Health inspection·November 19, 2021

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (Resident #7) of two sampled residents, reviewed for ADLs, out of a total sample of 37 residents. Residents Affected - Few The findings include: On 11/15/2021 at 11:03 AM, Resident #7 was observed in her room with wet/greasy hair. On the front of her scalp, she had several clusters of dry, scaly patches dark beige in color. An attempt was made to interview the resident, but she was unable to answer any questions. A review of the clinical record indicated that Resident #7 was admitted into the facility on 7/23/2021. Her diagnoses included cerebral infarction due to embolism; hemiplegia affecting right dominant side; traumatic hemorrhage of cerebrum; unspecified seizures and anxiety disorder. A review of the quarterly minimum data set (MDS) assessment, dated 10/30/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had no speech and rarely or never understands and is rarely or never understood. Resident #7 was also assessed to require extensive assistance with bed mobility, dressing, eating and personal hygiene. There were no skin issues identified on the assessment. On 11/16/2021 at 10:41 AM, Resident #7 was observed for a second time in her room with wet/greasy hair, with clusters of dry and scaly patches along the front of her scalp. (Photographic evidence obtained) A review of Resident #7's latest care plan completed on 11/12/2021 did not reflect any focus or goals related to dry skin/scalp or dandruff. On 11/17/2021 at 10:37 AM, Resident #7 was observed for a third time in her room. She appeared to have just received a bed bath/hygiene care, however, her scalp remained with dry/scaly patches. During an interview on 11/17/2021 at 11:09 AM with Employee L, Certified Nursing Assistant (CNA), she stated that she was familiar with Resident #7. She stated the resident requires one person assist and does not refuse care. She stated that Resident #7 receives regular bed baths which includes washing all body parts, cleaning under the fingernails, and shampooing and conditioning hair and scalp. The resident's skin is checked during this time and if there are any irregularities, they are reported to the nurse and documented in the CNA's charting. She confirmed that she gave the resident a bed bath this morning which included shampooing and conditioning her scalp. When she was asked about Page 1 of 19 105682 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0677 Resident #7's clusters of dry scaly patches, she could not explain what it was. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/18/2021 at 11:33 AM with Employee K, Licensed Practical Nurse (LPN), she stated that she was familiar with Resident #7. She confirmed that the CNAs provide ADL care and are responsible for looking for and reporting any skin issues. She stated that the CNAs are to report to the nurse as well as document their observations. She stated that on 11/17/2021 Employee L, CNA informed her that Resident #7's had dandruff in her scalp. She then went to see the resident and observed what looked like cradle cap or dandruff. She notified the physician, who gave an order for a medicated shampoo. She acknowledged that prior to 11/17/2021, she was not aware of the resident's scalp condition. She confirmed that she had seen the resident on 11/15/2021 and 11/17/2021 but she had not looked at her scalp nor did the CNA report anything regarding the resident's scalp. She confirmed that based on her observations, it was something that should have been reported and documented. Residents Affected - Few . 105682 Page 2 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive, person-centered care plan, by failing to 1) Ensure an Agency nurse appropriately assessed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors, and suicidal ideation, out of four residents reviewed. The facility failed to ensure the Agency nurse recognized and addressed an emergent situation for a fall-risk resident, which contributed to her death. The facility also failed to 2) Ensure a resident's right to receive treatment for one (Resident #11) residents who required a mammogram, and 3) Ensure one (Resident #23) of one resident sampled, received physician-ordered medication for insomnia (Sleeplessness) for two months, resulting in the resident's increased sleeplessness. There was a total of 37 residents in the sample. Residents Affected - Few The facility's employees and service providers failed to provide services to Resident #191 that were necessary to avoid physical harm. During the 3:00 p.m. to 11:00 p.m. shift on [DATE], Certified Nursing Assistant (CNA) B told Licensed Practical Nurse (LPN) C (Agency Nurse) 14 to 18 times throughout the shift, that Resident #191 was observed with agitation, restlessness, and repeated attempts to jump out of bed. CNA B repeatedly asked LPN C to do something. CNA B continued to check the resident every 10 to 15 minutes, noting that Resident #191 kept raising her bed into the highest position, and was twisting and turning in the bed repeatedly. LPN C failed to respond. She failed to assess the resident, notify the resident's physician, document changes in condition and/or any interventions attempted, and she failed to ensure Resident #191 was adequately supervised to prevent serious injury. At approximately 11:15 p.m. on [DATE], Resident #191 was discovered with her torso and lower body off the bed in an upright position and her neck wedged between the bed rail and the mattress. Her face was pressed against the mattress. She had expired. LPN C continued providing nursing services to facility residents during and after this incident and was scheduled to work the 11:00 p.m. to 7:00 a.m. shift on [DATE]. Immediate Jeopardy at a scope and severity of J (isolated) was identified at 3:55 p.m. on [DATE]. On [DATE], at 11:15 p.m., the Immediate Jeopardy began. On [DATE] at 1:30 p.m., the Administrator was notified of the IJ determination. Immediate Jeopardy was removed upon survey exit on [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D. On [DATE], the facility census was 93. Any resident receiving care by an Agency staff nurse was at risk for serious harm or death. The findings include: Cross Reference to F600, F726, F742, and F867. 