Health inspection·December 22, 2022

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 review the facility failed to honor one resident's (#83) dignity by not providing appropriate customer service related to communication to the resident from a staff member out of thirty-six sampled residents. Findings included: The admission Record revealed that Resident #83 was admitted initially on 5/27/20 and re-admitted on [DATE]. The record included diagnoses not limited to major depressive disorder, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and unspecified anxiety disorder. The Admission/5-day Minimum Data Set (MDS), dated [DATE], identified Resident #83 as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS revealed the resident had no identified moods or behaviors, and required extensive assistance with bed mobility, dressing, and personal hygiene. The MDS indicated the resident was always incontinent of bladder and frequently incontinent of bowel requiring total assistance from 1-person for toileting needs. During an interview with Resident #83, on 12/20/22 at 9:58 a.m., the resident related that approximately two weeks prior the resident turned on the call light at 4:30 a.m. to be changed. She reported an unknown certified nursing assistant (CNA) arrived and informed the resident that she (the resident) should have waited another hour so the CNA could have sat for another hour. The resident reported on Thanksgiving night (2022) during the 11 p.m. - 7 a.m. shift, the CNA stated to the resident, It's people like you; why I can't be with my daughter today. On 12/21/22 at 12:56 p.m., Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) reported Resident #83 had voiced an issue about a CNA on the 11(p.m.)-7 (a.m.) shift, and that she (Staff B) filed a grievance on it, and had provided education (with staff). A review of the November and December 2022 Resident/Family Concern Log did not reveal a grievance had been filed on behalf of Resident #83 in regard to the statements made by the CNA. A continued interview was conducted, at 3:51 p.m. on 12/21/22, with Staff B. Staff B stated the incident occurred on the (past) weekend and a grievance had been written up on Monday (12/19/22). Staff B stated she wrote a grievance but did not remember exactly what it was about, thought it might have been over a brief change. Staff B asked if she could review the grievance and left the nursing Page 1 of 14 105730 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0550 Level of Harm - Minimal harm or potential for actual harm station, returning a few minutes later. Staff B related that it seemed like the resident had had diarrhea and the resident had informed her that the CNA was not very nice to her, was not specific on the day it had occurred but it was on the night shift. Staff B stated Resident #83 was on 1-hour observations during the night and had filed a grievance. Staff B reported the resident had not complained of staff prior to this incident. Residents Affected - Few Staff C, CNA stated on 12/21/22 at 3:59 p.m. Resident #83 had complained about the 11-7 shift and weekend staff. Staff C related the complaints were ongoing, involved other residents on the unit, and Resident #83 asked for something to be done and they (staff) did not want to do it. She stated in case of complaints she notified the nurse or Staff B, the unit manager. An interview was conducted, on 12/21/22 at 4:12 p.m., with the Nursing Home Administrator (NHA). The NHA reported a grievance had been filed related to Resident #83. She reported the resident reported call lights were not answered promptly and customer service could be better on the 11-7 shift. The NHA stated the resident was on 1-hour observations that are being documented and education had been provided for customer service. Resident #83's comments were reviewed with the NHA, who stated this was the first time hearing of it and she had not spoken with the resident lately. She stated that it would be easy to find out which staff member had said it and agreed the statement made on Thanksgiving was very specific. On 12/21/22 at 4:56 p.m., the NHA reported Resident #83 was sticking to the story, that it would be investigated, and she could not believe the resident had not said anything to anyone about it. The NHA stated the CNA, who the facility thought it was, had not worked since Thanksgiving. The NHA stated, on 12/22/22 at 9:15 a.m., the facility spoke with the suspected CNA, who reported she knew of the alleged incident and related bantering back and forth with Resident #83. The NHA stated a grievance had been completed for Resident #83 regarding the CNA. The NHA stated all staff had been interviewed and they had known of the incident, the supervisor on 11-7 shift had removed