Health inspection·October 27, 2022

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure staff recieved training in abuse, neglect, and exploitation upon hire and annually, as per facility policy and facility assessment, for 8 of 14 sampled staff personnel records reviewed for training (Staff I, Staff J, Staff K, Staff L, Staff M, Staff N, Staff O, and Staff P). Residents Affected - Few The findings included: Review of the facility's policy for abuse, neglect and exploitation dated 01/01/2022 documents new employees should be educated on abuse, neglect, exploitation, and misappropriation of resident property during initial orientation. Existing nursing home staff should receive annual education and in-service training. A review of the Facility Assessment also documents that trainings for new hires at orientation and annually include abuse, neglect, exploitation prevention. Review of 14 staff members for abuse training revealed that 8 did not have abuse training, of the 8 staff files reviewed, 2 were agency staff and 6 were facility staff. The following personnel files were reviewed with the Human Resource Director on 10/27/22 at 2:30 PM, and revealed the following: Staff I, CNA (Certified Nursing Assistant), date of hire 10/01/21, last had abuse training completed on 10/01/21. Staff J, CNA, date of hire 08/18/22, did not have any abuse training in her employee file. Staff K, LPN (Licensed Practical Nurse), date of hire 05/27/22, did not have any abuse training in her employee file. Staff L, Physical Therapist, date of hire 08/15/22, did not have any abuse training in her employee file. Staff M, Registered Nurse date of hire 08/04/22, did not have any abuse training in her employee file. Staff N, Physical Therapist, date of hire 08/07/17, with last date of abuse training dated 12/26/17, did not have any abuse training in her employee file. Staff O, Agency staff, Certified Nursing Assistant, date of hire 05/10/22, did not have any abuse training in her employee file. Page 1 of 17 105659 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0607 Staff P, Agency staff, LPN, date of hire 06/07/22, did not have any abuse training in her employee file. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/27/22 at 3:34 PM, the Human Resources Director, who started on 10/03/22, stated that all new hire orientation is completed online through Relias. The staff then do individual orientation with facility. She was asked to show the surveyor the orientation training schedule, but stated she was unable to come up with one. Residents Affected - Few A interview was conducted on 10/27/22 at 5:27 PM with the Abuse Coordinator/Social Service Director who began on 08/08/22. She was asked about recent abuse training she did. She stated she had completed the training and wanted to make sure everyone had availability to her. I didn't do it because there was an issue. When asked about the abuse policy and training, she stated that she did not know the policy on abuse training, and voiced she should do it at least quarterly, once every three months. 105659 Page 2 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

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** 3) Review of the Abuse/Neglect log revealed and entry for Resident #172 dated 05/30/22. Review of the record revealed Resident #172 was originally admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Residents Affected - Few On 10/27/22 at approximately 9:15 AM, the Administrator was asked to locate and provide documented evidence of their investigation for alleged abuse and or neglect of Resident #172, from 05/30/22 as per their log. On 10/27/22 at 12:25 PM, the Director of Social Services (SSD) provided the AHCA (Agency for Health Care Administration/State Agency) Five Day Report. The SSD explained she was not an employee of the facility at the time of the incident, and the AHCA report was all that she could find. The SSD voiced she is aware of the need for a documented thorough investigation, but agreed the facility could not provide one. Review of the AHCA report revealed a DCF (Department of Children and Families) representative arrived at the facility on 06/01/22 with an anonymous complaint of neglect of Resident #172. The AHCA report documented the resident's history, condition, and that staff and residents were interviewed. The report documented the allegation was not substantiated. There was no evidence of a documented thorough investigation. Based on record review and interview the facility failed to ensure there was a documented thorough investigation for 3 of 4 sampled residents, reviewed for incident investigations (Resident #98, Resident #102 and Resident #172). The findings included: 1) Review of Resident #98's medical record revealed Resident #98 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Dementia, Age-related Osteoporosis, Pathological Fracture, Unspecified Psychosis and Major Depressive Disorder. The Annual MDS (Minimum Data Set) dated 09/01/22 documented the BIMS (Brief Interview for Mental Status) with no score which indicated the resident was not able to complete the interview. Review of the Progress Notes, dated 09/05/22 at 2:31 PM, documented the following: the resident was complaining, moaning of pain on left hip. Full assessment completed, no discolorations or bruises noted on the site. On 09/05/22 11:57 X- Ray done and faxed to Medical Doctor (MD) after reviewing it, new order received to send resident to hospital for fracture of the proximal left femur through the lateral cortex. On 09/06/22 9:10 AM, a diagnosis of osteoporosis added per MD. On 10/26/22 the surveyor requested the investigation that was completed for this incident. A review of the incident/investigation documented revealed the following: a AHCA 1 and 5 day was completed; Abuse hotline called and Department of Children and Family came to the facility and only one statement was completed by the nurse who wrote what she put in the progress note on 09/05/22. No other statements or investigation was seen in the document. During a family interview conducted on 10/26/22 with the family member, she stated the family received a call at night saying that the resident had a hip fracture but they were never told how it happened. 