1. A review of Resident #191's medical record revealed an admission date of [DATE]. The resident expired in the facility on [DATE]. Resident #191's primary medical diagnosis was Parkinson's disease (central nervous system disorder affecting movement, often including tremors) and secondary diagnoses included altered mental status, encephalopathy (any brain disease that alters brain function), 105682 Page 3 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few respiratory failure, rhabdomyolysis (a breakdown of muscle tissue which can cause kidney damage), a history of post-traumatic stress disorder (PTSD), and atrial fibrillation (irregular heartbeat that commonly causes poor blood flow, leading to shortness of breath and fatigue). A review of the resident's admission Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. She required extensive to total assistance with all activities of of daily living and was incontinent of bowel and bladder. The MDS assessment identified a history of falls prior to the resident's admission. A review of a nursing progress note authored by the Director of Quality Assurance (DQA) and dated [DATE] at 1:18 a.m. read, This writer received a call from the facility to inform this writer that the resident had expired, and it looked as if the resident had fallen since it was unwitnessed and there was a change in plane. This writer arrived at the facility and observed the resident on the floor in a praying position with head between the mattress and the bedrail. This writer knows that the resident is alert and oriented, she would be able to lift her head up and down, use the side rails appropriately for mobility and she was able to voice needs and wants to staff. This writer examined the resident prior to and after placing the resident back on the bed. There was no bruising or redness to the resident's head or neck area. This writer notified the resident's responsible party and informed her of the resident's expiration. Writer also notified the physician and the funeral home. This writer was informed by staff that the resident was restless all night and had been attempting to get out of the bed. The resident was last checked around 10:45 p.m. and again at 11:00 p.m. The gap measurements of the mattress and bed rail were confirmed to be 1.25 inches, and if the rail and mattress are pushed in opposite directions the gap never exceeds 2.75 inches. On [DATE] at 2:42 p.m., an interview was conducted with CNA A. She confirmed that she was familiar with Resident #191, and that she cared for the resident on [DATE] during the day shift. She explained that Resident #191 used to yell out a lot, and she mostly just wanted conversation. She added that on the [DATE] day shift, the resident really started yelling out a lot more. I kept going in to see about her because I was afraid she was going to get out of bed. She eventually calmed down until I left, then I don't know what happened. She further explained that upon returning to work the following week, she was told the resident had fallen and caught her neck in the bed rail. On [DATE] at 2:53 p.m., an interview was conducted with Certified Nursing Assistant (CNA) B. She confirmed that she was assigned to Resident #191 on [DATE] during the 3:00 p.m. to 11;00 p.m. shift. She explained that she had only cared for the resident this one time. She explained that the entire shift the resident was trying to jump out of the bed, and that she had to keep going in the resident's room every 10 to 15 minutes to check on the resident. She added that the resident kept raising the bed up high and was twisting and turning in the bed repeatedly. The CNA explained that she went to the nurse at least 14 to 18 times and kept telling the lady over and over that we needed to do something. She was an Agency nurse and wouldn't do anything. CNA B stated she practically begged the nurse to let her get the resident up in a chair, but the nurse never really said anything and wouldn't go check on the resident. The CNA explained that at approximately 10:55 p.m., she checked the resident one last time before her shift was over. She stated the resident was lying in bed watching television at that time and that the bed was in the low position. She left the facility but was called back in by the facility at approximately 11:15 p.m. to write a statement because the resident had been found deceased . On [DATE] at 3:22 p.m., an interview was conducted with the Director of Quality Assurance (DQA). 105682 Page 4 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She confirmed that she was familiar with Resident #191, and that she was responsible for conducting the investigation into the resident's death. She identified the resident as requiring enteral nutrition, and that she was admitted to the facility for rehabilitative services with a goal to return home. She also added that she had cared for the resident on a few occasions as a nurse on the floor. Regarding the resident's death, she explained that staff called her at the time and told her the resident was kneeling on the floor and was deceased . She stated she directed the staff to leave the resident in the same position and not touch the resident. Upon arriving at the facility, she observed the resident in a praying position with her head resting on the bed rail. The DQA stated the resident's head/neck were not caught between the bed rail and the mattress. The head of the bed was at a 90-degree angle. She was not able to recall the bed height but thought it wasn't that high. She explained that she interviewed the nurse that cared for Resident #191 on the 7:00 a.m. to 3:00 p.m. shift, who explained that the resident started getting real agitated and restless around 3:00 p.m. that day. The resident was moving around a lot in bed. No assessments were conducted at that time and the physician was not notified. At approximately 10:30 p.m., the 3:00 p.m. to 11:00 p.m. nurse observed the resident lying in bed watching television. That was the last time the nurse saw the resident until after the incident. The DQA explained that the 3:00 p.m. to 11:00 p.m. CNA identified the resident as having been fidgety in the bed the whole shift. She stated the CNA went into the room at 10:45 p.m. and the resident was in bed. The 11:00 p.m. to 7:00 a.m. CNA went into the room around 11:10 p.m. to 11:15 p.m. and found the resident deceased . The DQA added, Some people say she was talking about suicide. She was fine a couple nights before because I had taken care of her on the floor. Per the DQA, no photographic evidence was taken by the facility. The police were not notified on the night of the incident because she was a DNR (Do Not Resuscitate). The facility did notify the police, however, when DCF reported allegations of neglect to the facility. She explained that the facility did not normally call the police for unexpected deaths. On [DATE] at 11:45 a.m., an interview was conducted with the Social Services Director (SSD). She confirmed that she was familiar with Resident #191. She identified Resident #191 as having mentioned suicidal thoughts or ideations to one of the therapists that was treating the resident. As far as the SSD was aware, the resident had mentioned suicide one time. The psychologist determined the resident was not a threat to herself or anyone else at the time of the visit and felt that a [NAME] Act was not necessary. Resident #191 had no other behaviors that the SSD was aware of. When asked for the facility's policy regarding safety of residents who verbalize thoughts of suicide, the SSD explained that the facility didn't really have a policy. She explained that the staff would be expected to place the resident on continuous