the CNA from the assignment and had not reported it to anyone as she thought she had handled it. The NHA stated the supervisor should have made the NHA aware of it, as it could have been handled three weeks ago. The policy titled, Person Centered Care Statement, copyrighted 2018, indicated that, The very core of Person Centered Care is about the relationships that exist between patients/residents, their loved ones, and staff. We promote patient/resident dignity and self-worth through honoring preferences and choices. The interpretation and implementation of the policy indicated, We support the choice of individually selected wake-up times and individualized morning routines and We support the choice of other individualized requests being honored in practice and documented in the plan of care. 105730 Page 2 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure a Self-Administration of Medication Evaluation was completed for one resident (#393) of thirty-six sampled residents prior to leaving medications at bedside for the resident to administer without the presence of nursing staff. Residents Affected - Few Findings included: The admission Record indicated Resident #393 was admitted on [DATE]. The record included diagnoses of unspecified chronic obstructive pulmonary disease, unspecified systemic lupus erythematosus, and a need for assistance with personal care. The Admission/5-day Minimum Data Set (MDS), dated [DATE], indicated Resident #393's Brief Interview for Mental Status (BIMS) score was 15 out of 15, identifying intact cognition. On 12/19/22 at 10:52 a.m., an observation was made of a medication cup containing a thick-looking golden liquid and a small bottle of a topical medication on the over-bed table in Resident #393's room. The medication cup was labeled [Room Number and Bed Identifier] and the resident was not in the room. (Photographic Evidence Obtained) An interview was conducted, at 10:59 a.m. on 12/19/22, with Staff E, Licensed Practical Nurse (LPN). Staff E stated Resident #393 had just left the facility with a family member and the liquid at bedside was Nystatin Swish and Swallow. She stated there should not be any medication at bedside and the staff member had administered 30 milliliters (mL) of Nystatin and Megace, then the resident had asked for a pain pill. Staff E stated she did not notice the resident had not taken all of the Nystatin and there should be three medication cups. Staff E reviewed the photographic evidence of the medications and confirmed the liquid was Nystatin Swish and Swallow and stated, That's not our bottle (of Nystop), you can look, ours don't look like that. On 12/19/22 at 12:05 p.m., Resident #393 was observed in the hallway of the unit speaking with another resident. Resident #393 stated, on 12/19/22 at 12:57 p.m., Oh that's my fault. The resident reported that Nystatin was supposed to be taken after her breathing treatment and a friend had come to take her out of the facility and the breathing treatment had been taken. The resident stated she had told the nurse that she would take the Nystatin Swish and Swallow but had not. A review of Resident #393's previous completed evaluations, on 12/19/22 at 2:26 p.m., revealed an Evaluation for the Self-Administration of Medications had not been completed. A review on 12/19/22 at 2:28 p.m. of the resident's care plan identified that a physician's order had been obtained to allow Resident #393 to self-administer Nystatin powder and instructed staff to assess the resident for the ability to self-administer the medication specified on the admission/re-admission, quarterly, with a change in resident medications, and with significant changes in condition. The review of physician orders, on 12/19/22 at 2:33 p.m. did not reveal the resident had a physician's order to allow for the self-administration of any medication. Staff B, LPN/Unit Manager confirmed, on 12/19/22 at 2:50 p.m., that Resident #393 did not have a physician's order allowing for the self-administration of medications but did have a care plan focus indicating there was a physician's order. 