Health inspection·April 22, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident representative about a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition. Findings included: Review of an admission record revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and history of falling. Review of an order summary dated 3/1/2025 showed, apply steri strips to wounds on right forehead. Monitor every shift until healed. Review of a clinical note dated 3/1/2025 at 12:53 a.m. showed, Resident found lying on the floor in [room number]. Laceration noted to right forehead and right shoulder, steri strips applied, [physician] notified. daughter to be notified in the morning. Review of an eINTERACT Change in Condition Evaluation dated 3/1/2025 at 5:32 a.m. revealed under Section A. Signs and Symptoms Identified, Resident # 2 had a fall in the morning and obtained a skin wound or ulcer. Review of section B6. Skin Status Evaluation showed Resident # 2 skin changes were a laceration and skin tear on the right shoulder and above the right eye. Review of a System Note dated 3/1/2025 at 6:23 a.m. showed Resident #2 was sent to the hospital on 3/1/2025 at 6:15 a.m. for a head injury. During an interview on 4/22/2025 at 1:25 p.m. with the Nursing Home Administrator (NHA), Risk Manager (RM), and Director of Nurses (DON), the RM stated Resident # 2 had a fall on 3/1/2025 at 12:54 a.m. The resident was found lying on the floor next to the air conditioner in the room next door to her room. She sustained a laceration on her right forehead and on her shoulder. The nurse assessed the resident, conducted neurological checks, and steri-strips were applied. The nurse documented the resident did not have any signs of pain, mood, or behavior after the fall. Her vital signs were in normal limits before the resident went out to the hospital. The nurse documented she notified the on-call physician and noted she would notify the daughter in the morning. The RM stated when she asked the nurse why she waited four hours later to notify the daughter, the nurse stated she did not feel there was anything critical going on with the resident that she needed to wake the daughter up at the time. The RM stated when the daughter was notified about the fall, she came to the facility to see her mother and requested her mother be sent out to the hospital because she was concerned about the Page 1 of 4 105694 105694 04/22/2025 Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771

F 0580 bruise she saw on her mother. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Incidents and Accidents, last reviewed on 10/14/2024, showed the following: Residents Affected - Few Compliance Guidelines: 11. The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. 105694 Page 2 of 4 105694 04/22/2025 Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident's primary care provider to receive instructions for a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition. Residents Affected - Few Findings included: Review of an admission record revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and history of falling. Review of an order summary dated 3/1/2025 showed, apply steri strips to wounds on right forehead. Monitor every shift until healed. Review of a clinical note dated 3/1/2025 at 12:53 a.m. showed, Resident found lying on the floor in [room number]. Laceration noted to right forehead and right shoulder, steri strips applied, [physician] notified. daughter to be notified in the morning. Review of an eINTERACT Change in Condition Evaluation dated 3/1/2025 at 5:32 a.m. revealed under Section A. Signs and Symptoms Identified, Resident # 2 had a fall in the morning and obtained a skin wound or ulcer. Review of section B6. Skin Status Evaluation showed Resident # 2 skin changes were a laceration and skin tear on the right shoulder and above the right eye. Review of a System Note dated 3/1/2025 at 6:23 a.m. showed Resident #2 was sent to the hospital on 3/1/2025 at 6:15 a.m. for a head injury. During an interview on 4/22/2025 at 1:25 p.m. with the Nursing Home Administrator (NHA), Risk Manager (RM), and Director of Nurses (DON), the RM stated Resident # 2 had a fall on 3/1/2025 at 12:54 a.m. The resident was found lying on the floor next to the air conditioner in the room next door to her room. She sustained a laceration on her right forehead and on her shoulder. The nurse assessed the resident, conducted neurological checks, and steri-strips were applied. The nurse documented the resident did not have any signs of pain, mood, or behavior after the fall. Her vital signs were in normal limits before the resident went out to the hospital. The nurse documented she notified the on-call physician and noted she would notify the daughter in the morning. The RM stated when she asked the nurse why she waited four hours later to notify the daughter, the nurse stated she did not feel there was anything critical going on with the resident that she needed to wake the daughter up at the time. The RM stated when the daughter was notified about the fall, she came to the facility to see her mother and requested her mother be sent out to the hospital because she was concerned about the bruise she saw on her mother. The RM stated the daughter was very upset she was not notified about her mother at the time of the incident. The RM stated when she called the nurse to interview her, the nurse stated she never spoke to the resident doctor that night, but she left a voice message on the doctor's phone. The nurse stated she called the on-call number and left a message with the on-call service. The RM stated the nurse's story kept changing, so they reported her license to the board and she was terminated because she would not cooperate with the investigation. The DON stated the nurse documented in her progress note she notified the doctor, but she did not notify the doctor and the on-call doctor services said they did not have a record of a message from that night. The DON stated when she reached out to the resident's provider, he said he was on call that night and he would have gotten the message but he did not receive a call or have a message from the facility about 105694 Page 3 of 4 105694 04/22/2025 Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771

F 0684 Resident #2's fall. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Incidents and Accidents, last reviewed on 10/14/2024, showed the following: Residents Affected - Few Compliance Guidelines: 9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). 105694 Page 4 of 4