2) Review of Resident #102 records revealed he was admitted to the facility on [DATE] with 105659 Page 3 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses to include Difficulty Walking, Muscle Weakness, Psychotic DIsorder with Delusions, Altered Mental Status, Depressive DIsorder and Parkinson's Disease. A review of the Quarterly MDS dated [DATE] documented a BIMS with no score, indicating severe cognitive impairment. Review of the Progress Notes for 07/13/22 at 12:45 PM, documented: the assigned nurse reported to another nurse seeing the resident walking the hallway by his room, with some blood to his face. The resident was assisted to a wheelchair and transferred him back to his room. Nursing assessment revealed a cut to his left forehead; Direct pressure applied; Neuro check initiated along with 911. There was no mental status changes or signs or symptoms of pain observed. The Medical Doctor authorized to send the resident to the hospital. Wheelchair was locked inside the room, armrest checked negative for any sharp objects. Resident wore his proper non skid stocks, floor was dry, no fall hazard noted but some fresh blood. On 07/13/22 8:15 PM, Resident #102 returned from the hospital witha Left forehead laceration with sutures observed due to post fall, covered with dry dressing and no drainage noted. The resident was administered Tylenol 650 mg for pain and a supplement was offered and accepted. Neuro check in progress call light with within reach. The surveyor requested on 10/27/22 at 11:00 AM, to review the investigation. At 12:00 PM, the DON stated she was unable to find an investigation for this incident but did have an incident report. The surveyor reviewed the report dated 07/13/22. The report documented that a nurse saw Resident #102 walking the hallway by his room, with some blood to his face; assisted resident to Wheelchair and transferred back to his room; Nursing assessment revealed a cut to his left forehead; Direct pressure applied; and Neuro check initiated along with 911. This was the same information as in the progress note. The report also documented the resident had an abrasion to top of scalp, laceration to forehead and laceration to forearm, with predisposing physiological factors documented as the resident being confused, gait imbalance, impaired memory, weakness, and incontinent. The documented predisposing situational factors included ambulating without assist, and wanderer. There were no witnesses found. Only 1 interview was completed with the nurse and the investigation was not completed. The DON stated on 10/27/22 at 11:04 AM, she was the Unit Manager on first floor until two weeks ago but was familair with the incident with Resident #98. She stated that a nurse reported that the resident had complained of pain in her hip, when they called the doctor he ordered an X-Ray and the results showed a fracture hip. She had just had a hip replacement on same side a year before, and the doctor sent her out for surgery. During an interview on 10/27/22 at 12:17 PM, with the Social Service Director/Abuse Coordinator, she stated she was not employed by the facility for either of the incidents for Resident #98 or Resident #102. She then stated that the Corporate DON (Director of Nursing) asked her to submit the one and five AHCA report of an injury of unknown origin for Resident #98. She stated it was never brought to her attention about possible abuse. The DON that did the investigation is no longer here. She only got one interview and that was it. During an interview on 10/27/22 at 1:45 PM with Staff R, CNA (Certified Nursing Assistant), revealed Staff R worked the 7AM-3PM shift, had been here for 2 years. On the morning of 09/05/22, she went into Resident #98 room, she was sitting in bed having breakfast. After breakfast she went back into her room to change her, sponge bathe her and get her dressed and put her into her chair to go to activities. She did not complain of anything after breakfast. She stated she sponge bathed her top to go to the bottom, and when she turned her she began to complain her hip hurting, all I did turn her on the other side. She was complaining of pain where I was washing her. I put her back on her back and she then began to complain again. There was no redness, no bruise or inflammation. She said she 105659 Page 4 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few covered her and kept her in bed and went out of the room to find the nurse who was at the medication cart in the hallway. The nurse came into her room and assessed her. She touched it and checked it and the resident tried to show her where she hurt and nurse said she was going to call the doctor. They sent someone to do X-ray and they found something wrong. When resident was in the hospital, DCF (Department of Children and Family) and police came and questioned her about it. They also spoke to the nurse. The CNA was asked if anyone from the facility interviewed her or had spoken to her about the incident. She stated no. She was asked if she had the Abuse Training and she stated yes, they use to do it monthly and have us sign something but not sure when the last one was but it was less then a year. 105659 Page 5 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