105730 Page 3 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/19/22 at 2:57 p.m., the Director of Nursing (DON) reviewed the care plan and confirmed it said Resident #393 had a physician's order for the self-administration of Nystatin topical powder. She reviewed the current orders and confirmed there was no physician order regarding self-administration of medications. She stated the self-administration (assessment) would be conducted by either the therapy or nursing staff. She confirmed the evaluation of self-administration of medications could be done by nursing. She stated she could speak with the physician (regarding an order) for self-administration of medications. The DON did not respond on how the care plan team would know there was a physician order (without it being in the physician orders). The DON stated she would look for Resident #393's self-administration evaluation. On 12/19/22 at 3:27 p.m., a review was conducted of Resident #393's available evaluations. The review identified a Self-Administration Evaluation V2, effective on 12/19/22 at 3:02 p.m., was IN PROGRESS and the score was TBD (to be determined). The evaluation indicated the number of medications considered for self-administration was 1 and the order was for Nystatin powder. This evaluation was effective approximately 4 hours after the observation of the topical powder and Nystatin liquid left at Resident #393's bedside. The evaluation indicated that Interdisciplinary (IDT) met and resident can self-administer Nystatin powder safely and that a physician order had been obtained on 12/19/22. Resident #393's clinical record identified a Self administration of Medication Evaluation V2, effective 12/19/22 at 4:03 p.m., was completed to indicate the resident had been evaluated to administer 1 medication - nystatin swish and swallow. This evaluation was effective 5 hours after the observation of the medication, Nystatin Swish and Swallow had been left at Resident #393's bedside. The evaluation reported that IDT and nursing agree resident can safely self-administer the Nystatin Swish and Swallow, and a physician order had been obtained on 12/19/22. Resident #393's Self-Administration Evaluations, dated 12/19/22 at 3:02 p.m. and 4:03 p.m., identified, Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, change in function/condition that might affect the resident's ability to safely self administer medications. On going assessment should occur at a minimum quarterly. Use clinical judgement with section B to determine if or what level of self-administration will be allowed. The DON provided, on 12/19/22 at 4:12 p.m., a physician progress note, dated 12/19/22, that indicated Resident #393 could self-administer topical and oral meds. The DON reported the physician was an early bird. The physician order, dated 12/19/22 at 3:58 p.m., identified the resident may self-administer Nystatin powder and Nystatin swish and swallow. The policy title, Self Administration of Medication, copyrighted 2008, indicated the purpose was To provide evaluation process to determine if a resident is capable to self-administration. The procedure identified the following steps: - 1. If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a Self Administration of Medication Evaluation. - 2. The nurse will interview the resident to determine their ability to identify, prepare, and administer Medications. - 3. Based on the interdisciplinary team's assessment, a decision is made as to whether or not the 105730 Page 4 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0554 Level of Harm - Minimal harm or potential for actual harm resident is a candidate for self-administration. This will be recorded on the Self Administration of Medication Evaluation. - 4. The nurse will obtain a physician's order for each resident conducting self-administration of medications. Residents Affected - Few - 5. The nurse to educate the resident regarding reaction and side effects of the medication. - 6. Nurses will evaluate compliance of self-administration and document self-administration of medications in the Medication Administration Record (MAR). - 7. Storage of self-administered medications will comply with state and federal requirements for medication storage. 105730 Page 5 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 ensure residents were accurately screened for possible mental disorders or intellectual disabilities prior to admission for one resident (#9) of three residents sampled for Preadmission Screening and Resident Review (PASARR) screenings. Residents Affected - Few Findings included: A review of Resident #9's admission Record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of anxiety disorder, depression, and Post-Traumatic Stress Disorder (PTSD). A review of Resident #9's hospital admission History and Physical (H&P), dated 11/12/2022, revealed Resident #9 had a history of PTSD, depression, and anxiety. A review of Resident #9's Level I PASARR assessment, dated 11/17/2022, revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Anxiety Disorder, Depressive Disorder, and Other (specify), were not checked. A review of Resident #9's Minimum Data Set (MDS) assessment, dated 11/28/2022 revealed, under Section I: Active Diagnoses, Resident #9 had psychiatric/mood disorders to include anxiety disorder, depression, and PTSD. An interview was conducted on 12/21/2022 at 1:25 p.m. with the Staff F, Transitional Care Manager (TCM), the