supervision and notify the physician of the changes. The resident would be maintained on continuous supervision until psych releases them. When asked if she had any information regarding the resident's death, she stated, I was not here. I know nothing. I haven't heard anything. On [DATE] at 1:25 p.m., a follow-up interview was conducted with the DQA and Director of Nursing (DON). The DQA was asked to clarify her statement made on [DATE] regarding the position of the resident's head and neck versus what she had written in the progress note. She explained again that when she arrived at the facility, the resident's head was resting on top of the bed rail. On [DATE] at 2:30 p.m., an interview was conducted with Registered Nurse (RN) E. The nurse explained that she had worked in the facility for 13 years. She confirmed that she was on duty at the time Resident #191 was found deceased . She explained that she was sitting at the nurses' station and was approached by the 11:00 p.m. to 7:00 a.m. Agency nurse. She stated the nurse's eyes were huge. The nurse asked for help and said, There is a resident that has her head stuck in the rail and I think she's dead. RN E responded to the room with 105682 Page 5 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few another nurse from the North wing. She observed Resident #191 with her neck stuck between the mattress and the rail. The head of the bed was as high up as it could go, and the bed remote had been detached from the wiring. RN E stated she attempted to reattach the remote to let the head of the bed down, so she could dislodge the resident's neck, but the cord wouldn't reach. She and the second North wing nurse removed the resident's neck from between the rail and the mattress after she pulled heavily on the rail and bent it. RN E described the resident's face as being smushed in the mattress. After removing the resident from between the rail and mattress, RN E observed an imprint from the rail on the resident's right cheek bone. She stated she believed the resident's neck was constricted enough to prevent air flow. She also added that she checked for a pulse, couldn't find one and that cardiopulmonary resuscitation (CPR) was not initiated because the resident had a Do Not Resuscitate Order (DNRO). RN E said she then called the Director of Nursing (DON) for assistance, but the DON stated she was unable to respond. On [DATE] at 12:01 p.m., an interview was conducted with the Medical Director. She explained that she was notified of the incident involving Resident #191 over the weekend (10/30 - [DATE]) and that the facility conducted a conference call on [DATE], which included the Medical Director, Administrator, and Risk Manager. She further explained that she was told the resident's head was resting on the rail and/or mattress. The Medical Director was not aware of staff witnessing the resident's neck wedged between the bed rail and mattress. She stated she was also not informed of CNA B's concerns that she had requested the assistance of LPN C several times over the course of the 3:00 p.m. to 11:00 p.m. shift. The Medical Director stated the facility discussed doing bed rail inspections. When asked about the resident's supposed cause of death (senile degeneration of the brain), the Medical Director stated that sometimes people are agitated and restless immediately preceding death but that it wouldn't last for that many hours. The Medical Director acknowledged that the nursing staff should have responded to the resident's change in condition at the time it was occurring. On [DATE] at 1:28 p.m., an interview was conducted with LPN C (Agency Nurse) via telephone. She acknowledged that she was familiar with Resident #191 and that she was providing care for the resident on [DATE] during the 3:00 p.m. to 11:00 p.m. shift. When asked what care and services she provided Resident #191 on that shift, the nurse stated, I only had to give her medications. When asked whether CNA B had reported any concerns about the resident's change in condition, the nurse stated, She just said she was having some behaviors. When asked what her response was to the resident's behaviors, the nurse stated, I checked on her a couple times as needed. The nurse was unable to recall what the resident was doing when she checked on the resident. The nurse stated she last checked the resident at approximately 10:30 p.m. on [DATE] when she walked down the hallway to let an employee in the door. The nurse stated she did not enter the room at that time and was not able to recall what the resident was doing. The nurse stated she did not notify the physician of the behaviors and couldn't recall whether she documented them in the medical record. The nurse stated she was not present when the resident was found deceased . On [DATE] at 5:16 p.m., an interview was conducted with LPN Q (Agency Nurse). She explained that one of the CNAs came running and saying please come check this lady. She added that she was not assigned to the resident at that time, but that she had counted the medication cart with LPN C (Agency Nurse) so that LPN C could leave early. LPN Q added that another Agency Nurse came in and decided that she didn't want to stay and immediately left the building. LPN Q wasn't sure who that nurse was. LPN Q explained that when she entered Resident #191's room, the resident was positioned on the left side of the bed. The bed was way up high. The room curtain was pulled. She checked Resident #191 for a pulse and couldn't find one. The nurse then checked the resident's code status and ran to the North wing for assistance where she encountered RN 105682 Page 6 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few E. LPN Q explained that she was not in the room when the staff freed the resident from the bed. The nurse further explained that she had worked the 3:00 p.m. to 11:00 p.m. shift that day and had been across the hall from Resident #191's room at some points during the shift. She was unable to recall the specific times. She explained that she noticed the call light on several times and went into the room to check on the resident at least twice. The resident was repeatedly saying, I'm going to leave. I'm going to leave. LPN Q stated she encouraged the resident to wait on us to help you, and that she had last seen Resident #191 a little after 10:00 p.m. Throughout the interview, LPN Q repeatedly stated, She was just so anxious that whole shift. She added that she had observed the CNAs going in and out of the room constantly throughout the 3:00 p.m. to 11:00 p.m. shift. The nurse then added that if she had been assigned to the resident, she would have gotten the resident out of bed to prevent the resident from falling. On [DATE] at 6:00 p.m., an interview was conducted with LPN R (Agency Nurse). He explained that he responded to Resident #191's room after a nurse came running onto the North unit saying she needed help. LPN R stated upon entering the room he observed Resident #191's