Health inspection·May 5, 2023

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** Based on interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for 1 of 1 resident reviewed for neglect from a total sample of 3 residents, (#1). Residents Affected - Few Findings: Review of the medical record revealed resident #1 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 6/17/2022. The nursing, Progress Notes dated 4/26/2023 noted the resident had contusions to her left eye and left arm/shoulder. The resident was transported to the emergency room and returned to the facility the same day with diagnoses of hematoma around her left eye, and multiple contusions. On 4/30/2023, the resident sustained a fall from her wheelchair resulting in bleeding from her nose and required medical transport to the emergency room where she was admitted to the hospital. The Minimum Data Set annual assessment with Assessment Reference Date 2/15/2023 noted the resident scored 1 out of 15 on the Brief Interview for Mental Status Exam, which indicated the resident was severely cognitively impaired. The resident had no behavioral symptoms or rejections of evaluation or care for health and wellbeing. The assessment showed resident #1 required extensive staff assistance for activities of daily living and had 1 fall since the prior assessment. On 5/04/2023 at 2:57 PM, the Director of Operations explained the facility began an investigation on 4/26/23 into resident #1's injuries that nursing staff reported they had observed the same day. She said witness statements were provided from nurses, Certified Nursing Assistants (CNA), and a Patient Care Attendant (PCA) who had been assigned to the resident and those working on the same unit. Review of the statement from CNA B noted the resident had not sustained a fall. The statement received from PCA A noted the resident sustained a fall on 4/25/2023 and he assisted CNA B with getting the resident off the floor and into her bed. On 5/4/2023 at 3:12 PM, the Director of Nursing (DON) said she obtained statements by telephone from PCA A and CNA B on 4/26/2023. She explained she was concerned because the statements were contradictory. She stated she provided education to both staff during the telephone call about reporting falls. On 5/4/2023 at 3:15 PM, the DON provided an unsigned statement from PCA A that was undated. She said she wrote the date 4/25/2023 on the form to indicate the date of the incident. She explained she completed the form during her telephone call with PCA A on 4/26/2023. The statement showed PCA A said, no fall or injuries during my time. The DON provided an additional unsigned statement that she explained was handwritten by PCA A. The form was dated 4/27/2023 and noted on 4/25/2023, CNA B Page 1 of 2 105671 105671 05/05/2023 Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requested PCA A's assistance to get resident #1 off the floor, because she had fell. She provided an undated and unsigned statement and stated that it was completed during her telephone call with CNA B on 4/26/2023 that read, she did not fall. On 5/4/2023 at 3:30 PM, The Director of Operations said no further investigation into the incident was necessary because no other information had been provided. She said the facility had conducted education related to falls and incident reporting to all clinical staff, and it was still ongoing. On 5/05/2023 at 3:56 PM, the Director of Operations said the facility had received two conflicting statements which meant they did not know what happened to resident #1. She stated the facility had not investigated other potential causes of the resident's injuries including abuse, even though there were directly opposite versions of events from the two primary staff involved. She explained, based on PCA A's statement, the facility concluded their investigation on 5/04/2023, and determined the root cause of the resident's injuries was that the resident fell on 4/25/2023. She acknowledged the facility was responsible for protecting residents and preventing any future potential neglect, abuse, or mistreatment during an investigation. She conveyed the facility's policy required all staff involved in abuse or neglect allegations to remain on suspension from duty during an investigation. She could not explain why CNA B was suspended from duty during the facility's investigation, while PCA A was not suspended and was permitted to continue to work and care for residents. The facility's Policies and Procedures: Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI), dated 3/02/2019 read, IV. Identification: Identify events, such as suspicious bruising of residents, occurrences . that may constitute abuse, VI. Protection: Protect resident from harm during an investigation., 2. Have evidence that all alleged violations are thoroughly investigated. 3. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 105671 Page 2 of 2