facility's Social Services Director (SSD), and the facility's Director of Nursing (DON). Staff F, TCM stated she reviews all resident PASARR assessments prior to admission to the facility to ensure the completion of the PASARR and to verify any findings of the PASARR in comparison to the hospital paperwork. The resident's H&P and progress notes are reviewed and interviews are conducted with the resident and/or resident's family prior to admission to the facility to verify admitting information. Staff F, TCM stated if the PASARR assessment is discovered to be inaccurate during review, it would be sent back to the previous facility in order to be corrected. Staff F, TCM also stated if a resident had a history of PTSD or any other mental disorders, it should be documented on the resident's PASARR assessment. The SSD and DON reviewed Resident #9's PASARR assessment and addressed that the Resident #9's history of PTSD, anxiety, and depression were not documented on the assessment. A policy related to resident PASARR assessments was requested from the DON on 12/21/2022 at 12:28 p.m. The DON stated the facility did not have a policy related to the PASARR process. 105730 Page 6 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure 1. the medication regimen for one resident (#83) included medications with relevant diagnoses and 2. one resident (#93) received medications appropriately and per directions of the physician out of thirty-six sampled residents. Residents Affected - Few Findings included: 1. The admission Record for Resident #83 identified an initial admission date of 5/27/20 and a readmission on [DATE]. The record revealed diagnoses not limited to unspecified chronic obstructive pulmonary disease, and unspecified systolic (congestive) heart failure. The Admission/5-day Minimum Data Set (MDS), dated [DATE], identified Resident #83 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS indicated the resident received as needed pain medication. A review of Resident #83's active physician orders for December 2022 included the following physician orders: - Acetaminophen 325 milligram (mg) tablet - Give 2 tablet by mouth every 6 hours as needed for diagnosis (dx:) elevated temperature greater than 100 Fahrenheit (F) ** If given for fever, notify MD** Not to exceed (NTE) 3 gram (gm) per 24 hours. Give a total dose of 650 mg. This order started on 11/7/22. - Acetaminophen 325 mg - Give 2 tablet by mouth every 6 hours as needed for diagnosis (dx:) pain scale 1-10 Tylenol (APAP). Not to exceed 3 gm in 24 hours from all sources. - Tylenol 325 mg tablet (Acetaminophen) - Give 2 tablet by mouth every 8 hours for fever. This order started 12/12/22. A progress note, dated 12/12/22 at 7:07 a.m., indicated Resident #83 had a temperature of 104.4 F and the resident had received at 10:46 a.m. the as needed dose of Acetaminophen for fever. The scheduled 650 mg of Tylenol for fever order was to start at 2:00 p.m. on 12/12/22 and continue every 8 hours (6 a.m., 2 p.m. and 10 p.m.). The December 2022 Medication Administration Record (MAR) identified staff were documenting Resident #83's pain level when administering Tylenol for fever. The MAR indicated staff had administered 650 mg of Tylenol every 8 hours daily for the diagnosis of fever. The MAR indicated the resident had a temperature over 99 F three times during the month of December: 99.9 F during the night shift on 12/13, 99.1 F during the day shift on 12/15, and 99 F during the day shift on 12/15/22. A review of the Weights and Vital Summary identified that Resident #83's temperature exceeded 99 F during the month of December: one time on 12/12/22 at 10:46 a.m. (104.4 F), one time on 12/14/22 at 5:23 a.m. and 5:24 a.m. (99.9 F), and one time at 7:30 a.m. on 12/15/22 (99.1 F). The Advanced Registered Nurse Practitioner (ARNP) note, dated 12/12/22, indicated Resident #83 was positive for a fever of 102.9 F and the resident was lethargic, complained of cough, fatigue, muscle aches and dysuria. The note identified the resident was status post antibiotic treated for 105730 Page 7 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pseudomonas Urinary Tract Infection, found that morning (12/12/22), an oxygen saturation of 90%, and COVID swab was negative. The plan was to restart antibiotic until repeat urinalysis culture and sensitivity results, STAT (immediate) chest x-ray, STAT COVID swab, STAT respiratory panel including influenza A, B, and RSV (Respiratory syncytial virus), and to add Albuterol and oxygen treatments for hypoxia. The plan indicated to continue treatment for COPD exacerbation with nebulizer, oxygen and Medrol. The note did not include the addition of Tylenol to the resident's regimen. On 12/22/22 at 10:13 a.m., Staff D, Licensed Practical Nurse (LPN), stated Resident #83 was scheduled at 2 p.m. because last week the resident had spiked a fever. Staff D stated that it was not appropriate to give Tylenol for a diagnosis of fever if the resident was not running a fever but the physician did not give a stop date. On 12/22/22 at 10:49 a.m., the Director of Nursing (DON) stated the facility has an as needed standing order for Tylenol for the diagnoses of pain and fever. She stated she would have to clarify Resident #83's order and that staff probably did ask the physician (for clarification). The ARNP stated, on 12/22/22 at 11:53 a.m., she did remember the Tylenol order for Resident #83 and it was meant to be double for pain and fever, as it was a blanket order. She stated yes, the staff should have asked for the diagnosis to be clarified. 2. The admission Record for Resident #93 identified an original admission date of 8/16/19 with a readmission on [DATE]. The record included the diagnoses of Parkinson's Disease, Irritable Bowel Syndrome without diarrhea, and rectal abscess. The Minimum Data Set (MDS) assessment, dated 11/12/22, identified a BIMS score of 15 out of 15, indicating intact cognition. The MDS revealed Resident #93 was always continent of bowel and not rated due to an indwelling catheter for bladder continence. Resident #93's MDS indicated the resident required extensive assistance from one person for dressing and toileting and limited one person assistance for transferring. On 12/19/22 at 1:38 p.m., Resident #93 reported having diarrhea for one week about two weeks ago, received Milk of Magnesia today, and he informed he was going to get an enema if no bowel movement (BM) today. The resident reported not having a BM for a week. Resident #93 reported, on 12/20/22 at 3:46 p.m., of just getting back into his wheelchair as he had been in the bathroom, commenting that he felt like I was going to [explicative] myself. The resident stated it was an ongoing issue - having diarrhea then getting a laxative. On 12/21/22 at 12:44 p.m., Resident #93 was sitting in his wheelchair and reported he had been sitting in his chair since 8 a.m. and no one had come from therapy. On 12/21/22 at 12:51 p.m., Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM), stated Resident #93 did complain of bowels sometimes and received Milk of Magnesia when he complained of constipation. A review of the active physician orders, as of the 12/22/22, Medication Review Report, revealed the following bowel protocol orders: - Docusate Sodium 100 milligram (mg) tablet - Give 1 tablet by mouth at bedtime for bowel 105730 Page 8 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0757 management. Level of Harm - Minimal harm or potential for actual harm - Milk of Magnesia Concentrate Suspension (Magnesium Hydroxide) - Give 30 milliliter (mL) by mouth every 24 hours as needed for diagnosis (dx:) constipation. Administer if no BM for 3 days. Do not exceed more than 1 dose in 24 hours. If no response from MOM, administer Dulcolax supp(suppository) 10 milligram times 1 as needed (unless on Dialysis). Residents Affected - Few - Bisacodyl -Evac Suppository 10 mg. Insert 1 dose rectally every 24 hours as needed for dx: constipation. Do not exceed 1 dose in 24 hours. Administer if no result from MOM. If no result from Dulcolax, administer Fleets enema rectally times 1 as needed. - Enema disposable enema - Insert 1 dose rectally every 24 hours as needed for dx: constipation. If no response from Dulcolax, administer a disposable enema if no result, notify MD. A review of the Certified Nursing Assistant (CNA) documentation of Resident #93's bowel continence indicated the following: - 12/9/22: medium sized loose/diarrhea at 10:06 p.m. - 12/10/22: large sized loose/diarrhea at 2:59 p.m. - 12/11/22: large sized loose/diarrhea at 4/16 a.m., 1:41 p.m., and twice at 1:43 p.m. - 12/12 and 12/13/22: no bowel movements - 12/14/22: large sized loose/diarrhea at 9:14 p.m. - 12/15/22: no bowel movement - 12/16/22: medium sized formed/normal at 10:14 a.m. - 12/17/22: medium sized loose/diarrhea at 2:59 p.m. - 12/18/22: large sized loose/diarrhea at 2:21 p.m. - 12/19/22: large sized formed/normal at 7:15 p.m. - 12/20/22: medium sized formed/normal at 12:41 p.m. and large sized formed/normal at 8:37 p.m. - 12/21/22: large sized loose/diarrhea at 8:43 p.m. A review of Resident #93's Medication Administration Record (MAR) for December 2022, indicated the resident was scheduled to receive Docusate Sodium at bedtime daily for bowel movement. The MAR identified the resident refused Docusate on 12/3, 12/4, and 12/18/22 and had been administered MOM at 7:47 a.m., following documentation on 12/18 of large sized loose/diarrhea, 12/17 of medium sized loose/diarrhea, and medium sized formed/normal bowel movement on 