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** 5) Review of the record revealed Resident #121 was originally admitted to the facility on [DATE], with the most current readmission on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #121 had received insulin 6 of 7 days, of the 7 day look-back period (10/08/22 through 10/14/22). This MDS also documented Resident #121 received an anticoagulant medication 7 of 7 days. Residents Affected - Some Review of the corresponding October 2022 Medication Administration Record (MAR) revealed Resident #121 received insulin on 10/08/22, 10/10/22, 10/12/22, 10/13/22, and 10/14/22, which would be 5 of the 7 days. Further review of this MAR lacked any documented administration of any anticoagulant during the seven day look-back period. During an interview on 10/26/22 at 4:50 PM, Staff A, a Registered Nurse (RN)/MDS Coordinator was asked to review the medication section of the 10/14/22 MDS. When asked to review the insulin, the MDS Coordinator confirmed Resident #121 only received insulin 5 of the 7 days. When asked what anticoagulant was administered to Resident #121 during that look-back period, Staff A stated the resident was on Axiban (an anticoagulant) earlier in the month, but confirmed the resident did not receive any during the look-back period of this MDS. 3) Review of Resident #79 records reveal that she was admitted to the facility on [DATE] with a diagnosis to include Mild Protein-Calorie Malnutrition, Dementia, Anxiety, and Major Depressive Disorder. Further review of Resident #79 records reveals her weights as follows: 06/01/22 weighed 147.4 lbs., 07/07/22. weighed 137.2 lbs., this is a 6.02% weight loss, 08/03/22 weighed 117 lbs., July to Aug is a 14.72% weight loss, and on 10/05/22 weighed 110.2 lbs. which from June to October is a 25.03% weight loss. Reviewing the MDS (Minimum Data Set) Quarterly dated 09/23/22 documents in section K asks has the resident had a weight loss of 5% or more in last month or loss of 10% or more in last 6 months. It was marked No. 4) Review of Resident #99 records reveal that she was admitted to the facility on [DATE] with a diagnosis to include Moderate Protein-Calorie Malnutrition, Parkinson's Disease, Psychotic Disorder with Delusions, Altered Mental Status, and Major Depressive Disorder. Further review of Resident #79 records reveals her weights as follows: 08/03/22 137.8 lbs., 09/06/22 125 lbs., this is a 9.29% weight loss. A review of Resident #99 MDS Medicare 5 day dated 09/13/22 documents under section K swallowing/nutritional status asks the question has the resident had a weight loss of 5% or more in last month or loss of 10% or more in last 6 months. It was marked yes on a weight loss regimen. During an interview on 10/27/22 at 8:10 AM with Dietician and Dietician Consultant acknowledges the MDS coding in not correct for Resident #79 or Resident #99. Resident #79, it should be a yes and not a no and that Resident#99 is not on a weight loss regiment, no one in the facility is. During an interview on 10/27/22 at 8:54 AM with Staff Q, MDS Coordinator and Staff A, MDS Coordinator/RN they were asked to review section K for Resident#79 and Resident#99, both MDS Coordinator acknowledged that the coding is wrong it should have been Yes for weight loss and not a weight loss regiment. They stated that it is the Dietician who fills out section K. Based on interview and record review, the facility failed to ensure of an accurate Minimum Data Set (MDS) assessment was completed for for 5 of 23 sampled residents, related to Hospice (Resident #31), catheter (Resident #47), nutrition (Resident #79 and Resident #99), and medications (Resident 105659 Page 6 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0641 #121). Level of Harm - Minimal harm or potential for actual harm The findings included: Residents Affected - Some 1) Resident #31 was admitted to the facility on [DATE]. A comprehensive MDS assessment dated [DATE], documented the resident was not on hospice services. A review of Resident #31's physician orders revealed an order dated 07/01/22 for admission to hospice. Resident #31 was also care planned for hospice services. An interview was conducted with the MDS Coordinator on 10/27/22 at 3:00 PM. The MDS Coordinator acknowledged Resident #31 was inaccurately assessed on the MDS assessment dated [DATE]. 2) Resident #47 was admitted to the facility on [DATE]. An MDS assessment dated [DATE] documented the resident had a urinary catheter. A review of the residents orders did not reveal any orders for a urinary catheter. An observation of Resident #47 on 10/24/22 revealed the resident did not have a catheter. An interview was conducted with the MDS Coordinator on 10/27/22 at 3:00 PM. The MDS Coordinator acknowledged Resident #47 was inaccurately assessed on the MDS assessment dated [DATE]. The MDS Coordinator stated the resident did not have a catheter while at the facility. 105659 Page 7 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0679 Provide activities to meet all resident's needs. 