Health inspection·October 4, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by an Interdisciplinary Team (IDT) composed of individuals with direct care knowledge of the resident and his/her needs. This impacted 1 of 2 sampled residents, Resident #1, reviewed for care plans. The findings included: Clinical record review conducted on 10/03/23 revealed Resident #1 was admitted to the facility on [DATE] with diagnosis that included Cerebrovascular Accident (CVA/stroke). Review of Resident #1's Minimum Data Set (MDS), admission assessment with reference date of 06/29/23, revealed the resident was assessed as moderately impaired for skills of daily decision making and required extensive assistance with activity of daily living (ADLs). Review of Resident #1's Interdisciplinary Team (IDT) Care Conference of 07/05/23 revealed no registered nurse with direct care responsibility for the resident, no nurse aide / certified nursing assistant with direct care responsibility for the resident, and no therapist with direct care responsibility participated in the care conference. Interview with the Administrator, Director of Nursing and Regional Nurse Consultant on 10/04/23 at 2:23 PM, confirmed the document provided did not validate participation of direct care staff. The administrator will look for further details. Page 1 of 9 105762 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

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, policy reviews, and interview, the facility failed to ensure care and services were provided to 1 of 2 sampled residents, Resident #1, that included failure to implement recommended discharge instructions for follow up diagnostic studies, failure to obtain recommended consults and failure to communicate and coordinate with the resident's responsible party the changes in treatment plan; and facility staff failed to report a skin injury, and subsequently did not investigate and implement additional interventions to minimize reoccurrence for 1 of 2 sampled residents, Resident #1. Residents Affected - Few The findings included: 1. Clinical record review conducted on 10/03/23 revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. The resident's diagnosis included Cerebrovascular Accident (CVA/stroke) with severe deficits. Review of the Minimum Data Set (MDS) admission assessment with reference date 06/29/23 revealed the resident was assessed as moderately impaired for skills of daily decision making. Review of the Baseline plan of care dated 06/22/23 and comprehensive plan initiated on 07/13/23 documented the resident has altered cardiovascular status related to Atrial Fibrillation, High Cholesterol and Hypertension. Review of the discharge instructions from the acute care setting dated 06/22/23 indicated Resident #1 had instructions for a follow up CT (computerized tomography) scan to determine if the anticoagulation therapy could be restarted and to follow up with the cardiologist and the neurologist. The hospital records validated Resident #1 was receiving Heparin, anticoagulation medication and Aspirin while hospitalized . Review of the clinical record failed to provide evidence of the completion of the follow up CT scan and referrals for the cardiology and neurology appointments. The medication administration records dated 06/2023 through 08/2023 indicated the resident did not receive anticoagulation therapy. Interview with the Director of Nursing, Regional Nurse Consultant and Administrator on 10/03/23 at 3:45 PM revealed, after review of the record, there was no evidence the CT study was completed or the follow up appointments were scheduled. The resident had an outside care manager who arranged the necessary appointments. Interview with the Case Manager conducted on 10/04/23 at 9:15 AM revealed the family members contracted her services weeks after the resident admission to the facility and the facility staff did not make her aware of the need of cardiology and neurology follow up appointments. Interview with the Physician on 10/04/23 at 12:35 PM revealed, as the attending physician and based on the clinical findings, the resident had a large middle cerebral artery stroke and was at high risk for bleeding, and the recommended CT was not done. The physician stated he was not going to resume anticoagulation for Resident #1, so the CT was unnecessary and he is not ordering unnecessary tests. The physician added the recommendations for cardiology and neurology were nebulous, as the 105762 Page 2 of 9 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0684 resident was stable. Level of Harm - Minimal harm or potential for actual harm The physician was asked if the changes in the plan of care were discussed and agreeable to the family members making decisions for Resident #1, who stated he could not recall specific discussions and acknowledged that there is no documentation to validate discussions regarding the omission of the follow up studies, anticoagulation therapy and follow up appointments. Residents Affected - Few The investigation determined that the facility staff and physician failed to follow hospital recommendations for after discharge care. The physician failed to communicate to the responsible party the changes in treatment plan regarding anticoagulation therapy and recommended studies and consults for a resident who sustained a cerebrovascular accident and was receiving anticoagulation therapy at the acute setting. The facility and physician failed to document clinical rationale for the change in treatment plan and failed to provide clinical rationale for not obtaining recommended consults. Resident #1 developed multiple blood clots requiring re-hospitalization. 