12/16/22. An interview was conducted on 12/22/22 at 10:15 a.m. with Resident #93's nurse, Staff D, LPN. The nurse reported that It's a big cycle, one day the resident may have diarrhea, the next day it might 105730 Page 9 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be constipation and staff give something to make him have a bowel movement. Staff D stated that Colace (Docusate) or Milk of Magnesia (MOM) should not be given if the resident was having diarrhea. Staff D reported that staff do not receive any notification on the electronic record if the residents have or have not had a bowel movement. The resident's nurse reported she has to just ask the aide if the resident has had a bowel movement and if not, she administers MOM, which was part of the facilities protocol. Staff D reviewed the CNA task documentation of bowel movements and stated she did not know she could look in the aide tasks tab for bowel information and does not get information in the nursing report related to bowel movements. The nurse confirmed the resident had diarrhea the night before (12/18), and he had been administered MOM by Staff B, LPN/UM. On 12/22/22 at 10:54 a.m., the Director of Nursing (DON) stated the facility has standing orders (for bowel management) which included Miralax, MOM, suppositories, and enemas. She stated typically or usually the facility will let residents know of the protocol and if they do not want the protocol, they offer alternatives. She stated MOM is given if no BM after 3 days, then a suppository, then an enema. She stated staff ask the residents daily if they have had a BM, assesses the resident, and (are) notified in report. The DON stated if a resident has diarrhea, the facility generally educates, if they are requesting it, it's given if they have a physician order for it. The DON reviewed Resident #93's medical record regarding the administration of MOM, administration of Colace, and physician orders and stated it would be an education piece to done related to the administration of MOM when the resident has diarrhea. The Director of Nursing stated, on 12/22/22 at 12:14 p.m., that she spoke with Resident #93 and he was aware of getting a stool softener every day and had requested MOM. She stated it was given per resident choice and that documentation should be done regarding education of the resident. The DON stated the facility does not have a policy regarding bowel and bladder management. On 12/22/22 at 2:05 p.m., Resident #93 reported getting a cup of pills that he had just taken and the stool softener was in the cup. The spouse of the resident stated the resident takes a stool softener twice a day and probably should not get it if having diarrhea but has always (done so). The spouse stated the resident gets confused and reports to her of not having a bowel movement in days. According to webmd.com (https://www.webmd.com/drugs/2/drug-323/docusate-sodium-oral/details), the use of Docusate Sodium treats occasional constipation as a stool softener. Docusate works by increasing the amount of water the stool absorbs in the gut, making the stool softer and easier to pass. The directions for use indicated to decrease your dose or stop taking this medication if you develop diarrhea. The website revealed that side effects of Docusate include stomach pain, diarrhea, or cramping and if any of these effects last or get worse, tell your doctor or pharmacist promptly and that your doctor has assessed that the benefit to you is greater than the risk of side effects. According to webmd.com (https://www.webmd.com/drugs/2/drug-146276/milk-of-magnesia-concentrated-oral/details) indicated that Milk of Magnesia was a laxative used to treat occasional constipation. Milk of Magnesia is thought to work by drawing water into the intestines. The website instructs users to use as directed and that overuse may also cause diarrhea that doesn't go away, dehydration, and mineral imbalances. 105730 Page 10 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The admission Record indicated on 11/08/22 Resident #93 was admitted to the facility. The record included diagnoses not limited to Parkinson's disease and benign prostatic hyperplasia with lower urinary tract symptoms. The 5-day Minimum Data Set (MDS), dated [DATE], identified a Brief Interview for Mental Status score of 15 out of 15, indicating intact cognition. During an initial interview, on 12/19/22 at 1:36 p.m., Resident #93 reported receiving therapy for one hour per day then sitting in the room for the other 23 hours of the day. The resident related speaking with Staff B Licensed Practical Nurse/Unit Manager (LPN/UM) regarding many issues and the case manager [Staff G] would come talk with him. On 12/20/22 at 3:46 p.m., Resident #93 was observed sitting in his