Health inspection·April 3, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to promote a dignified and homelike dining experience while assisting dependent residents with breakfast when staff stood over residents during the meal for 2 (Resident #84 and #54) of 2 residents observed for eating assistance. Findings include: An observation was made on 04/01/24 beginning at 8:53 AM, Resident #54 and Resident #84 [roommates] were in bed, where Staff A, Certified Nursing Assistant (CNA), was standing between Resident #54 and Resident #84 who each had a breakfast tray on their bedside table. Staff A, CNA was observed assisting Resident #54 with a spoonful of breakfast then moving to Resident #84 and assisting with a spoonful of breakfast, continuing to move between both residents to assist with eating breakfast. An interview was conducted with Staff A, CNA, related to feeding both residents at the same time. Staff A stated he wasn't sure of the right way as he had only been a CNA for a short time. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented in Section GG that Resident #84 was dependent on staff for eating. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented in Section GG that Resident #54 was dependent on staff for eating. Review of the policy titled Resident Rights, last reviewed on 2/26/2025 read, Policy Explanation and Compliance Guidelines. 4. Respect and dignity. The resident has a right to be treated with respect and dignity. Page 1 of 7 105664 105664 04/03/2025 Gainesville Health and Rehabilitation 4000 SW 20th Ave Gainesville, FL 32607

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 interviews, and record reviews, the facility failed to ensure each resident was provided with an assessment which accurately reflects the resident's status for 4 (Resident #151, #76, #302, #74) of 8 resident assessments reviewed for respiratory care, skin conditions, and end stage renal disease care. Residents Affected - Some Findings include: 1.) Review of the admission record for Resident #151 documented the resident was admitted to the facility on [DATE] with a diagnosis that included schizophrenia, heart failure, atherosclerotic heart disease, and anemia. Review of the physician's order for Resident #151 dated 3/18/25 read, Aripiprazole Oral Table 30 MG (milligrams) Give one tablet orally at bedtime for schizophrenia. Review of the discharging hospital's history and physical note dated 3/7/25, on page 4, reads .on Aripiprazole 30 mg medication since 6/12/20. Review of the Minimum Data Set (MDS) admission assessment dated [DATE], did not document an active diagnoses of schizophrenia. During an interview on 4/3/25 at 9:34 AM, Staff F, Licensed Practical Nurse (LPN), MDS Coordinator, and Staff G, LPN, MDS Coordinator, Staff G, stated We need 6 months of documentation of treatment to record diagnosis of schizophrenia in the MDS. I have no further instructions, I cannot confirm what we need to record the diagnosis. 2.) During an observation on 3/31/25 at 10:31 AM, Resident #74 was sitting shirtless on his bed, a rash, along with numerous raised elongated open areas, on his neck, arms, and chest. During an interview on 3/31/25 at 10:31 AM, Resident #74 stated, I do not know what it [rash] was from, just itchy. He further stated that he has had this [rash] for about 2 or 3 months. Review of Resident #74's admission record documented an admission date of 9/23/22 with diagnosis that include disorder of skin and subcutaneous tissue dated 2/25/25 and Prurigo Nodularis [a skin condition that causes itchy bumps on your skin] dated 3/20/25. Review of the dermatologist visit note dated 3/19/25 read Impression/Plan. Erythematous [superficial reddening of the skin] nodules with central erosions distributed on the left anterior [front and inner side] medial [closer to midline of body] distal [farther from the attachment of the limb to the trunk] upper arm , left anterior lateral [farther from the midline of the body] distal upper arm, arms, legs, and neck. Plan/Counselling. Prurigo Nodularis is a self-inflicted lesion that results from picking and rubbing the same spot of skin over and over again. Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented under skin conditions that Resident #74 did not have any other ulcers, wounds or skin problems. During an interview on 4/3/25 at 9:40 AM, Staff F, Licensed Practical Nurse (LPN), MDS Coordinator, and Staff G, LPN, MDS Coordinator, stated this is a rash; we don't code for a rash. We did not know 105664 Page 2 of 7 105664 04/03/2025 Gainesville Health and Rehabilitation 4000 SW 20th Ave Gainesville, FL 32607

