitting on the edge of the bed to maintain core strength. During an interview on 11/1/2023 at 10:04 AM, Staff A, Licensed Practical Nurse/ Unit Manager stated there was no documentation Resident #161 had participated in a restorative program. During an interview on 11/1/2023 beginning at 10:10 AM, Staff D, Restorative Certified Nursing Assistant stated Resident #161 was not on a restorative program and Resident #161 had been on restorative around August and they only had restorative on her for a certain amount of time. Staff D confirmed there was no documentation to show Resident #161 had participated in a restorative program or of a date for Resident #161 to stop receiving restorative services. During an interview on 11/1/2023 at 10:15 AM, the Director of Rehabilitation stated, We did not put stop times or dates or period of time for restorative programs until recently when the new Director of Nursing came. 105652 Page 8 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain appropriate parameters of nutritional status for 1 of 8 residents reviewed for nutrition, Resident #169. Residents Affected - Few Findings include: During an observation on 10/30/2023 at 12:36 PM, Resident #169 was eating independently in her room, with no supplement noted on her meal tray. During an observation on 10/31/2023 at 12:40 PM, Resident #169 was eating independently in her room, with no supplement noted on her meal tray. During an interview on 11/1/2023 at 12:35 PM, Resident #169's family member stated, I have not seen any supplements come with her lunch meals when I have been present. Review of Resident #169's physician order dated 9/14/2023 reads, Liberal Renal Diet, Regular Texture, Thin Consistency. Review of Resident #169's physician order dated 9/21/2023 reads, Weight: Daily x [times] 3 consecutive days and then weekly one time a day every Mon [Monday]. Review of Resident #169's Nutrition Assessment with an effective date of 10/11/2023 Reads, A. Data . 5. Rate of weight loss/gain as 5%. B. Nutrition . 3. Current Nutritional Supplementation: Med Pass 2.0. 4. Current appetite: a. poor . 10. Meal Assistance: a. independent . E. Nutritional Assessment/ Diagnosis/ Intervention/ Monitoring: 1. Assessment Narrative: [Resident #169's name] is being reevaluated today s/p [status post] return from hospital admission and high risk nutrition status. Upon previous admission she had a series of weight loss PTA. Her po [oral] intake and appetite were very poor upon that admission and following her hospital stay she is now down from 141# [pounds] to a current weight of 123# (5% + weight loss in less than a month). She has expressed interest in certain foods, which will be ordered, however her po intake remain low. Will continue to follow . Nutritional Goals: Resident will maintain weight within 2-3% of current BW. Resident will consume 50%+ of supplements in addition to current meal intake. Nutritional Interventions: Recommend enhanced foods due to continued poor po intake which continues to influence wt. [weight] loss. Also, recommend Boost or equivalent BID to supplement K calories and protein. Review of Resident #169's orders revealed no Med Pass or other supplement in addition to her diet. Review of Resident #169's Weights and Vital Summary revealed missing weights on 9/25/2023, 10/16/2023, 10/23/2023, and 10/30/2023. During an interview on 11/1/2023 at 9:40 AM, the Registered Dietician stated, Intake has been fair. Med Pass three times a day and continue to eat. I can rewrite the order and have the doctor sign off on it. It should be once a week any time. I see a trend in weight loss. We put a recommendation to do weekly weights. She was 126 and now she is 122; more than 8% weight loss. She has been on the radar of concern poorly motivated and difficult because they are not willing to try. Review of the facility policy and procedure titled Referrals to the Dietician with the last review date of 3/30/2023 reads, Policy: The facility is committed to providing the best quality nutritional 105652 Page 9 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0692 care to its residents. All residents at nutritional risk will be referred to the dietician, or Nutrition and Dietetics Technician Registered (NDTR) as assigned, by the Dietary Manager. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105652 Page 10 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 3. During an observation on 10/30/2023 at 11:23 AM, Resident #104's nebulizer mask was on top of the drawer without a bag. The tubing was not dated (photographic evidence obtained). Residents Affected - Some During an interview on 10/30/2023 at 11:24 AM, Resident #104 stated, I was congested and I am using the nebulizer for treatment for my cough and shortness of breath. Review of Resident #104's physician order dated 9/11/2023 reads, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML [milligram/milliliter] 3 ml inhale orally every 4 hours as needed for SOB [shortness of breath] or wheezing via nebulizer. Review of Resident #104's physician order dated 9/29/2023 reads, Nebulizer equipment change: change nebulizer mask/HHN and tubing weekly, every day shift every Wed [Wednesday]. Review of Resident #104's physician order dated 10/24/2023 reads, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML 1 vial inhale orally every 4 hours related to acute cough. During an interview on 11/1/2023 at 10:41 AM, the Director of Nursing stated, Nebulizer mask should be stored in a bag when not in use and labeled with date. 4. During an observation on 10/30/2023 at 10:48 AM, Resident #142's oxygen tubing was wrapped on top of the oxygen concentrator machine. The tubing was dated 9/28/2023 (photographic evidence obtained). During an observation on 10/31/2023 at 8:05 AM, Resident #142's oxygen tubing was wrapped on top of the oxygen concentrator machine. The tubing was dated 9/28/2023. Review of Resident #142's physician order dated 8/28/2023 reads, Oxygen @ 2 L/Min via NC inhalation as needed, as resident allows. During an interview on 11/1/2023 at 10:45 AM, the Director of Nursing stated, Tubing should be changed every 7 days and bagged when not in use. Review of the facility policy and procedure titled Respiratory Therapy Equipment with the last review date of 3/30/2023 reads, Purpose: The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to residents and staff. Procedure. Oxygen Administration . 4. Change oxygen cannula and tubing as necessary . Medication Nebulizers/Continuous Aerosol: 1. Obtain equipment. 2. Perform hand hygiene. 3. After completion of therapy: a. Remove nebulizer container; b. Rinse container with fresh tap water; and c. Dry with clean paper towel or gauze sponge. 4. Use caution not to contaminate internal nebulizer tubes. 5. Store circuit in plastic bag, marked with date and resident's name, between uses. 6. Perform Hand Hygiene. Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 4 of 6 residents reviewed for respiratory care, Residents #123, #231, #104 and #142. Findings include: 105652 Page 11 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. During an observation on 10/30/2023 at 12:36 PM, Resident #123's oxygen (O2) tubing had no date. The respiratory plastic bag was on top of the O2 condenser located at the bedside, which was dated 9/13/2023 (photographic evidence obtained). During an observation on 10/31/2023 at 3:47 PM, Resident #123's respiratory plastic bag was dated 9/13/2023. There was no date on the oxygen tubing (photographic evidence obtained). During an interview on 10/31/2023 at 3:47 PM, Resident #123 stated, I need my oxygen on all the time. I get very winded without having it on. During an interview on 11/1/2023 at approximately 1:00 PM, the Director of Nursing stated, I don't have any words. Review of Resident #123's physician order dated 8/1/2023 reads, Oxygen @ [at] 2 L/Min [Liters/Minute] via NC [nasal cannula] inhalation as needed. Review of Resident #123's physician order dated 8/1/2023 reads, Oxygen tubing, cannula/mask change weekly and PRN [as needed] every evening shift every Thu [Thursday]. 2. Review of Resident #231's physician order dated 10/12/2023 revealed Budesonide Suspension 0.5 milligrams/ 2 milliliters to be inhaled orally every 12 hours for shortness of breath. During an observation on 10/30/2023 at 10:10 AM, there was an unbagged nebulizer mask on top of Resident #161's bedside table. The nebulizer mask was not stored in a bag. During an interview on 10/30/2023 at 10:15 AM, Resident #231 stated, I use the nebulizer every once in a while. During an interview on 11/1/2023 at 8:22 AM, the Director of Nursing stated Resident #231's nebulizer mask should be stored in a dated bag and changed every 7 days. 105652 Page 12 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #147's