wheelchair and was interviewed while in his room. On 12/21/22 at 12:44 p.m., Resident #93 reported the case manager had not been in to speak with him. Staff B, LPN/UM stated, on 12/21/22 at 12:51 p.m., Resident #93 had spoken with her about discharging on Monday (12/19/22) morning and she thought she had informed the case manager but could not be 100% sure if she had. On 12/21/22 at 2:00 p.m., Staff G, Case Manager stated she did not know that the resident wanted to go home. She related that usually the team, which included therapy staff , talked on Wednesdays regarding discharges, then they spoke with the residents. Staff G stated she speaks with residents (regarding discharge plans) at the time of admission. A review of Resident #93's Case Management Narrative Notes identified one note from his admission, dated 12/21/22 at 4:40 p.m., which documented the case manager had called the [family member] to talk about the resident's discharge. The note indicated the resident had called the [family member] informing her of his discharge this week and she told him that it was next week and the spouse had apologized for the confusion. The note identified the resident had informed the case manager he was supposed to go home this week but his [family member] had told him it was next week. On 12/22/22 at 2:05 p.m., an interview was conducted with Resident #93 and his spouse. The spouse stated the resident does get confused at times. The spouse stated they had called the case manager on Monday to discuss discharge and home health. The spouse stated the case manager had called her yesterday and informed her that she had heard the resident wanted to be discharged prior to Christmas and that the [family member] was told if she wanted to come get the resident for the day she could, as long as, the resident was returned to the facility by midnight. The spouse stated the first time she had heard about a discharge date was Monday when she had called the case manager. Staff G, Case Manager stated, on 12/22/22 at 12:28 p.m., a discharge depended on progress in therapy and (the facility) has a big meeting (to discuss) on Wednesdays which includes therapy, nurses, Unit Manager, Director of Nursing, Nursing Home Administrator, and the physician. She stated a pre-discharge plan was done at the time of admission and the plan consists of Durable Medical Equipment (DME), support, medications and if any new medications are needed they get called in, and if there was home health services. She reiterated this is done at the time of admission. Staff G reported making notes on tracker but not consistent with notes in the electronic medical record. She stated on 12/19 105730 Page 11 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she had discussed with the spouse a pickup time on 9 a.m., that the spouse wanted a print out of nursing homes, the family had requested a specific home health agency, and the discharge date was 12/29. A review of the Medicare Stay Tracking Log, which Staff G provided, as it was not part of the medical record, indicated the first note after the resident's admission was on 12/8, [Family member] wants air mattress (special mattress for wounds, no gel pack), trapeze, 12/19. The next note was 12/19: discharge (d/c) date, 9 a.m., print out nursing home. Family home health, and the note dated 12/22, D/C concern?, stated 12/29, DME (same). The log did not indicate a specific discharge date was talked about with the [spouse] until 12/22/22 despite the [spouse] reporting it was talked about on 12/19/22. Resident #93's care plan, created on 11/9/22, indicated Resident wishes to return/be discharged to with no location documented. The revision on 11/17/22 identified the resident wished to return/be discharged home. The intervention to this focus was for staff to Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan. The Post-Discharge Plan of Care policy identified that Pre-discharge Planning will be coordinated by the Case Management Social Service Department for the development of post-discharge plan of care. The procedure explained that Upon admission of the resident, the facility team meets to discuss and document in the medical record the resident's discharge plan and anticipate date of discharge. Based on resident record review, staff interview and review of policy and procedure, it was determined the facility failed to ensure two residents' (#121 and #93) medical records were accurately documented and systematically organized to include documentation of re-evaluation and updates of discharge needs and plans of three residents reviewed for discharge planning and out of a total sample of 36 residents. Findings included : 1. Review of the admission Record for Resident #121 revealed he was admitted to the facility for