Health inspection·October 1, 2024

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were informed of the bed hold policy upon transfer to hospital for 3 of 3 residents reviewed for discharge to hospital, Residents #1, #2 and #3. Findings include: 1. Review of Resident #1's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, mood affective disorder, major depressive disorder and dysphagia. Further review of the records showed the resident was informed of bed hold policy of the facility. Review of Resident #1's progress note dated 9/5/2024 showed it read, Resident noted physically and verbally to staff this pm [afternoon]. Remain on 1:1 supervision. Resident and his roommate were fighting over the TV remote unable to redirect. Resident got upset and started hitting staff. Call made to on call spoke with Dr. [Physician's name] verbal orders given to transfer resident to [Local Emergency Room's name] for psych evaluation. Review of Resident #1's SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 9/5/2024 showed the resident was transferred to (Local Hospital's name) due to the resident being combative towards staff, with the risk alert documented as agitation with risk to harm self or others. Review of Resident #1's medical records showed no written bed hold notice was provided to the resident or their representative. 2. Review of Resident #2's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic kidney disease, atrial fibrillation, iron deficiency anemia and type II diabetes mellitus. Record review of Resident #2's eInteract Change in Condition Evaluation dated 8/8/2024 showed it read, 3. Review Findings and Provider Notifications . 4. Summarize your observations, evaluations and recommendations: Labs were drawn hgb [hemoglobin] 6.6 MD [Medical Doctor] recommendations transfer to hospital for possible blood transfusion. Review of Resident #2's SNF/NF to Hospital Transfer Form dated 8/8/2024 showed the resident was transferred to [Local Hospital's name] due to abnormal hemoglobin or hematocrit (low). Page 1 of 2 105664 105664 10/01/2024 Gainesville Health and Rehabilitation 4000 SW 20th Ave Gainesville, FL 32607

F 0625 Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] showed the BIMS (Brief Interview for Mental Status) score of 15 (intact cognition). Review of Resident #2's medical records showed no written bed hold notice was provided to the resident or their representative. Residents Affected - Some 3. Review of Resident #3's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including systemic lupus erythematosus, rheumatic mitral stenosis with insufficiency, atrial fibrillation, and type II diabetes mellitus. Review of Resident #3's physician order dated 9/15/2024 showed it read, Resident sent to the Emergency Room. Review of Resident #3's SNF/NF to Hospital Transfer Form dated 9/15/2024 showed the resident was transferred to (Local Hospital's name) due to chest pain. Review of Resident #3's quarterly MDS dated [DATE] showed the BIMS score of 15. Review of Resident #3's medical records showed no written bed hold notice was provided to the resident or their representative. During an interview on 10/1/2024 at 10:30 AM, the Administrator stated, When they [residents] are sent to the hospital, they are considered discharged and then they [hospitals] send a referral through an online program and we accept them [residents] if we have beds and can meet their needs. During an interview on 10/1/2024 at 10:35 AM, the Director of Nursing (DON) stated, When we send them [residents] out, we call the family and let them know that your family member has been sent out. We did not have a bed hold notification form that we give to the residents or their family. Bed hold notices for Residents #1, #2, and #3 were requested. None was provided. Review of the facility policy and procedures titled Transfer and Discharge (including AMA [Against Medical Advice] revised on 7/13/2023 showed it read, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility except in limited circumstances . Policy Explanation and Compliance Guidelines . 12. Emergency Transfers/Discharges . g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated . i. The resident will be permitted to return to the facility upon discharge from the acute care setting. 105664 Page 2 of 2