F 0641 he had lesions. Level of Harm - Minimal harm or potential for actual harm 3.) Review of the admission record for Resident #302 documented an admission date of 12/14/24 with the most recent admission date of 3/4/25 with diagnosis that included end stage renal disease dated 12/14/24. Residents Affected - Some Review of Resident #302's Minimum Data Set (MDS), Quarterly assessment dated [DATE] did not document under Section O: Special Treatments, Procedures and Programs that the resident was receiving dialysis treatments. Review of Resident #302's physician's order dated 4/2/25 read, Dialysis .TUESDAY THURSDAY SATURDAY .CHAIRTIME IS @ 6:15 AM. During an interview on 4/3/25 at 10:30 AM, Staff G, Licensed Practical Nurse, MDS Coordinator, stated, it [section O of the Minimum Data Set) was basically human error that it wasn't coded. 4.) Review of the admission record for Resident #76 documented an admission date of 9/11/23 with a diagnosis that included chronic respiratory failure with hypoxia [insufficient oxygen to the body] and obstructive sleep apnea [a breathing disorder where the upper airway becomes blocked during sleep, leading to brief pauses in breathing]. Review of Resident #76's Minimum Data Set (MDS), Quarterly assessment dated [DATE] did not document the resident uses a CPAP (continuous positive airway pressure). Review of Resident #76's physician's order dated 2/20/24, read, CPAP at night for obstructive sleep apnea. During an interview on 4/3/25 at 10:30 AM, Staff G, Licensed Practical Nurse, MDS Coordinator, stated it [section O of the Minimum Data Set) was basically human error that it wasn't coded. 105664 Page 3 of 7 105664 04/03/2025 Gainesville Health and Rehabilitation 4000 SW 20th Ave Gainesville, FL 32607

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care and services were provided consistent with professional standards of practice for 1 (Resident #151) of 4 residents reviewed for oxygen therapy. Residents Affected - Few Findings include: Review of the admission record for Resident #151 documented an admission date to the facility of 3/14/25 with a pertinent diagnosis that included of heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris [buildup of plague in artery walls without chest pain], and anemia. During an observation on 3/31/25 at 12:29 PM, Resident #151 has oxygen tubing hanging from the over bed table (OBT). During an observation on 4/1/25 at 9:36 AM, Resident #151 has oxygen tubing hanging from the OBT with the oxygen concentrator up against the bed. During an interview on 4/1/25 at 9:36 AM, Resident #151 stated, I only use it when I am short of breath, I only use it when I need to, and I've used it several times. During an observation on 4/2/25 at 7:42 AM, Resident #151 has oxygen tubing hanging from the OBT with the oxygen concentrator up against the bed. During an interview on 4/2/25 at 10:11 AM, Resident #151 stated, I turn the oxygen machine on myself, it is already set to 4 liters. Review of the physician's orders for Resident #151 documented no orders for oxygen. During an interview on 4/2/25 at 9:47 AM, the Assistant Director of Nursing (ADON) stated, I did not know [Resident #151 Name] had oxygen in the room. We need to have a physician's order for PRN (as needed) use for him to use the oxygen. Review of the policy titled, Oxygen Administration, last reviewed on 2/26/25, read, Policy. Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines. 1. Oxygen is administered under the orders of a physician, except in the case of an emergency. In such a case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 105664 Page 4 of 7 105664 04/03/2025 Gainesville Health and Rehabilitation 4000 SW 20th Ave Gainesville, FL 32607

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. 2.) Review of Resident #79's physician's order dated 3/19/25 reads, Aquaphor External Ointment (Emollient) Apply to BUE & BLE [bilateral upper extremities and bilateral lower extremities] topically every 12 hours as needed for dry skin. During an observation on 3/31/25 at 9:45 AM, a tube of Aquaphor with a prescription label was sitting on Resident #79's bedside table. During an interview on 3/31/25 at 9:45 AM, Resident #79 stated, That's my medicine, I don't know why it's there, they [facility staff] use it [Aquaphor]. 3.) Review of Resident #22's admission record documented an admission date of 10/18/24 with diagnosis that included Chronic Obstructive Pulmonary Disease (COPD). During an observation on 4/1/25 at 1:00 PM, Resident #22 was observed to have Trelegy [prescription medication for COPD] and Triamcinolone [prescription medication for skin irritations] located at bedside in a wash basin on the left side of his bed. During an interview on 4/1/25 at 1:00 PM, Resident #22 stated, Those are my personal belongings, I keep my Trelegy to make sure that I get it. Review of Resident #22's physician's order dated 1/14//25 for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 (Fluticasone-Umeclidinium-Vilanterol), MCG/ACT [micrograms/actuation] 1 puff inhale orally two times a day for SOB [shortness of breath] Rinse mouth and expectorate after use. Review of Resident #22's electronic medical record revealed no order for Triamcinolone cream. During an interview on 4/3/25 at 11:15 AM, the Director of Nursing stated there are no residents here that are supposed to have meds at bedside. 4.) During an observation on 4/1/25 of medication cart #1, there was a bottle of Folic Acid 400 mg (milligrams) with an expiration date of 03/2025 on the bottom of the bottle. (photo evidence obtained.) During an observation on 4/1/25 at 10:30 AM of medication cart #1, there was a bottle of Latanoprost 0.005% eye drops for Resident #51 that did not have an opened date on the bottle. During an interview with on 4/1/25 at 10:40 AM, Staff K, Licensed Practical Nurse (LPN) stated all resident specific bottles should be dated, because they are only good for 30 days or the length of the prescription. Expired medications should not be on the cart. During an interview on 4/1/25 at 11:30 AM, the Director of Nursing stated there should never be expired meds on the cart. Review of the policy titled Medication Storage, with a review date of 2/26/25, reads, Policy: It is 105664 Page 5 of 7 105664 04/03/2025 Gainesville Health and Rehabilitation 4000 SW 20th Ave Gainesville, FL 32607