neck entrapped between the bed rail and the mattress. The remote had been dislodged from the bed and the bed was very high. The head of the bed was as high as it could go. He explained that once the resident was freed, he did assist in placing her back into bed for postmortem care. He stated the DQA had not yet arrived at the facility at the time the resident was placed back into bed. Based on the circumstances the resident was found in, he believed the resident was playing with the remote and somehow raised the bed up and rolled out of the bed with her neck becoming lodged between the bed rail and the mattress. A review of the resident's comprehensive care plans revealed a focus area for fall risk. An intervention dated [DATE] read, Observe for unsafe actions and intervene as needed. Further review of Resident #191's medical record revealed the adaptive bed rail assessment had not been conducted. (Photographic Evidence Obtained) A review of the facility's policy for side rails, titled Adaptive Rails (revised [DATE]), was reviewed. The policy directed staff to conduct an assessment/evaluation/screening to determine the resident's symptoms or reason for using adaptive side rails. Additionally, the policy read, Pertinent information related to adaptive rail utilization should be documented in the resident's clinical record. Use of adaptive rails as an assistive device should be present in the resident-centered plan of care. Informed consent for the use of less restrictive devices will be obtained from the resident or resident representative. (Photographic Evidence Obtained) A review of a blank Adaptive Rail Assessment revealed Question #23, which read, Could the adaptive rails create a possible accidental hazard or barrier for this resident? Could the resident attempt to climb over, around or between the rails, exit the bed in an unsafe manner, or be at-risk for getting caught between the rails or the rails and the mattress, etc. (Photographic Evidence Obtained) A review of the facility's policy for changes in condition, titled Change in a Resident's Condition or Status (effective 10/14, no revision date) was reviewed. The policy read, The facility shall promptly notify the resident, his or her attending physician, and representatives of changes in the resident's medical/mental condition and/or status. The policy also directed the nurse supervisor or charge nurse to record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. (Photographic Evidence Obtained) The facility's job description for Licensed Practical Nurses was reviewed. The job description 105682 Page 7 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Immediate jeopardy to resident health or safety directed the nurse to Initiate emergency support measures (i.e. CPR (cardiopulmonary resuscitation), protect guest from injury). (Photographic Evidence Obtained) The facility's job description for Registered Nurses was reviewed. The job description directed the nurse to Initiate emergency support measures (i.e. CPR, protect guest from injury). (Photographic Evidence Obtained) Residents Affected - Few 3. On [DATE] at 2:00 p.m., Resident #23 stated she had not received her sleeping pills for three days and it had been very difficult for her to get some restful sleep. She added that she was told the medication had not been delivered by the pharmacy. A review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included depressive disorder and insomnia (sleeplessness). A review of the [DATE] Physician's Order Sheets revealed a current order for Restoril (temazepam - sleep aid), 7.5 mg (milligrams) by mouth at bedtime for insomnia, ativan 0.5 mg three times a day for anxiety, and celexa 40 mg one time daily for depression. A review of the resident's quarterly minimum date set (MDS) assessment, dated [DATE], revealed she had a brief interview for mental status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. She required extensive assistance for bed mobility, transfers, and toileting. A review of the comprehensive care plan revealed the resident was at risk for adverse effects from antidepressants and sedative medication. Administer medications as ordered by the physician and monitor for side effects. During an [DATE] interview with Licensed Practical Nurse (LPN) O at 10:46 a.m., she confirmed the resident had no narcotic sheet for the Restoril. LPN O checked the medication cart and she could not locate the medication. She then contacted the pharmacy via telephone and was informed that the last refill was provided on [DATE] for 30 days. When asked what it meant when there were blanks on the medication administration record (MAR), LPN O stated it meant the medication was not administered, and when initials were documented on the MAR, it meant the medication was administered. She also confirmed that the nurses had documented the medication was given while there was none in stock or in the EDK (emergency drug kit). On [DATE] at 11:40 a.m., an interview with the DON confirmed that the medications were documented as given while there was no medication in stock. She stated, To be honest, the facility has had a lot of Agency staff and they lack a sense of responsibility. You are making me know what I need to fix. A review of the resident's narcotic sheet, indicated the last dose of Restoril was administered on [DATE]. (Copy obtained) Further review the resident's MAR revealed the following: For the month of [DATE], it was documented that Resident #23 received Restoril on [DATE], 11, 15, 16, and 17. For the month of [DATE], the resident was documented as having received Restoril on [DATE], 4, 7, 12, 13, 14, 15, 19, 21, 22, 23, 25, 28, and 27. Another interview was conducted on [DATE] at 4:50 p.m. with Resident #23. She restated that she had not been sleeping well and when she asked for her sleeping medication, the nurses would tell her that she got melatonin (dietary supplement used for insomnia) for sleep and they did not have anything else for her. 105682 Page 8 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The facility's policy titled Charting and Documentation with a revision date of [DATE], was reviewed. It included guidelines for charting which were to include: A complete account of the resident's care treatment, response to the care, signs, symptoms, etc., as well as progress of the resident's care. Guidance to the physician in prescribing appropriate medication and treatments. Assistance in the development of a Plan of Care for each resident, and the staff were also to document The elements of quality medical nursing care. A review of the facility's policy and procedure titled Administration of Drugs'' (effective 10/2014 with no revision date) revealed, Residents shall receive their medications on a timely basis and in accordance with our established policies. The procedure indicated that medications must be charted by the person administering the drug immediately following the administration. The date, time administered, dosage etc., must