Health inspection·February 19, 2025

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on observation, record review, and interviews, the facility failed to implement an accurate and up to date system for the accounting of residents' personal funds entrusted to the facility for three (#3, #5, and #6) of three residents sampled for resident funds review. Findings included: Review of accounts records for Resident's #3, #5 and #6 showed the residents' cost of care being withdrawn from their personal funds account did not consistently match what the Medicaid Access eligibility had determined, and Social Security direct deposits for January and February 2025 were not reflected in the accounts. On 02/19/2025 at 10:23 a.m. Resident #6 was observed in her room and she agreed to an interview. During the interview, she stated she had a concern with her resident trust fund, the monies held by the facility. She said, I am not sure if my balance is accurate. A couple of months ago they took a two-month payment at one time and then no payment for my room and board bill. I worry if I have enough money there. On 02/19/2025 at 1:30 p.m. a telephone interview was conducted with Resident #3's representative. She stated she believed there was some kind of fraudulent activity going on with Resident #3's patient trust account. She stated they went in and took 500 dollars out of it, I told them to stop. Review of a grievance filed for Resident #5, dated 02/13/2025, documented Request RFMS (Resident Funds Management System) report thru (through current accounting). An interview with the Nursing Home Administrator (NHA) on 02/19/2025 at 12:50 p.m., when asked the reason for the grievance, she said, it was just a request for his fund transactions. We gave them the statement, that was when we noticed the cost of care payment of $3015.60 withdrawn from Resident #5's account, it did not make sense. The RFMS system is not accurate. Review of Resident #5's admission record showed an admission date of 06/2023, with the resident currently residing in the facility. Resident's payor source was listed as Medicaid. Review of Resident #5 's Medicaid Access system print out listed the patient liability - room and board cost to be $1,790.60 per month for 2024 and $1838.60 per month for 2025. Review of Resident #5's Resident Fund statement for 06/2024 through the date of survey, 02/19/2025, revealed: Page 1 of 8 105725 105725 02/19/2025 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0568 Review of 2024 records showed Resident #5 had a Social Security income of $1948.00 per month. For 2025, no direct deposit of Social Security income was listed for January or February. Level of Harm - Minimal harm or potential for actual harm The Cost of Care charges showed: Residents Affected - Some 06/18/2024=1,790.60 07/24/2024=1,790.60 08/30/2024=1,790.60 09/19/2024=3015.60 10/31/2024=1,790.60 11/20/2024=1,790.60 12/18/2024=1,790.60 No further cost of care listings were listed through 02/19/2025. Review of Resident #3's clinical chart, the admission Record documented an admission of 08/2023, with the resident currently resident in the facility. Resident's payor source was Medicaid. A review of the Medicaid Access system print out which listed the patient liability (room and board cost) for Resident #3 to be $1,199.64 per month for 2024 and $1240.64 per month for 2025. Review of Resident #3's Resident Fund statement for 01/2024 through the date of survey, 02/19/2025 revealed: Resident #3, during 2024, had a Social Security income of $1626.00 per month. For 2025, no direct deposit of Social Security income was listed for January or February. For Cost of Care charges, the review showed: 01/10/2024=1,307.00 02/23/2024=1,307.00 04/04/2024 (March)=1,307.00 04/16/2024=1,307.00 05/17/2024=1,233.48 06/18/2024=1,199.64 07/24/2024=1,119.64 105725 Page 2 of 8 105725 02/19/2025 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0568 09/19/2024=2,399.28 Level of Harm - Minimal harm or potential for actual harm 10/31/2024=1,199.64 11/20/2024=1,899.28 Residents Affected - Some 12/18/2024=1199.64 No further cost of care listings were listed through 02/19/2025. Review of Resident #6's admission record documented an admission date of 06/2018, with the resident currently resident in the facility. Resident's payor source was listed as Medicaid. Review of the Medicaid Access system print out which listed the patient liability (room and board cost) for Resident #6 to be $2121.69 per month for 2024 and $2177.82 per month for 2025. Review of Resident #6's Resident Fund statement for 01/2024 through the date of survey, 02/19/2025 showed: Resident #6, during 2024, had a Social Security income of $1231.00 per month. For 2025, no direct deposit of Social Security income was listed for January or February. For Cost of Care charges: 01/10/2024=2100.00 02/23/2024=2188.69 04/04/2024 (March)= 2188.69 04/16/2024=2188.69 05/17/2024=2188.69 05/30/2024=3000.00 06/18/2024=2188.69 07/24/2024=2188.69 08/30/2024=2121.69 10/31/2024=8000.00 11/20/2024=2121.69 12/18/2024=2121.69 105725 Page 3 of 8 105725 02/19/2025 