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations. Policy Explanation and Compliance Guidelines. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medications pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of the [Pharmacy Name] Medications with Shortened Expiration Dates, not dated documented Xalatan, generic name, Latanoprost ophthalmic solution reads, Once a bottle is opened for use, it may be stored at room temperature up to 77 degrees and is good for 42 days. Based on observations, interviews, and record reviews, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional standards for 1 of 5 medication carts and failed to ensure that drugs and biologicals were stored in a secured manner for 2 of 3 units. Findings include: 1.) During an observation on 3/31/25 at 9:32 AM of Resident #23's room, 5 unidentifiable pills were sitting in a clear medicine cup on the residents over the bed table, and an unlabeled creamlike substance in a small plastic medicine cup was sitting on the residents bedside table. During an observation on 3/31/25 at 10:00 AM of Resident # 23's room, 2 unidentifiable pills in a clear medicine cup were still sitting on the residents bedside table. During an interview on 4/1/25 at 10:00 AM, Resident #23 stated that the staff always leave his pills on his bedside table and he takes them later. During interview on 4/3/25 at 8:37 AM, Staff E, Licensed Practical Nurse (LPN) Unit 300, confirmed the medication on Resident #23's bedside table, and stated, That this [referring to the medications in the cup] is not the expectation for residents to have any prescribed medication at bedside. During an interview on 4/3/25 at 8:31 AM, the Assistant Director of Nursing stated, Medications are not supposed to be at the bedside unless the resident has been accessed for self-administration and then the medication still need to be secured. 105664 Page 6 of 7 105664 04/03/2025 Gainesville Health and Rehabilitation 4000 SW 20th Ave Gainesville, FL 32607

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure resident medical records were accurate and complete for 1 (Resident #22) of 2 residents reviewed for advanced directives. Residents Affected - Few Findings include: 1) Review of the admission record for Resident #22 documented an admission date of 10/18/24 with diagnosis that included chronic obstructive pulmonary disease unspecified, major depressive disorder, generalized anxiety disorder, iron deficiency anemia unspecified, and hypertension. Review of the electronic medical record resident profile for Resident #22 read, Code Status: (Advance Directives) Full Code. Review of Resident #22's physician's order dated 2/5/25 reads, FULL CODE. Review of the Social Services Assessment for Resident #22 dated 1/16/25 documented Do Not Resuscitate on page 1 and the summary note on page 3 read, Resident will remain DO NOT RESUSCITATE (DNR) and plans to remain a short term resident at [the facility's name]. Review of Resident #22's comprehensive resident centered care plan, last revised on 1/21/25, reads, Resident has an established DNR (DO NOT RESUSCITATE) order in place. During an interview on 4/1/25 at 1:45 PM, Resident #22 stated, I do not remember talking to anyone about my wishes to be a DNR. During an interview on 4/1/25 at 2:00 PM, the Director of Nursing stated, [Resident #22's Name] is a full code; there is no DNR on file for him. [Resident #22's Name] assessment and care plan was inaccurate and should have been care planned for full code status. Social Services had added it wrong. A policy titled, Advanced Directives Code Status Issued: 1/24 reads, Standard: It is the policy of the facility to honor Advanced Directives, Code Status and DO Not Resuscitate Orders in accordance with stated and federal regulations. CODE STATUS - Listed in the resident's medical chart. Obtained upon admission and reviewed at least quarterly and/or upon resident/representatives request. ADMISSION/readmission Code status verified upon admission with Resident/Representative by admitting NURSE. Nurse reviews code status with the resident/representative and confirms decision with the attending physician (MD). 105664 Page 7 of 7