be documented in the medical record and signed by the person administering the medication. Medication ordered for one resident may not be administered to another resident. On [DATE] at 4:00 p.m., the facility provided their immediate actions to remove the Immediate Jeopardy. These immediate actions were verified by the surveyors on-site as having been completed as follows: Change in condition tools were placed on each nurse's cart for use as a guideline. This was verified as having been completed on each medication cart by survey exit. Re-education on the identification of change of condition, documentation, and interventions including notification of the physician was provided to licensed staff by the Director of Clinical Services (DCS) on [DATE] and continued. A review of a training attendance form revealed seven licensed nurse signatures, including LPN C (Agency Nurse). During an interview with the DCS on [DATE] at 6:45 p.m., she confirmed that no facility or Agency nurse would be permitted to work with the residents until the nurse completed the training. The facility created a document entitled Agency Staff Acknowledgement of Orientation and Expectations. The topics addressed were medication administration via oral and inhalation routes along with insulin. The form was completed and signed by eight Agency Nurses between [DATE] and [DATE]. The facility management stated they were creating Agency job competencies with topics to include advance directives, documentation/assessments, resident rights, administration of medications, change of condition procedures, and electronic medical records. The form would require the Agency employee to sign, indicating they had completed the competencies. A mentor or supervisor would also initial the documentation. It would then be forwarded to the supervisor who signed and dated the document, determined whether the employee had completed their orientation and had demonstrated a reasonable command of each topic. On [DATE] at 6:50 p.m., an interview was conducted with the DON. She stated the facility was awaiting approval from Corporate for facility-wide competencies. On [DATE] at 6:35 p.m., an interview was conducted with the Regional Director of Clinical Services. She explained that the documents and processes had been created and the facility was awaiting final approval from Corporate. On [DATE] at 6:10 p.m., an interview was conducted with LPN G. She explained that she had received training on changes in condition and the requirements to notify the physician for changes in condition. The nurse also acknowledged that change in condition tools had been placed on her medication cart. 105682 Page 9 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 6:20 p.m. during an interview with LPN R, he confirmed that he had received training on [DATE] regarding changes in condition and required notification of the physician. The nurse also acknowledged that change in condition tools had been placed on his medication cart for reference. 2. A review of Resident #11's progress note, dated [DATE] at 8:49 p.m., revealed, Resident bilateral breasts with mass noted. Resident no complaint of (c/o) pain and discomfort. Called MD (physician) and made aware. Order received Ultrasound. A review of Resident #11's discontinued physician's orders, revealed an order written on [DATE], instructing the nursing staff to Schedule for Mammogram re: abnormal ultrasound result of her breast. The order was discontinued by the physician on [DATE] due to the resident having been admitted to the hospital. A review of a progress note dated [DATE] at 1:47 p.m., revealed that a care plan meeting was conducted via telephone and indicated, Daughter made aware of bilateral breast mass, ultrasound results and order for mammogram. Informed daughter facility staff will be working with physician to find possible alternate way of getting mammogram done due to her mother is non-ambulatory and requires Hoyer (mechanical) lift for all transfers. Following the meeting, this writer informed resident of the ultrasound results and order for mammogram. An interview with the Clinical Support Specialist (CSS) was conducted on [DATE] at 9:43 a.m. During the interview, the CSS stated Resident #11 was unable to stand up to have the mammogram done. She stated she called three medical centers. Each clinic stated that the resident would have to be able to stand to receive the mammogram. An interview was conducted with the Administrative Assistant at one of the three medical centers on [DATE] at 10:26 a.m. During the interview, the Administrative Assistant was asked if the clinic provided mammogram services for someone unable to stand or requiring a wheelchair. The administrative assistant stated the clinic did provide mammogram services for patients in wheelchairs and they received those types of patients all the time. The facility's policy and procedure for setting medical appointments was requested from the Director of Nursing (DON) on [DATE]. The DON stated a policy and procedure for setting medical appointments was not available for review, and no policy was received over the course of the survey. 105682 Page 10 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to ensure resident safety, by failing to ensure the nursing staff recognized and managed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors and suicidal ideation, out of four residents reviewed, from a total of 37 residents in the sample. The facility's failure to ensure nursing staff maintained appropriate skills sets and competencies contributed to Resident #191's death. The facility's employees and service providers failed to provide services to Resident #191 that were necessary to avoid physical harm. During the 3:00 p.m. to 11:00 p.m. shift on [DATE], Certified Nursing Assistant (CNA) B told Licensed Practical Nurse (LPN) C (Agency Nurse) 14 to 18 times throughout the shift, that Resident #191 was observed with agitation, restlessness, and repeated attempts to jump out of bed. CNA B repeatedly asked LPN C to do something. CNA B continued to check the resident every 10 to 15 minutes, noting that Resident #191 kept raising her bed into the highest position, and was twisting and turning in the bed repeatedly. LPN C failed to respond. She failed to assess the resident, notify the resident's physician, document changes in condition and/or any interventions attempted, and she failed to ensure Resident #191 was adequately supervised to prevent serious injury. At approximately 11:15 p.m. on [DATE], Resident #191 was discovered with her torso and lower body off the bed in an upright position and her neck wedged between the bed rail and the mattress. Her face was pressed against the mattress. She had expired. LPN C continued providing nursing services to facility residents during and after this incident and was scheduled to work the 11:00 p.m. to 7:00 a.m. shift on [DATE]. Immediate Jeopardy at a scope and severity of J (isolated) was identified at 3:55 p.m. on [DATE]. On [DATE], at 11:15 p.m., the Immediate Jeopardy began. On [DATE] at 1:30 p.m., the Administrator was notified of the IJ determination. Immediate Jeopardy was removed upon survey exit on [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D. On [DATE], the facility census was 93. Any resident receiving care by an Agency staff nurse was at risk for serious harm or death. The findings include: Cross Reference to F600, F684, F742, and F867. 