rehabilitation on 11/27/22. A Minimum Data Set (MDS) admission Assessment was completed on 12/1/22. Review of Section C Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) indicated a score of 15 out of 15, which indicated cognitively intact mental status. A care plan, initiated 11/29/22 and revised 12/6/22, revealed, [Resident #121] wishes to return/be discharged to community. The goal of the care plan indicated, The resident will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date (Target date 2/27/23). Interventions, initiated 11/29/22 and not revised, indicated: *Establish a pre discharge plan with the resident /family/caregivers and evaluate progress and revise plan. *Evaluate the resident's motivation to return to the community. Wishes to return/ be discharged to 105730 Page 12 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0842 community. Level of Harm - Minimal harm or potential for actual harm Review of Resident #121's medical record revealed an Interdisciplinary team note, documented on a form entitled Baseline Care Plan Summary and dated as reviewed with resident/representative on 12/5/22. The note revealed, On task with therapy goals, making progress - states he needs more work on strength and will need another surgery soon. Requests to stay as: Long as insurance is paying. I'm not ready to go yet. Discussed needs upon discharge - has family support. Residents Affected - Few There was no other documentation found in Resident #121's medical record of further re-evaluation of Resident #121's wishes related to discharge. An interview was conducted with Resident #121, on 12/19/22 at 2:02 p.m. Resident #121 stated he was told that he was being discharged home on [DATE] because his Medicare funds ran out. He stated he had asked about paying privately. He stated he has not had surgery on his hip and has no hip. He reported he was concerned how he would manage at home as his (spouse) was elderly and could not help him. Resident #121 stated he was told someone would come shower him, but no other help was offered once he was home. An interview was conducted with Staff G, Registered Nurse (RN) Case Manager, on 12/21/22 at 10:21 a.m. She stated that Resident #121 was going home on [DATE]. She stated his [family members] want him to go home and she had set up DME (Durable Medical Equipment) to be delivered tomorrow and he will have either home health or outpatient therapy. She stated he was supposed to have hip surgery and the plan was for him to have the hip surgery and come back to the facility for rehab (rehabilitation) after the surgery, however the surgeon had postponed the surgery due to the scab on his shin. She stated originally Resident #121 wanted to stay and continue with therapy until the surgery, however, now he and his family have agreed he will go home. There was no documentation in Resident #121's medical record of the current discharge plan of 12/22/22 until 12/21/22 at 10:48 a.m. Staff G documented that she confirmed with Resident #121 and his [family members] that he was going home on [DATE] and there had been no concern voiced related to the pending discharge. On 12/21/22 at 11:07 a.m., Staff G stated she just spoke with Resident #121 and his [family member] and she doesn't know what the confusion was as he stated to her he was fine with going home and did not express that he was not ready. Staff G, RN Case Manager stated she just documented this in Resident #121's medical record. Review of the medical record for Resident #121 with Staff G revealed no other documentation related to discharge planning. Staff G confirmed she had not been documenting discharge planning entries in the medical record. She stated she keeps a log for herself where she documents discharge planning conversations and stated she could write late entries in the medical record regarding the conversations she had had with Resident #121 and his family. Staff G provided a copy of her handwritten notes related to Resident #121's discharge plans. Review of Staff G's handwritten notes, written on a Medicare Stay Tracking Log, revealed: 12/8 [family members] to discuss pos discharge 12/12 [family member] called to make me aware of plans/ surgery/discharge/appt. 12/14 [family member] asked for wider walker 105730 Page 13 of 14 105730 12/22/2022 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0842 12/20 [family member] called to check on equipment, walker, hospital bed, wheelchair. Level of Harm - Minimal harm or potential for actual harm Review of the medical record for Resident #121 revealed a nursing note indicating he was discharged home with his spouse on 12/22/22 at 10:15 a.m. with narcotics sent and no complaints of pain or discomfort from the resident. Residents Affected - Few 105730 Page 14 of 14