physician order dated 9/12/2022 reads, Liberal Renal diet, Regular Texture, Thin consistency. Residents Affected - Some Review of Resident #147's physician order dated 9/12/2023 reads, Dialysis: Vitals Signs Pre Dialysis every day shift every Mon, Wed, Fri for Dialysis. Review of Resident #147's physician order dated 9/12/2023 reads, Dialysis: Vitals Signs Post Dialysis every evening shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for Dialysis. Review of Resident #147's physician order dated 9/12/2022 reads, Dialysis: AV Fistula- Monitor for Signs & Symptoms of Infection every shift. Assess site for any change in skin condition. Report any noted redness, edema, or increased skin temperature to MD every shift. Review of Resident #147's Medication Administration Record for October 2023 for vital signs post dialysis revealed no recording on 10/2/2023,10/6/2023, 10/9/2023, 10/11/2023, 10/13/2023, 10/16/2023, 10/20/2023, and 10/30/2023. Review of Resident #147's Medication Administration Record for October 2023 for vital signs pre dialysis revealed no recording on 10/9/2023 and 10/23/2023. Review of Resident #147's Medication Administration Record for October 2023 for weight from dialysis revealed no recording on 10/2/2023, 10/6/2023, 10/9/2023, 10/16/2023, 10/20/2023, and 10/23/2023. Review of Resident #147's Dialysis Communication Binder with the Director of Nursing on 11/2/2023 at 8:05 AM revealed no additional pre or post vitals or weights from dialysis recorded. During an interview on 11/2/2023 at 8:05 AM, the Director of Nursing stated, We have no other record of vitals or weights. We have gaps in the documentation. Review of the facility policy and procedure titled Care of the resident receiving Dialysis with the last review date of 3/30/2023 reads, Policy: The facility will provide care to the resident receiving dialysis to maintain the patency of the arteriovenous shunt, prevent complications such as infections, bleeding and trauma, and identify specific measures to follow if complications occur. The care will be directed by license nurses. Based on record review and interview, the facility failed to ensure dialysis services were provided consistent with professional standards related to the assessment of the resident's condition and monitoring for 2 of 2 residents reviewed for dialysis, Residents #9 and #147. Findings include: 1. Review of Resident #9's admission record revealed the resident was originally admitted on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of Resident #9's physician order dated 9/29/2023 reads, Dialysis: Vital Signs Pre-Dialysis every night shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday], Please fill out Dialysis Communication form at desk and send with resident with vitals and other information needed. 105652 Page 13 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0698 Level of Harm - Minimal harm or potential for actual harm Review of Resident #9's Medication Administration Record for the period of 10/1/2023 through 10/31/2023 revealed Resident #9's vital signs had not been recorded on Tuesday 10/3/2023, Thursday 10/12/2023, Tuesday 10/17/2023, and Tuesday 10/24/2023, being coded as 9 (Other/See Progress Notes), on Saturday 10/7/2023 and Tuesday 10/10/2023, being coded as 7 (Sleeping), and on Saturday 10/28/2023, being coded as 5 (Hold/See Progress Note). Residents Affected - Some During an interview on 10/31/2023 at 9:47 AM, Staff A, Licensed Practical Nurse/ Unit Manager, acknowledged that Resident #9's vital signs had not been recorded as ordered by the physician. She confirmed it was the nurses' responsibility to complete pre-dialysis vitals and bruit and thrill monitoring. Review of Resident #9's progress notes with the Director of Nursing revealed no documentation related to the reasons Resident #9's vital signs had not been recorded on 10/3/2023, 10/12/2023, 10/17/2023, 10/24/2023, and 10/28/2023. Review of Resident #9's dialysis communication forms with the Director of Nursing showed Resident #9's pre-dialysis vital signs had not been entered on the dialysis communication form for the dates not recorded on the medication administration record. During an interview on 11/2/2023 beginning at 8:09 AM, the Director of Nursing confirmed Resident #9's pre-dialysis vital signs had not been recorded on either the medication administration record or on the