1. A review of Resident #191's medical record revealed an admission date of [DATE]. The resident expired in the facility on [DATE]. Resident #191's primary medical diagnosis was Parkinson's disease (central nervous system disorder affecting movement, often including tremors) and secondary diagnoses included altered mental status, encephalopathy (any brain disease that alters brain function), respiratory failure, rhabdomyolysis (a breakdown of muscle tissue which can cause kidney damage), a history of post-traumatic stress disorder (PTSD), and atrial fibrillation (irregular heartbeat that 105682 Page 11 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0726 commonly causes poor blood flow, leading to shortness of breath and fatigue). Level of Harm - Immediate jeopardy to resident health or safety A review of the resident's admission Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 points, indicating intact cognition. She required extensive to total assistance with all activities of of daily living and was incontinent of bowel and bladder. The MDS assessment identified a history of falls prior to the resident's admission. Residents Affected - Few On [DATE] at 11:50 a.m., an interview was conducted with the Director of Nursing (DON) regarding the facility's protocol for ensuring Agency staff were receiving adequate training and verification of competencies. The DON explained that the person who was responsible for conducting the training with Agency staff quit on Friday, and that she wasn't sure what the process was. She stated she believed there was an agenda that was given to the employees. On [DATE] at 11:38 a.m. a follow-up interview was conducted with the DON regarding the facility's policies for Agency staff orientation. She provided a copy of a three-page packet. When asked whether any competency checks or other education was conducted with Agency staff, the DON stated she wasn't aware of anything aside from the packet that was provided, and then she stated, To be honest, there is a lot of Agency in here. You are telling me where I need to start to fix things. There is no accountability from these Agency staff at all. We need to get them out of here. The DON confirmed there was no facility policy for education related to Agency staff. On [DATE] at 2:19 p.m., an interview was conducted with Licensed Practical Nurse (LPN) F (Agency Nurse). She explained that she had worked at the facility two times and was employed with a Staffing Agency. When asked about this facility's orientation process, she stated, I didn't get orientation. The nurse explained that she was shown where her unit was and was given the regular, daily nursing report. Then she began her shift. She stated she didn't receive any written documentation, references, or guides. She stated she did not receive a job description. On [DATE] at 5:23 p.m., an interview was conducted with LPN G (Agency Nurse). She explained that she had worked at the facility since [DATE] and that she was employed by a Staffing Agency. When asked about her orientation process for this facility, she stated, It only took a few minutes. They just gave me a couple of papers and sent me on my way. She stated she did not receive a job description. On [DATE] at 1:28 p.m., an interview was conducted with LPN C (Agency Nurse assigned to Resident #191 on the date/shift of the incident) via telephone. When asked about any training or orientation she had received from the facility, she stated, I didn't have any training. None whatsoever. They told me to sign the papers and then I was on the cart. She stated she did not receive a job description. On [DATE] at 5:16 p.m., an interview was conducted with LPN Q (Agency Nurse). During the interview, the nurse confirmed that she was employed by a Staffing Agency. When asked whether she had received any orientation from this facility, she said she had not. She stated she did not receive a job description. On [DATE] at 6:00 p.m., an interview was conducted with LPN R (Agency Nurse). During the interview, he confirmed that he was employed by a Staffing Agency. The nurse stated he hadn't received any orientation when he started working at this facility, but that the facility had given him orientation on [DATE], which he stated he was grateful for. He stated he had not received a job description. 105682 Page 12 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The facility's Staffing Agency contract was reviewed. The contract was dated [DATE] and was signed by the Administrator. The contract read, The care center will properly supervise assigned employees performing its work and be responsible for its business operations, products, services, and intellectual property. (Photographic Evidence Obtained) The facility's job description for Licensed Practical Nurses was reviewed. The job description directed the nurse to Initiate emergency support measures (i.e. CPR (cardiopulmonary resuscitation), protect guest from injury). (Photographic Evidence Obtained) The facility's job description for Registered Nurses was reviewed. The job description directed the nurse to Initiate emergency support measures (i.e. CPR, protect guest from injury). (Photographic Evidence Obtained) During a review of facility records provided for review on [DATE] at 2:20 p.m., verification of competencies provided to Agency Staff who were on assignment at the facility could not be located. On [DATE] at 12:42 p.m., an attempt was made to contact the Administrator of the Staffing Agency used by the facility. A voicemail message was left identifying the caller, the purpose of the call, and a request was made for the provision of documentation for Agency employees. On [DATE] at 1:39 p.m., the Staffing Agency Administrator called. Nursing competencies were requested for Agency nursing staff who were assigned to work in this facility from [DATE] through [DATE]. The Administrator stated the information was not readily available and would have to be located. She would provide any paperwork she had once it was located. On [DATE] at 3:33 p.m., during an interview with the facility's Staffing Coordinator, she stated she had been employed at the facility for 10 years. She stated, Typically it is the responsibility of the Director of Education (DE) to ensure the competencies and education are complete and current, however, that position became vacant on [DATE]. The DON has taken over those duties, but has not conducted any competencies or education to date. She stated all nursing staff must be licensed or certified