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 ensure that activities meet the needs for 1 of 3 sampled residents reviewed for Activities (Resident #58). Residents Affected - Few The findings included: Record review for Resident #58 revealed an admission to the facility on [DATE]. The resident's MDS (Minimum Data Set) assessment, dated 07/31/22, documented the resident's Brief Interview for Mental Status (BIMS) score was 0, indicating severe cognitive impairment. The resident's function level was documented as total dependence on the staff. Review of Resident #58's care plan for activities documented that the staff should ensure that the resident's TV (television) should be tuned to a Spanish channel as needed, due to the fact the resident is Spanish speaking only. On 10/24/22 at 10:22 AM, Resident #58 was observed in her room in bed and the TV tuned to an English channel. On 10/25/22 at 9:30 AM, an observation of the resident's room revealed the resident was in bed and the television was again tuned to an English channel. On 10/26/22 at 10:01 AM, an interview was conducted with the Activities Director, and she was informed of the findings. 105659 Page 8 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 implement preventative measures of ordered specialty air mattresses, repositioning, offloading, and wound care, to prevent the development or worsening of pressure ulcers for 3 of 4 sampled residents (Resident #84, #109, and #274). Residents Affected - Few The findings included: 1) An observation on 10/24/22 at 9:30 AM revealed Resident #84 lying in bed, dressed, with a Hoyer (a mechanical devise used to transfer a dependent resident from one surface to another) lift pad under the resident. A specialty air mattress was noted, but the power switch was not turned on. The specialty air mattress felt flat and lacked air. A supplemental observation on 10/24/22 at 11:31 AM revealed Resident #84 still in bed, in the same position as noted at 9:30 AM, with the Hoyer lift pad still under the resident. The specialty air mattress was still powered off. An observation on 10/25/22 at 9:10 AM revealed Resident #84 in bed, dressed, with the Hoyer lift pad under her. The specialty air mattress was powered off (photographic evidence obtained). A supplemental observation on 10/25/22 at 10:40 AM revealed two staff getting Resident #84 out of bed using the Hoyer lift. An observation on 10/26/22 at 12:21 PM revealed Resident #84 in a geri-chair (recliner type wheeled chair), in the second floor Day Room, being fed by Staff B, a Certified Nursing Assistant (CNA). On 10/26/22 at 5:10 PM, Resident #84 was still in the geri-chair, but in her room. During an interview at this time, Staff C, the resident's evening CNA, explained she leaves Resident #84 up in the geri-chair for dinner, then puts her back to bed. On 10/26/22 at 6:41 PM Resident #84 was still up in the geri-chair. Staff C stated she was waiting for help with the Hoyer lift. On 10/26/22 at 6:59 PM, Resident #84 was transferred back to bed via the Hoyer lift. The Wound Care Nurse was present for the observation. Upon removal of the resident's adult brief, it was noted to be heavy, sagging when lifted, and saturated with urine. The resident's buttock appeared moist and an open area noted. The Wound Care Nurse confirmed this was a new open area that needed care. Review of the record revealed Resident #84 was originally admitted to the facility on [DATE], and was transferred to her current room on 06/20/22. Review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 had cognitive impairment and was rarely or never understood. This MDS documented the resident required the total assistance of one or two staff for all Activities of Daily Living (ADLs), to include mobility, toileting, hygiene, and eating. This MDS documented Resident #84 was at risk for the development of pressure ulcers, but did not have one at that time. A documented skin observation on 10/25/22 at 8:43 PM revealed Resident #84's skin was intact. An order dated 08/29/22 revealed the specialty low air loss mattress was initiated and staff were to check function and placement every shift. Review of the October 2022 Treatment Administration Record (TAR) documented the function and placement of the specialty air mattress was completed every shift, as evidenced by a check-mark. During an interview on 10/27/22 at 11:18 AM, Staff D, a Physician Assistant (PA) for the wound care physician's group stated Resident #84 has had a pressure injury in the same location in the past, and confirmed the resident now presented with a stage II pressure ulcer. 105659 Page 9 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0686 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/27/22 at 11:51 AM, Staff E, a Licensed Practical Nurse (LPN), who had cared for Resident #84 on the day shift during the survey, was asked if there was any reason the air mattress was off on both Monday and Tuesday mornings about 9 AM. The LPN stated she checks the specialty air mattresses every morning during rounds, as sometimes they get turned off. When asked again, the LPN had no answer or reason. Residents Affected - Few During a phone interview on 10/27/22 at 1:50 PM, Staff F, the CNA who cared for Resident #84 during the day shift (7 AM to 3 PM) on 10/26/22, was asked what care was provided to the resident the previous day. Staff F explained that after providing personal care to Resident #84 that morning, she got her up at 11 something and checked her before 2 PM. The CNA stated she was dry so she just left her in the geri-chair for 3 PM to 11 PM staff. When asked how she checked Resident #84 to see if she was wet or dry, the CNA stated she just opened up her diaper and she was dry. When asked if she repositioned the resident in any way while in the geri-chair, the CNA stated that she put a pillow under her legs and feet during the day. When asked if she repositioned the resident in any way off her bottom or back, the CNA stated she did not, she just left her in the chair. The CNA volunteered, I'm just per-diem and don't have her very often. Earlier on 10/27/22 at approximately 1:00 PM, when asked for the phone number for Staff F, the Second Floor Unit Manager stated Staff F always works the second floor (where Resident #84 resides), explaining they have another CNA with the same first name who always works the first floor. When provided the phone number for Staff F, the Staffing Coordinator had stated the CNA had worked at the facility at least since this past summer, further explaining that was when she took over the staffing position. 