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0568 12/23/2024 (debit)=2121.69, unknown charge Level of Harm - Minimal harm or potential for actual harm 01/30/2025=2177.82 No further entries were noted Residents Affected - Some The review of records for Resident #3, #5, and #6 revealed the cost of care charges for the three residents was not consistent with the patient liability determined by Medicaid Access. An interview was conducted with the Nursing Home Administrator (NHA) on 02/19/2025 at 12:20 p.m. regarding the RFMS (Resident Fund Management System) print outs of the resident trust fund transactions. She stated the printouts were not accurate. She stated the Business Office Manager had been a contracted person who had come in once a week to handle the resident trust accounts and had left the position the preceding week to the survey. No person was currently in the BOM position. The NHA said she had formulated a Performance Improvement Plan (PIP) for the RFMS. During the interview, the NHA was requested to share the PIP. During the survey, 02/19/2025, no further information was provided to the survey team as to any corrective action the facility had implemented for the irregular debits and credits within the resident trust fund accounts. Requested but did not receive a facility policy on accounting of resident's personal funds. 105725 Page 4 of 8 105725 02/19/2025 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure personal funds deposited with the facility were conveyed to the resident or resident representative within thirty days after discharge or death for three (#4, #7, #8) of three residents sampled for return of funds in a timely manner. Residents Affected - Some Findings included: On 02/19/2025, the facility provided a list of residents with personal trust fund accounts. During the review of the list provided, three residents were sampled for conveyance of funds, Resident #4, #7, and #8. Review of the facility's Resident Fund Management Services (RFMS), listing the following residents and resident fund balances as of 02/19/2025: Resident #4, with a balance of $3, 814.35. Resident #7, with a balance of $1,470.59. Resident #8, with a balance of $340.54 Review of Resident #4's clinical chart the admission record, documented an initial admission of 04/17/2020, readmission of 11/01/2024; and a discharge to the community on 12/17/2024. Review of Resident #7's clinical chart, the admission record, documented an admission of 12/09/2021, and discharge date of 10/29/2024. Review of Resident #8's clinical chart, the admission record, documented an admission of 09/24/2024, and discharge of 10/04/2024. On 02/19/2025 at 12:20 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated the RFMS information was not accurate but provided no alternative information regarding the balances listed. The NHA was asked to provide a policy for conveyance of personal funds. No policy was provided during the survey. 105725 Page 5 of 8 105725 02/19/2025 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interview, the facility failed to ensure a prompt resolution to a grievance for one (#3) of nine sampled residents. Residents Affected - Few Findings included: An interview was conducted on 02/19/2025 at 12:27 p.m. with the Social Service Director (SSD). A review of three grievances for Resident #3 was conducted. The SSD stated, one grievance, received on 11/18/2024, the (resident's representative) wanted the phone bill paid for Resident #3. The (resident's representative) was upset that the bill was not paid. The representative communicated to the business office who said they were going to pay the bill. The representative tracked the phone bill, and it was not paid. Further review of the grievance form reflected the former Nursing Home Administrator (NHA) had signed that the bill had been paid and the grievance resolved on 11/26/2024. The SSD stated, the next grievance received on 12/16/2024, the (resident's representative) was upset because the phone bill was not completely paid. Review of the grievance form reflected the former NHA signed the grievance as completed on 12/18/2024. The SSD stated, the next grievance was received on 02/01/2025, the (resident's representative) was upset because she had been told to pay the bill, and she would be reimbursed. A review of the grievance log reflected the grievance had been resolved on 02/07/2025. An interview was conducted on 02/19/2025 at 12:50 p.m. with the Nursing Home Administrator, she said she had just spoken to the owners of the facility and Resident #3's representative will be reimbursed by the end of the week for the bill. A phone interview was conducted with Resident #3's (representative) on 02/19/2025 at 1:30 p.m. She said, they are not paying Resident #3's phone bill. She said, I have paid it, and they have not reimbursed me. They are not responding to me. The social worker is writing it all down. I am very frustrated. Review of the facility's Resident Grievance Policy & Procedure, revised 06/12/2023, documented the policy: It is the policy of [name of facility] to provide an opportunity and a method for all residents, visitors, or designated representative to express grievances and complaints free of interference, coercion, discrimination, and/ or reprisal It is the policy that all complaints and grievances be addressed in a timely manner. 