prior to hire. She confirmed sufficient staffing was currently an issue in the facility, and Agency staff were used heavily. She also stated Agency staff should come with their competencies and the facility DON was responsible for verifying this. On [DATE] at 3:40 p.m. during an interview with the DON, she was asked again to provide copies of competencies for Agency staff. She replied that the facility did not complete any competencies for Agency staff. She stated Agency staff should have completed competencies with their Agency prior to reporting to work at the facility. The DON could not provide any verification that the Agency staff members had received competencies prior to reporting to work at the facility. On [DATE] at 5:33 p.m., an email was sent to the Staffing Agency requesting the competencies provided to their staff members upon hire and prior to being sent on an assignment. On [DATE] at 8:54 a.m., an email was received from an employee at the Staffing Agency. The email was also addressed to the DON at this facility and stated, We provided all of our onboarding procedures to the facility, including our procedure for assessing competency before nurses/CNAs are fully onboarded and sent out to facilities. On [DATE] at 10:20 a.m., the DON was asked about the documentation provided by the Staffing Agency 105682 Page 13 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and referred to in their email dated today. She stated the information explained the process however, it did not include competencies for Agency Staff as requested. She confirmed this information was not available. On [DATE] at 4:00 p.m., the facility provided their immediate actions to remove the Immediate Jeopardy. These immediate actions were verified by the surveyors on-site as having been completed as follows: Change in condition tools were placed on each nurse's cart for use as a guideline. This was verified as having been completed on each medication cart by survey exit. The facility created a document entitled Agency Staff Acknowledgement of Orientation and Expectations. The topics addressed were medication administration via oral and inhalation routes along with insulin. The form was completed and signed by eight Agency Nurses between [DATE] and [DATE]. The facility management stated they were creating Agency job competencies with topics to include advance directives, documentation/assessments, resident rights, administration of medications, change of condition procedures, and electronic medical records. The form would require the Agency employee to sign, indicating they had completed the competencies. A mentor or supervisor would also initial the documentation. It would then be forwarded to the supervisor who signed and dated the document, determined whether the employee had completed their orientation and had demonstrated a reasonable command of each topic. On [DATE] at 6:50 p.m., an interview was conducted with the DON. She stated the facility was awaiting approval from Corporate for facility-wide competencies. On [DATE] at 6:35 p.m., an interview was conducted with the Regional Director of Clinical Services. She explained that the documents and processes had been created and the facility was awaiting final approval from Corporate. Re-education on the identification of change of condition, documentation, and interventions including notification of the physician was provided to licensed staff by the Director of Clinical Services (DCS) on [DATE] and continued. A review of a training attendance form revealed seven licensed nurse signatures, including LPN C (Agency Nurse). During an interview with the DCS on [DATE] at 6:45 p.m., she confirmed that no facility or Agency nurse would be permitted to work with the residents until the nurse completed the training. On [DATE] at 6:10 p.m., an interview was conducted with LPN G. She explained that she had received training on changes in condition and the requirements to notify the physician for changes in condition. The nurse also acknowledged that change in condition tools had been placed on her medication cart. On [DATE] at 6:20 p.m. during an interview with LPN R, he confirmed that he had received training on [DATE] regarding changes in condition and required notification of the physician. The nurse also acknowledged that change in condition tools had been placed on his medication cart for reference. . 105682 Page 14 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Based on interview and record review, the facility failed to ensure that residents with a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain their highest practicable mental and psychosocial well-being, by failing to ensure that seven (7) active Agency nursing staff received education on the identification of a change in condition with proper interventions and documentation per the facility's plan of correction. As a result of the recertification and complaint survey completed on 11/19/2021, the facility was cited at

F742 (Treatment/Services for Mental/Psychosocial Concerns) at an Immediate Jeopardy (IJ) level. The IJ was removed at the time of the survey exit on 11/19/2021, however the facility remained out of compliance at a scope and severity of D. The facility's plan of correction was submitted on 12/17/2021 indicating a The findings include: A review of the facility's plan of correction revealed, 3. Re-education to licensed nursing staff to include licensed nurse Agency staff, will be completed on various dates by the DCS (Director of Clinical Services)/Designee on identification of change in condition with proper interventions and documentation. This education will be included in new hire orientation as appropriate based on discipline. The facility alleged the noncompliance was corrected by 12/21/2021. A review of the facility's Agency staff roster revealed a total of 28 current Agency nursing staff as of 02/04/2022. (Copy obtained) A review of course completion logs and in-service records provided at the time of the revisit, revealed a total of seven (7) Agency staff without documentation of having received education coinciding with the facility's plan of correction. (Copies obtained) A review of the staffing schedule for 02/04/2022, revealed one Agency employee who was scheduled to work the 11 p.m. to 7 a.m. shift this date who had not received education coinciding with the facility's plan of correction. (Copies obtained) On 02/04/2022 at 3:43 p.m., an interview was conducted with the Administrator and the Director of Nursing. The Administrator explained that a Quality Assurance Performance Improvement meeting was conducted on 12/23/2021, and the facility identified that it was not in compliance with the required training regarding abuse, neglect, and exploitation. The Director of Nursing explained that the facility began withholding access to the facility's electronic medical record system until the staff member completed the required training. As of 02/04/2022, the facility remained out of compliance. This was previously cited by a representative of this Agency during the recertification and complaint survey conducted from November 15-19, 2021. . 