2) Review of the facility matrix provided to the survey team on 10/24/22 revealed Resident #109 had a facility acquired pressure ulcer. During an observation on 10/26/22 at 12:13 PM, Resident #109 was in bed lying on her back. A specialty air mattress was noted and it was powered off and felt flat (photographic evidence obtained). The Wound Care Nurse arrived in the room during this observation and immediately noted the non-functioning air mattress and turned it on. An observation with the Wound Care Nurse revealed the resident's heels were directly on the non-functioning mattress. When asked if the resident's heels were to be offloaded (not touching the mattress), the Wound Care Nurse stated yes and confirmed the presence of a heel pressure ulcer. During an interview on 10/26/22 at approximately 1:00 PM, the Wound Care Nurse stated he located the resident's boots and placed them on Resident #109, but that she has been noncompliant with wearing the boots in the past. During a wound care observation on 10/26/22 at 1:54 PM, Resident #109 was still wearing the boots without issue. Review of the record revealed Resident #109 was admitted to the facility on [DATE], with the most current readmission as of 08/19/22. Review of the current MDS revealed Resident #109 needed extensive assistance of one staff for bed mobility, transferring, eating, and hygiene, but could walk with supervision. Further review of the record revealed bilateral heel DTIs (deep tissue injury) pressure ulcers were identified, one on 09/05/22 and one on 09/07/22. Documentation revealed the heel wounds were unavoidable related to the resident's non compliance with proper foot ware, and continued pacing throughout the facility, although orders were put in place as follows: 09/13/22 for staff to apply a multi podus boot to the resisdent's left foot every shift. 10/04/22 implementation of an air mattress and staff were to check placement and settings every 105659 Page 10 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0686 shift. Level of Harm - Minimal harm or potential for actual harm Review of the record revealed a current care plan initiated on 09/08/22, with revisions on 10/12/22, that Resident #109 has pressure ulcer wounds to bilateral heels and remains at high risk for further skin breakdown related to decrease mobility function, nutritional risk, urinary incontinence, and dementia with cognitive loss. She does not comply with the use of boots, she walks in footwear and pulls out wound dressing. Interventions included to encourage the resident to a sitting position, apply multi podus boot to left foot as ordered, but lacked any intervention related to the air mattress. Review of the October 2022 TAR documented staff were checking the placement and settings of the air mattress every shift, and applying the multi podus boot to the left foot every shift. Residents Affected - Few Observations during the survey revealed Resident #109 in bed, as noted above. An observation on 10/27/22 at 9:23 AM revealed Resident #109 in bed, sitting up eating breakfast, with the multi podus boot to the left foot and a foam boot to the right. 3. Resident #274 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was admitted to the facility with a stage 4 pressure ulcer (PU). Resident #274 was care planned for at risk for additional skin breakdown related to immobility. An intervention included a specialty bed surface. A progress note dated 07/23/22 at 11:51 PM documented Resident #274 was admitted to the unit at 6:00 PM from the hospital. The progress note further documented the resident had a deep wound on his coccyx. Record review did not reveal any further documentation of Resident #274's deep coccyx wound, until the resident was seen by Wound Care on 07/26/22. A review of the resident's wound care progress note dated 07/26/22 documented there was no pressure relieving mattress or low air loss mattress in place. The progress note documented Resident #274 was admitted with a stage 4 sacral wound/pressure ulcer. A low air loss mattress was recommended, and treatment orders for daily dressing change and as needed with Santyl and Dakin's solution (debridement treatment). A review of Resident #274's orders revealed an order dated 07/29/22 for a wound care consult, and treatment orders with Dakin's solution only (not what wound care ordered on 07/26/22). A review of Resident #274's Medication Administration Record (MAR) revealed no wound care was done for Resident #274 from 07/23/22-08/03/22. A wound care progress note dated 08/02/22 documented Resident #274 was not on a low air loss mattress (as ordered 07/26/22). The progress note recommended to continue the wound care with Santyl and Dakin's solution daily and as needed. A review of Resident #274's orders revealed an order dated 08/03/22 for dressing changes daily with Santyl and Dakin's solution (as originally recommended by Wound Care on 07/26/22). An interview was conducted with the Director of Nursing (DON) on 10/27/22 at 20:00 PM. The DON acknowledged Resident #274's wound care was not treated in a timely manner, or as ordered. 105659 Page 11 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0692 Provide enough food/fluids to maintain a resident's health. 