Health inspection·May 11, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide accurate Minimum Data Set (MDS) Resident Assessments on 3 of 5 residents sampled. (Residents #21, #64, and #71) Residents Affected - Few The findings include: Resident #21 A record review for Resident #21 was completed on 5/10/2023 at approximately 2:30 PM. This review noted an admission diagnosis of Schizophrenia dated 1/27/2023 and Anxiety Disorder dated 1/30/2023. A record review of the admission Annual MDS Assessment for Resident #21, dated 2/3/2023, noted no documentation in Section A1500 that acknowledged a Level II Preadmission Screening and Resident Review (PASARR) was completed for the diagnosis of Schizophrenia. Section A1510 of the MDS did not list the mental health conditions. A record review noted a positive Level II Screen for Resident #21 that was dated 2/8/2023 and a consent from Resident #21 for a Level II evaluation. A record review noted the Level II determination for Resident #21 was received on 2/17/2023. An interview was performed on 05/11/23 at approximately 11:42 AM with Staff A, a MDS Registered Nurse (MDS-RN) and Staff B, another MDS-RN. They agreed that the MDS had not been updated to reflect that a Level II MDS screening was submitted for the resident. They said his Level II assessment was done after admission and the MDS had already been submitted and they had not yet updated the change in MDS. Resident #64 A record review for Resident #64 was completed on 5/10/2023 at approximately 3:30 PM. The record noted a secondary admission diagnosis of Paranoid Schizophrenia and Antisocial Personality Disorder dated 5/17/2021 and an added diagnosis of Unspecified dementia - unspecified severity with agitation added on 10/18/2022 and Major Depressive Disorder added on 11/28/2022. A record review of the Annual MDS Assessment for Resident #64 dated 5/25/2023 noted no documentation in Section A1500 that acknowledged a Level II PASARR screening was completed for the mental illness diagnoses. Section A1510 did not list the mental illness conditions. A record review for Resident #64 noted an updated PASARR was completed on 11/21/2022 which noted Page 1 of 4 105747 105747 05/11/2023 Rosewood Healthcare and Rehabilitation Center 3107 North H Street Pensacola, FL 32501

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mental illness diagnoses of depressive disorder, schizophrenia, and antisocial personality disorder. A Level II PASARR screen was triggered and completed on 11/21/2022. The MDS assessment was not updated to reflect PASARR Level II update and diagnoses. In an interview on 05/11/23 at approximately 11:42 AM, Staff A, MDS-RN, and Staff B, MDS-RN, agreed that the MDS had not been updated once the PASARR was updated to reflect that the Level II PASARR review was submitted on Resident #64. Resident #71 A record review for Resident #71 noted a 5-Day MDS dated [DATE]. Section K0510 of the MDS was checked yes indicating that the resident had a feeding tube. In an interview with Resident #71 on 5/7/2023 at approximately 2:55 PM, Resident #71 stated he hasn't been hungry lately, but he has never had any sort of feeding tube. A record review of the Nutrition Risk Screen with Mini Nutritional Assessment for Resident #71 dated 4/18/2023 noted under Section B, Nutritional Orders and Intake that the resident does not have an enteral tube of any type. A review of dietary notes for Resident #71, dated 2/13/2023, noted a diet of regular/thin with 50-75% oral intake documented. A review of dietary notes dated 4/21/2023 documented his diet as Regular/No added salt/thin with 50% oral intake. Neither dietary note made any mention of any type of feeding tube. On 5/11/2023 at approximately 10:50 AM, the registered dietitian confirmed during an interview that Resident #71 had never had a feeding tube. In an interview on 05/11/23 at approximately 11:42 AM, Staff A, MDS-RN and Staff B, MDS-RN stated that the MDS that reflected the resident had a feeding tube was in error. The dietary manager had accidentally checked that Resident #71 had a feeding tube when he had actually been receiving intravenous fluids. 105747 Page 2 of 4 105747 05/11/2023 Rosewood Healthcare and Rehabilitation Center 3107 North H Street Pensacola, FL 32501

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility failed to follow provider orders and document measurable objectives in the care plan for monitoring of behaviors and medications side effects for 2 of 2 residents sampled. (Resident #51 and #64) The findings include: Resident #51 A review of provider orders for Resident #51 noted orders dated 6/1/2022 for monitoring of behaviors and side effects observations. A review of the care plan for Resident #51 noted the resident was care planned for mood problem related to bipolar diagnosis with interventions to include Administer medications as ordered. Monitor/Document for side effects and effectiveness. Monitor/record/report to MD prn mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability, frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. A review of the Medication Administration Record for Resident #51 April 1-30, 2023 noted 32 of 90 shifts where documentation of behaviors and side effects of medication was missed. A review of the Medication Administration Record for Resident #51 for May 1-9, 2023 noted 7 of 27 shifts where documentation of behaviors and side effects of medications was missed. Resident #64 A review of provider orders for Resident #64 noted orders on 5/19/2021 for monitoring of behaviors and side effects observations. A review of the care plan for Resident #64 noted the resident was care planned for mood problem related to depression, anxiety, insomnia and schizophrenia with interventions to include Administer medications as ordered. Monitor/record/report to MD acute episode feeling or sadness; loss of pleasure and interest in activities; feeling of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. Resident #64 was care planned for ineffectiveness of medication or untoward side effect/adverse reaction or psychotropic use. With interventions to observe resident for signs and symptoms of constipation, orthostatic hypotension, urinary retention, motor restlessness, involuntary movement, confusion, blurred vision, or dry mouth. A review of the Medication Administration Record for Resident #64 for April 1-30, 2023 noted 32 of 90 shifts where documentation of behaviors and side effects of medication was missed. A review of the Medication Administration Record for Resident #64 for May 1-9, 2023 noted 7 of 27 shifts where documentation of behaviors and side effects of medications was missed. 105747 Page 3 of 4 105747 05/11/2023 Rosewood Healthcare and Rehabilitation Center 3107 North H Street Pensacola, FL 32501

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 05/11/23 at approximately 09:46 AM, the Assistant Director of Nursing (ADON) was asked how behavior and medication side effect monitoring is documented. She stated it is on the Medication Administration Record (MAR), but sometimes you have to go look for it. She stated it doesn't automatically trigger to complete it. The ADON was advised that there were multiple gaps in the documentation of behavior and medication side effect monitoring for April 2023 and May 2023 for Resident #51 and Resident #64. She stated it should be documented ever shift and the staff may not know how to get it to trigger for them, it isn't that automatic. A review of the policy titled Care Plan - Comprehensive dated November 2019 states that A Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. 105747 Page 4 of 4