105682 Page 15 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to maintain the kitchen in a safe and sanitary manner for the 90 residents in the facility. The findings include: During a visit to the kitchen on 11/15/21 at 10:28 AM, the following observations were made and acknowledged by the Certified Dietary Manager (CDM). 1. The toaster had breadcrumbs inside and outside of the equipment with splatters on it. (Photographic evidence obtained) 2. The microwave had splatter on the tray inside of the machine and had brown splatter on the inside of door. (Photographic evidence obtained) 3. The walk-in freezer had spills on the floor. 4. The thermometer could not be found inside the walk-in freezer. 5. Dry storage closet had food in boxes on the floor. 6. The dry items: flour and sugar were observed in large plastic containers without dates. 7. The ice maker was observed with grayish color on the inside top part of the unit. The outside of unit had white substance build up on the corner of the hinge door. 8. The 3-compartment sink had a piece of back wall hanging on floor with brown stain on it. (Photographic evidence obtained) On 11/18/21 at 11:27 AM, a second visit to the kitchen was made with the following observations and acknowledged by the CDM. 1. The walk-in freezer still had stains and spills on floor. 2. The ice machine still had grayish tint on the inside top part of unit. 3. The ice cream freezer had no thermometer in the unit. 4. The dry storage closet still had packaged food on floor. (Photographic evidence obtained) 5. One bag of rice cereal was unsealed sitting on a self in dry storage without any date. 6. One bag of grits was not sealed or dated. 7. The microwave still had splatters in it. 105682 Page 16 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0812 Level of Harm - Minimal harm or potential for actual harm On 11/18/21 at 3:03 PM, an observation of the three-compartment sink was not able to be done because the CDM stated it was not working. The CDM stated she was putting big pans through dishwasher until she could get Ecolab to fix the sanitizer. . Residents Affected - Many 105682 Page 17 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

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 interviews, record review and facility policies and procedures, the facility failed to maintain complete and accurate medical records in accordance with professional standards for one (Resident #23, who was receiving controlled medication for insomnia) of six residents sampled for unnecessary medication use were complete and accurate, from a total sample of 38 residents. The findings include: On 11/15/21 at 02:00 PM, an interview was conducted with Resident #23 in her room. She reported that she had not received her sleeping pills for the past three days and it had been very difficult for her to get some restful sleep. She was told by staff that the medication had not been delivered by the pharmacy. A record review for Resident #23 revealed an admission date of 5/8/19, with diagnoses including syncope and collapse, major depressive disorder, and insomnia. A review of Resident #23's quarterly minimum data set (MDS) assessment, dated 8/16/21 revealed a brief interview for mental status (BIMS) score of 14, indicating cognitively intact. Care plan for Resident #23 indicated, she was at risk for adverse effect from antidepressant and sedative medication. Interventions included administer medications as ordered by physician and monitor for side effects. A review of Resident #23's current physician's orders included: Restoril (temazepam) 7.5 mg by mouth at bedtime for insomnia with start date of 10/9/20, Ativan 0.5 mg three times a day for anxiety with start date of 2/18/20, and Celexa 40 mg one time a day for depression with start date of 6/18/19. During an interview on 11/18/21 at 10:46 AM, Employee D, Licensed Practical Nurse (LPN) confirmed that Resident #23 did not have a narcotic sheet for Restoril 7.5 mg. She checked the medication cart for the medication but did not find any. She contacted the pharmacy and was informed that the last refill for Restoril 7.5 mg was done on August 18, 2021, for 30 days. When Employee D, LPN was asked what it meant if there were blanks in the medication administration record (MAR), she stated, It means the medication was not given. She confirmed that nurses had documented on the MAR that Restoril 7.5 mg was given to Resident #23 when there was none in stock nor in the Emergency Drug Kit (EDK). On 11/18/21 at 11:40 AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the medication Restoril 7.5 mg for Resident #23 was documented as given several times on the October and November 2021 MAR while the medication was not in stock. She said, To be honest, the facility has had a lot of agency staff and they lack a sense of responsibility. You are making me know what I need to fix. A record review of Resident #23's narcotic sheet indicated the last dose of Restoril 7.5 mg was administered on 9/17/21. A review of Resident #23's MAR for November 2021 revealed documentation the resident received Restoril medication on the 4th, 10th, 11th, 15th, 16th and 17th. A review of the MAR for October 2021 revealed documentation the resident received Restoril medication on the 1st, 2nd, 4th, 7th, 12th, 13th, 14th, 15th, 19th, 21st, 22nd, 23rd, 25th, 26th and 27th. (Copy obtained) 105682 Page 18 of 19 105682 11/19/2021 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A follow up interview was conducted with Resident #23 on 11/18/21 at 4:50 PM. She restated that she had not been sleeping well. When she asked the nurses for her sleeping medication, they would tell her that she gets melatonin for sleep, and she did not have anything else. A review of the facility's policy Charting and Documentation with a revision date of September 2020 revealed the following guidelines: 1. A complete accounts of the resident's care, treatment, response to the care, signs, and symptoms, etc. as well as the progress to the resident's care. 2. Guidance to the physician in prescribing appropriate medication and treatments. 5. Assistance in the development of a Plan of Care to the Resident. 6. The elements of quality medical nursing care. (Copy obtained) A review of the facility's policy and procedure Administration of Drugs'' with effective date of October 2014 revealed, Residents shall receive their medications on a timely basis and in accordance with our established policies. Medications must be charted by the person administering the drug immediately following the administration. The date, time administered, dosage etc. must be documented in the medical record and signed by the person administering the medication. Medication ordered for one resident may not be administered to another resident. (Copy obtained) . 105682 Page 19 of 19