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, interview, and policy review, the facility failed to ensure monitoring of hydration status, provision of recommended extra fluids, and timely provision of IV (intravenous) fluids for 2 of 4 sampled residents (Residents #116 and #172). Residents Affected - Few The findings included: Review of the requested policy Critical Values Reporting Procedure (not dated), documented procedures for abnormal lab results, but lacked any specifics related to a critical lab result. This policy included the process that abnormal lab results were to be called or faxed to the attending physician on the same day results were received. Review of the policy titled Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification dated 04/22/22 documented, Policy: It is the policy of this facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results. Definitions: Promptly means that results shall be relayed with little or no delay to the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist. Policy Explanation and Compliance Guidelines: 1. The facility must promptly notify the attending physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results that fall outside of clinical reference ranges. This policy further explains the receipt of the lab should be documented as received, along with the processes to follow to include implementation of new orders. This policy lacked any specifics related to critical lab results. Review of the Hydration policy revised 05/20/22 documented interventions to include offering a variety of fluids during and between meals, addressing underlying causes of dehydration or fluid imbalance, monitoring the resident's condition and care plan interventions on an ongoing basis, and notifying the physician of the lack of improvement toward goals. This policy also instructed documentation to include the recording of observations pertinent to the resident's hydration status in the nurses' notes, recording beverage intake in designated locations (intake record or MAR/Medication Administration Record), and document physician/family notifications and any responses. 1) Review of the record revealed Resident #116 was admitted to the facility on [DATE]. Labs were drawn on 10/08/22, with results reported to the facility by the lab at 6:49 PM, which indicated Resident #116 was dehydrated, as evidenced by an elevated BUN level of 38 (normal reference range of 7 to 25), and an elevated Creatinine level of 1.62 (reference range of 0.60 to 1.20). The progress notes lacked any documented receipt of the laboratory results or notification to the physician, but the lab result itself documented a handwritten note to encourage hydration 250 cc (ml) q (every) shift and to repeat BMP (basic metabolic panel) 10/24/22. Documentation on the October 2022 Treatment Administration Record (TAR) revealed staff were encouraging the hydration, as evidenced by a checkmark. The electronic record lacked any documentation as to the amount of fluids being consumed by the resident. A progress note by the Registered Dietician (RD) on 10/21/22 recommended extra fluids to be added on the resident's tray. Review of the breakfast, lunch, and dinner menu tickets for Resident #116 lacked any documented provision of extra fluids. Review of the laboratory results of the 10/24/22 BMP revealed the laboratory notified the facility 105659 Page 12 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 10/24/22 at 1:08 PM of critically high results of a BUN of 207, a Creatinine of 5.58, and potassium level of 6.2 (reference range of 3.5 to 5.5). A fax machine time stamp documented the lab result was faxed to the facility on [DATE] at 3:49 PM. This faxed copy included handwritten orders to start IV fluids of half normal saline at 60 cc (ml)/hour for a total of three liters, along with other interventions. A progress note dated 10/24/22 at 2301, by Staff H, a Licensed Practical Nurse (LPN), documented a Midline (type of IV access) was inserted into the resident's right arm at 10:45 PM and the first liter of IV fluids was running. An observation on 10/25/22 at 9:37 AM revealed Resident #116 in bed with IV fluids infusing. The handwritten label documented the fluids had started on 10/24/22 at 10:45 PM (photographic evidence obtained). During an interview on 10/26/22 at 10:44 AM, Staff G, a Certified Nursing Assistant (CNA), confirmed Resident #116 needed assistance drinking fluids and stated she would not drink on her own. Staff G was unsure of the amount of fluids Resident #116 consumed and stated they did not document specific fluid amounts for the resident. During an interview on 10/26/22 at 10:51 AM, Staff E, a Licensed Practical Nurse (LPN) stated she would ensure Resident #116 had her large Styrofoam cup full of water each morning. The LPN stated sometimes she could drink herself and sometimes she could not. The LPN stated she would encourage the resident to drink two or three times daily, and would instruct the CNAs to do the same. When asked if there was any documented fluid intake for Resident #116, the LPN stated there was not. When asked if she received a call from the laboratory about the critical lab results on 10/24/22, the LPN explained she did get the call sometime between 1 and 2 PM. The LPN stated she asked the lab to fax the results to the facility and they did so very quickly. The LPN stated she let the Second Floor Unit Manager know about the pending critical labs, and the Unit Manager said she would take care of them. During an interview on 10/26/22 at 11:03 AM, the Second Floor Unit Manager stated Resident #116 was able to drink if you handed her a cup of water, but that she needed encouragement. The Unit