dialysis communication form for the 7 days reviewed. Review of Resident #9's physician order dated 9/29/2023 reads, Dialysis: AV [arteriovenous] Shunt/Fistula L [left] arm - Check Bruit and Thrill every shift. Auscultate for bruit and palpate for thrill. Document (+) if present and (-) if absent. Report absence of either bruit or thrill to MD [Medical Doctor] every shift. Review of Resident #9's Medication Administration Record for the period from 10/1/2023 through 10/31/2023 with the Director of Nursing revealed no entries indicating Resident #9 had been assessed for the presence and absence of bruit and thrill at first shift on 10/6/2023, 10/8/2023, 10/21/2023, 10/22/2023, and 10/25/2023, at second shift on 10/6/2023, 10/7/2023, 10/10/2023, 10/16/2023, 10/17/2023, and 10/22/2023, and at third shift on 10/6/2023. 10/8/2023, and 10/12/2023. During an interview on 11/2/2023 at 8:29 AM, the Director of Nursing confirmed Resident #9's medication administration record for October 2023 revealed no documentation indicating Resident #9 had been assessed for the presence and absence of bruit and thrill every shift for the days with no entries. 105652 Page 14 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles in 1 of 3 medication rooms, and 1 of 4 medication carts. Findings include: During an observation of the Medication Room in the Ocean View Unit with Staff B, Licensed Practical Nurse (LPN)/ Unit Manager, on [DATE] at 9:55 AM, there was an open vial of Latanoprost ophthalmologic drops with no opened and expiration date. During an observation of the Front Hallway [NAME] Cart with Staff B, LPN/ Unit Manager on [DATE] at 10:12 AM, there were one opened Lyumjev KwikPen with no opened and expiration date, one opened insulin glargine-yfgn pen with no opened and expiration date, one Breo Elipta inhaler with no opened and expiration date and the front label reading discard (6 weeks), and one unopened insulin glargine-yfgn 10 milliliter (ml) vial with the label reading refrigerate until opened. During an interview on [DATE] at 10:12 AM, Staff B, LPN/ Unit Manager, stated, My expectation for nurses to date the medication once opened. During an interview on [DATE] at 10:47 AM, Staff C, LPN, [NAME] Landing Unit Manager, stated, When a nurse opens medication, the nurse is supposed to be dating medication. During an interview on [DATE] at 1:48 PM, the Director of Nursing (DON) stated, My expectation is when the nurse opens a medication to date the medication they are using. Review of the instructions for use of Lyumjev KwikPen reads, Throw away the Lyumjev KwikPen you are using after 28 days, even if it still has insulin left in it. Review of the Specialty Rx document titled Medication with Shortened Expiration Dates reads, Many healthcare providers are not aware that the expiration dating of many products change once the items are removed from their primary packaging and are in use. Once these products are opened, they must be used within a specific time frame to avoid reduced potency and, potentially, reduce efficacy . Ophthalmic Products . Latanoprost, refrigerate until opened may be used for 42 days after opening. Review of the facility policy and procedure titled Medication Storage with the last review date of [DATE] reads, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with the FL [Florida] Department of Health guidelines. Procedure . F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 105652 Page 15 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored in the kitchen cooler and in the stock/storage room areas in accordance with professional standards. Residents Affected - Few Findings include: During an initial tour of the kitchen with the Certified Dietary Manager (CDM) on 10/30/2023 at 9:15 AM, there were a full-size black tub with 3 large raw roasts with no type of identifying label or date on the product or the container, a sandwich labeled tuna and dated 10/25, and a clear bag with what appeared to be pineapple and peaches or mandarin orange bits without a date or label in the walk-in cooler. There were boxes of vanilla wafers, and four opened bread containers with no received or opened date in the stock room. During an interview on 10/30/2023 at 9:30 AM, the CDM verified that all food items should be labeled and dated in the cooler and stock/storage room. The CDM confirmed that all sandwiches should be correctly labeled and dated for storage and discarded on the 3rd day. The CDM could not confirm if the date on the tuna sandwich was the date it was made or if it was the discard date. The CDM could not verify if the mixture was peaches or mandarin oranges with the pineapple in the clear bag. Review of the facility policy and procedure titled Food Storage with the last review date of 3/30/2023 reads, Procedure . 