105725 Page 6 of 8 105725 02/19/2025 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation record review and interviews, the facility failed to ensure adequate management of tube feeding services for two (#1 and #9) of two sampled tube fed residents out of a total of nine sampled residents related to inaccurate dating of enteral product, non-labeling of product type, rate and time of administration. Findings included: 1. Review of Resident #1's admission record documented an admission of 04/02/2022 and readmission of 06/12/2024. The diagnosis list included but not limited to: Cerebral infarction; chronic atrial fibrillation; aphasia following cerebral infarction; unspecified dementia, unspecified severity without behavioral disturbance psychotic disturbance, mood disturbance; lack of coordination. Review of Resident #1's Care Plan documented a focus - Resident is dependent upon a feeding tube to meet nutritional and fluid needs due to (d/t) dysphagia. The interventions included: Provide feeding and H20 flushes per orders. Review of Resident #1's Tube Feeding & Flushes Flow Record for 02/2025 reflected the following physician orders: -Between 10am & 2pm-flush the G-Tube every hour with 30 ML (milliliter) water The flow sheet had no documentation that indicated staff performed the service on 02/01, 02/02, 02/03 for 10 a.m., 11 a.m., 12 p.m., 1 p.m. and 2 p.m. and on 02/04 and 02/05, no documentation for the 2 p.m. flush. -Provide 200 ML flush every 6 hours (800 ML/Day) The flow sheet had no documentation for 02/01, at 12 p.m. and 6 p.m.; 02/11 at 12 p.m. and 6 p.m.; for 02/14 at 12 a.m. and 6:00 a.m. -Jevity 1.5 @ 45 ML/hour for 20 hours via G tube 10 a.m. off, 2 p.m. on The flow sheet had no documentation for 02/01 02/11. On 02/19/2025 at 2:43 p.m. A review of Resident #1's Tube Feeding & Flushes Flow Record for 02/2025 with the Director of Nursing (DON) was conducted. When the DON was asked about the blanks in the record, she stated she did not know why staff had not initialed. On 02/19/2025 at 2:49 p.m., an observation was conducted with the DON of Resident #1's tube feeding set up. The machine was not on. Resident #1 was observed in bed. An observation of the bag with tube feed product was conducted. No product name was present on the bag. The resident's name, room number, and date of 02/19/2025 was on the bag. No time was documented on the bag or rate. The bag was full with product up to the 1000 mark. An interview was conducted on 02/19/2025 at approximately 2:50 p.m. with Staff A, Licensed Practical Nurse. She stated she was coming on shift and had worked the day before. She stated she had hung 105725 Page 7 of 8 105725 02/19/2025 Elon Manor Nursing and Rehabilitation Center 1203 E 22nd Ave Tampa, FL 33605

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the bag at 6:00 a.m. this morning (02/19/2024). She reported the product in the bag was Jevity. When asked why the product had been transferred from the original packaging to the hanging bag, she stated it was a tubing issue, that the spike tubing for the Jevity bottle on the 2nd floor was not available; she said she had completed the hanging process as the preceding nurse had not completed it. 2. Review of Resident #9's admission record documented an admission of 01/29/2025. The diagnosis list included but not limited to Gastrostomy status and bed confinement status. Review Resident #9's chart, a physician telephone order, dated 01/30/2025: Jevity 1.5 @ 60 ml/ hr. for 20 hrs. & Flush 150 ml every 4 hours. Review of Resident #9's Care Plan, Focus area: The resident has nutritional problem r/t (diagnosis), limited mobility, NPO (nothing by mouth) status, enteral nutrition to meet nutritional needs, colostomy. On 02/19/2025 at 9:57 a.m., Resident #9 was observed in bed watching television. Resident #9 was observed to have a tube feeding set up next to her bed. The food product bottle, Jevity, was observed to be empty. The label on the bottle had areas for staff to put the patient's name, room number, date, start a.m. or p.m. and rate. The rate was blank, documented was the name, room number, hung on 02/18 at 14:10. On 02/19/2025 at 3:05 p.m., a review of Resident #9's tube feeding set up was reviewed with the DON. The bottle in place on the stand, Jevity 1.5 calorie, was observed to be full of product, up to the 1000 mark; had Resident #9's name, room number, 02/18 for the date hung, no time, and no rate. Review of the facility's policy and procedure for Enteral Tube Management revised on 11/2024, included The nurse's responsibilities when caring for a patient with an enteral tube include the following: Assessing the tube placement and patency Assessing and cleansing the insertion site Administering tube feeding Administering medication Irrigating/flushing the tub Suctioning the tube Monitoring for complications (Photographic Evidence Obtained) 105725 Page 8 of 8