Manager stated she would take a few sips when told, but was unsure as to the amount of fluids she was drinking. When asked about the documentation of the resident's fluid intake, specifically related to the order to encourage 250 ml of fluid each shift, the Unit Manager stated they usually would document that on the TAR, but agreed it was not done for Resident #116. During this continued interview, when asked the facility process related to critical labs, the Second Floor Unit Manager stated they automatically call the doctor to get orders. When asked when she received the critical labs for Resident #116 on 10/24/22, the Unit Manager showed the surveyor the fax time stamp of 1549 (3:49 PM on 10/24/22). The Unit Manager explained her next steps to include calling IV Access (a contracted service to place IV lines) to ask for the IV placement. When asked if she asked for the IV to be STAT (related to the critical labs), the Unit Manager stated she did not, but they had told her the technician would be there in 30 to 60 minutes. The Unit Manager then explained that she gave report to the Evening Nurse Supervisor, and she left the building just before 6 PM. When asked if IV Access had arrived before she left the building, or is she called them to follow up on a time, she stated she did not, but again had handed off to the Evening Nurse Supervisor. During a phone interview on 10/26/22 at 11:36 AM, a representative from Echo lab confirmed the critical lab values were reported to the facility on [DATE] at 1:08 PM, as documented on the lab results. The representative was unable to find who they spoke with, but stated their process is to call the facility with the results, and if there is no answer, they will try up to three times, and then 105659 Page 13 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0692 they will fax the results. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/26/22 at 5:51 PM, Staff H, the LPN who worked the 3 PM to 11 PM shift on 10/24/22 and started the IV fluids for Resident #116, confirmed the IV was not started until after 10 PM that night. When asked if he called the physician about the delay, the LPN stated he did not as the Evening Nurse Supervisor had called IV Access a couple of times and it didn't seem that long as he was so busy. When asked if he realized the resident had critical lab values, the LPN stated he did. Residents Affected - Few During an interview on 10/26/22 at 6:21 PM, the Evening Nurse Supervisor explained the Unit Manager had called the physician and called IV Access about the time she arrived for work. The Evening Nurse Supervisor stated the Unit Manager told her the wait time for the IV was 1 or 2 hours. The Evening Nurse Supervisor explained she called IV Access at 7 PM and was told the technician had one more stop, and called again later that evening, when she had another IV order. The Evening Nurse Supervisor stated IV Access usually comes within an hour or so, but when they are busy it's a different story. The Evening Nurse Supervisor stated when the technician arrived, he said there was a lot of traffic and they had been busy. When asked if she thought about calling the physician about the delay in getting the IV started, she stated the Unit Manager told her they were coming and that it was usually within 1 to 3 hours. When asked again about her report from the Unit Manager about the time-frame for IV Access, the Evening Nurse Supervisor stated she was not told by the Unit Manager that they would be there in 30 to 60 minutes, further stating she wasn't given any timeframe. When asked if they had staff that could start IVs, the Evening Nurse Supervisor stated they could do IVs, but their residents were usually hard sticks and they usually needed a Midline for long term IV use. During an interview on 10/27/22 at 1:14 PM, the Registered Dietician (RD) was asked the process when she recommends something and how it gets implemented, like the provision of extra fluids on the meal trays. The RD explained she would talk to the food service director who would add it to the menu ticket and implement. The RD stated she does not recall specifically about Resident #116, but it obviously got missed somehow. 2) Review of the record revealed Resident #172 was originally admitted to the facility on [DATE], with the most current readmission on [DATE], and subsequent transfer back to the hospital on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #172 had a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. This MDS documented Resident #172 needed the extensive assist of one person for eating. A physician order dated 03/01/22 documented, alterations in hydration three times a day for hydration record amt (amount). Review of the March, April and May 2022 Medication and Treatment Administration Records (MARs and TARs) lacked any documented amount of fluid intake. Further review of the electronic record lacked any documentation as to the resident's ability or response to the order for hydration. A side-by-side review of the record with the MDS Consultant of both the current and previous electronic record lacked any documented fluid intake amounts. 