1. Dry Storage Rooms . d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated . 2. Refrigerators . d. Date, label, and tightly seal all refrigerated foods, using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 48 hours. Discard items that are over 48 hours old. Review of the facility policy and procedure titled Food Safety and Sanitation with the last review date of 3/30/2023 reads, Receiving . Label foods with delivery date and discard by date . Refrigerated Storage . All leftovers should be labeled and dated. 105652 Page 16 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure medical records were documented accurately for wound care treatments for 1 of 3 residents reviewed for skin conditions (Resident #4), and for 1 of 3 residents reviewed for turning and positioning and 1 of 4 residents reviewed for discharge (Resident #430). Findings include: 1. During an observation on 10/30/2023 at 10:35 AM, Resident #4 was sitting in her wheelchair with a dressing dated 10/25/2023 on her right forearm. During an interview on 10/30/2023 at 10:35 AM, Resident #4 stated, I have a skin tear on my arm. Review of Resident #4's physician order dated 10/13/2023 reads, Cleanse right forearm skin tear with NS [Normal Saline] apply TAO [triple-antibiotic ointment] with dry dressing. Monitor for s/s [signs/symptoms] of pain, infection, and or any concerns. Notify MD [Medical Doctor] as needed, in the evening for right forearm skin tear. Review of Resident #4's Treatment Administration Record for October 2023 showed staff initials for completion of wound treatment for forearm skin tear on 10/26/2023, 10/27/2023, and 10/29/2023. During an interview on 11/1/2023 at 10:48 AM, the Director of Nursing stated, Staff is supposed to follow physician orders. Dressing should have been changed daily. Documentation should be done accurately. 2. Review of Resident #430's Bed Mobility Task for July 2023 revealed no information recorded at first shift on 7/14/2023, 7/16/2023, 7/17/2023, 7/22/2023, 7/23/2023, 7/24/2023, 7/25/2023, 7/29/2023, and 7/30/2023, at second shift on 7/14/2023 and 7/28/2023, and at third shift on 7/15/2023, 7/16/2023, 7/25/2023, and 7/29/2023. Review of Resident #430's Bed Mobility Task for August 2023 revealed no information recorded at first shift on 8/11/2023, 8/17/2023, 8/25/2023, 8/26/2023, 8/28/2023, 8/29/2023, and 8/30/2023, at second shift on 8/11/2023, 8/12/2023, 8/14/2023, 8/15/2023, 8/16/2023, 8/19/2023, 8/21/2023, 8/22/2023, 8/24/2023, 8/25/2023, 8/28/2023, and 8/29/2023, and at third shift on 8/13/2023, 8/22/2023, 8/25/2023, and 8/27/2023. During an interview on 11/3/2023 at 7:57 AM, the Director of Nursing stated, There are gaps in the documentation of the task. Staff should be documenting all completed tasks. 3. Review of Resident #430's Nursing Home to Hospital Transfer Form reads, Date admitted : 7/14/2023 . Sent to: [local hospital's name]. Date of Transfer: 6/3/2023 . Form completed: 7/31/2023. Review of Resident #430's Nursing Home to Hospital Transfer Form reads, Date admitted : 8/11/2023 . Sent to: [local hospital's name]. Date of Transfer: 7/31/2023 . Form completed: 8/31/2023. During an interview on 11/3/2023 at 7:57 AM, the Director of Nursing stated, [Resident #430's name] was discharged to hospital on 7/31/2023 and returned the same day. [Resident #430's name] was 105652 Page 17 of 18 105652 11/03/2023 Palatka Center for Rehabilitation and Healing 110 Kay Larkin Dr Palatka, FL 32177

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discharged to hospital on 8/31/2023 and did not return to the facility. There was a data entry error the date of transfers self-populate in the system as the most recent admission date and the nurse has to go back and manually change the date. Review of the facility policy and procedure titled Documentation, Clinical with the last reviewed date of 3/30/2023 reads, Purpose: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all interdisciplinary team members. 105652 Page 18 of 18