105659 Page 14 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 2) A medication storage observation and random narcotic reconciliation was completed on 10/27/22 at 11:39 AM, with Staff E, a Licensed Practical Nurse (LPN) for the medication cart on the 2E unit. Review of the narcotic book revealed Resident #62 had an order for Lorazepam (Ativan/an anti-anxiety medication) to be given every six hours as needed. Further review of this Medication Monitoring/Control Record documented the Lorazepam had been removed from the medication cart three times, including on 10/19/22 at 2:53 AM. Review of the corresponding Medication Administration Record (MAR) lacked any documented evidence of administration to Resident #62 at that time. During an interview at this time, Staff E confirmed the process related to narcotic administration was to sign the medication out of the lock box on the Medication Monitoring/Control Record and also to document the administration to the resident in the corresponding MAR. Based on observation, interview, and record review, the facility failed to accurately document medicating residents with controlled medications for 2 of 4 sampled residents (Resident #73, and #62). The findings included: 1) A narcotic medication reconciliation was conducted on 10/27/22 at 9:15 AM for Resident #73. A review of the Medication Monitoring/Control Record revealed the resident was medicated with Percocet (pain medication) on 10/22/22 at 6:30 AM, 10/23/22 at 10:14 PM, and 10/23/22 at 3:10 PM. A review of Resident #73's Medication Administration Record (MAR) did not reflect the resident was administered any Percocet at those times. The Director of Nursing was made aware of the above. 105659 Page 15 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

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. Based on observation, record review, interview, and policy review, the facility failed to ensure proper storage and labeling of drugs and biologicals. Specifically, 1 of 1 treatment carts was left open and unattended during a wound care observation for Resident #109; a medication was improperly disposed of during the medication pass observation for 1 of 7 residents; and an opened PPD (purified protein derivative) vial in the medication refrigerator was not properly labeled. The findings included: Review of the policy Medication Storage dated 04/02/22 documented, General Guidelines: a. All drugs and biologicals will be stored in locked compartments . 1) A wound care observation for Resident #109 was conducted on 10/26/22 at 1:54 PM, with the Wound Care Nurse, who gathered the supplies to include Dakins (a chloride type liquid) and Santyl (a debriding ointment). While gathering the supplies, Resident #99 stood next to the cart, talking to her stuffed animals. The Wound Care Nurse entered the residents room, leaving the treatment cart unlocked against the wall, with the drawers facing outward, accessible to anyone who tried to open them, with Resident #99 still next to the cart. Once inside the residents room, the surveyor informed the Wound Care Nurse of the unlocked treatment cart, for the safety of the residents on this locked unit. The Wound Care Nurse returned to the treatment cart, acknowledged the unlocked cart, and immediately locked it. Resident #99 was still in the hallway nearby, chatting with another confused resident. On 10/26/22 at approximately 6:45 PM, Resident #99 was observed standing at an unattended (locked) medication cart on the same 2E unit, holding her stuffed animals and moving items on top of the cart. 2) An observation of 1 of 2 medication rooms was conducted on 10/27/22 at 12:00 PM with Staff Z, a Licensed Practical Nurse. An opened multidose vial of immunization medication was observed in the refrigerator. Further observation of the multidose vial of medication revealed a lack of date and time when the medication was opened. Staff Z acknowledged multidose vials of medication should be labeled with date and time when opened. 3) A review of the facility's policy Destruction of unused drugs, dated 04/01/22, documented: Drugs will be destroyed in a manner that renders the drugs unfit for human consumption. A medication administration observation was conducted with Staff Y, a Licensed Practical Nurse, on 10/26/22 at 9:00 AM. Staff Y was observed handing a medication cup containing pills to a resident. The resident was observed dropping one pill on the floor while attempting to take the medication. Staff Y was observed picking up the pill off the floor and throwing it in the trash can located directly next to the resident. 105659 Page 16 of 17 105659 10/27/2022 Lake Worth Rehabilitation Center 1201 12th Avenue South Lake Worth, FL 33460

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to serve food in a sanitary manner. Residents Affected - Many The findings included: On 10/24/22 at 9:43AM, during an initial tour of the main kitchen, accompanied by the Food Service Director, the following was observed: (1) The oven was dirty with burnt on grease and food. (2) During an inspection of the walk-in refrigerator, there was a full crate of 8oz (ounces) of fat free milk with a date of 10/19/22. The cartons of milk were observed on the residents' breakfast trays to be served to the resident for breakfast. (3) There were two, 24oz containers of cottage cheese observed. The expiration date for one of the containers was 09/26/22 and the other 10/17/22. (4) A staff nurse was observed in the kitchen. The nurse was not wearing any head covering. (5) The toaster was dirty with baked on bread crumbs. (6) The floor and the ceiling vent in the preparation area was dirty with black dust. On 10/24/22 at 11:25 AM, the Food Services Director was informed of the findings. On 10/26/22 at 11:30 AM, a follow up visit to the main kitchen was conducted, accompanied by the Food Service Director, to observe the lunch service. The following were observed: (7) A 6 ounce glass of juice was noted at 48 degrees Fahrenheit (F), and (8) An 8oz container of regular milk temperature was at 43 F. On 10/26/22 at 2:00 PM, an interview was conducted with the Food Service Director, and he was informed of the findings. 105659 Page 17 of 17