2. Review of the facility policy, titled, Accidents/Incidents, revised February 2008 documented, in part, The Medical Director shall consult with the Administrator and Director of Nursing regarding accidents and incidents, and make recommendations about preventative approaches and corrective actions. Review of the facility policy, titled, Skin Tears, Abrasions and Minor Breaks, Care of, revised September 2013, documented, in part, Purpose The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Preparation 1. Obtain a physician's order as needed. Document physician notification in medical record. 2. Review the resident's care plan, current orders, and diagnoses to determine resident needs. 3. Check the treatment record. 4. Generate Non-Pressure form and complete. 5. Assemble the equipment and supplies as needed. General Guidelines 1. An abrasion is an area on the skin that has been damaged by friction, scraping, rubbing or trauma. A skin tear is the disruption of epidermis resulting in a lifting or friction of the skin. 2. If the wound is bleeding, gently apply a compress with pressure over the wound and reinforce the compress as needed to control any bleeding . Cleanse the wound with the ordered cleanser. Use a syringe to irrigate the wound, if ordered. If 105762 Page 3 of 9 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0684 using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). Level of Harm - Minimal harm or potential for actual harm 17. Use dry gauze to pat the wound dry. Residents Affected - Few 18. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing. Documentation Record the following information in the resident's medical record: 1. Complete in-house investigation of causation. 2. Generate Non-Pressure form. 3. Document physician and family notification, and resident education (if completed) in medical record. 4. How the resident tolerated the procedure. 5. Any problems or resident complaints related to the procedure. 6. Any complications related to the abrasion (e.g., pain, redness, drainage, swelling, bleeding, decreased movement). 7. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. 8. Interventions implemented or modified to prevent additional abrasions (e.g., clothes that cover 105762 Page 4 of 9 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0684 arms and legs). Level of Harm - Minimal harm or potential for actual harm 9. When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/ Accident. Residents Affected - Few Reporting 1. Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if the abrasion is uncomplicated or not associated with significant trauma. 2. Notify the physician of any abnormalities (i.e., excessive bleeding, localized swelling, redness, drainage, tenderness, pain etc.). 3. Report other information in accordance with facility policy/guideline and professional standards of practice. Clinical record review conducted on 10/03/23 revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. The Minimum Data Set admission assessment with reference date 06/29/23 revealed the resident was assessed as moderately impaired for skills of daily decision making, required extensive assistance with activity of daily living and had no skin conditions. Review of the Baseline plan of care dated 06/22/23 and comprehensive plan initiated on 07/13/23 documented the resident is at risk for skin impairment related to incontinence, weakness and decreased mobility. The interventions included: Monitor and observe skin while providing routine care. Notify nurse for any area of concern as indicated and preventative skin treatments as ordered and indicated, as tolerated by resident. The record indicated Resident #1 sustained an injury on 06/30/23. The nurse documented that while assisting the resident back to bed after physical therapy, a small scab on patients left shin came off with scant amount of blood. The skin was cleansed with normal saline and a band aid was placed over the scab. Review of the incident logs dated 06/01/23 through 10/03/23 failed to include an incident related to Resident #1. Interview with the Director of Nursing, Administrator and Regional Nurse Consultant on 10/03/23 at approximately 3:55 PM confirmed there is no incident report for the injury and there is no further documentation of the skin injury or treatments. The nurse who wrote the note is no longer employed at the facility. The investigation determined the nursing staff failed to follow policies and procedures for the skin injury sustained by Resident #1. 105762 Page 5 of 9 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0726 Level of Harm - Minimal harm or potential for actual harm 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 observation, record review, policy review and interview, the nursing staff were unable to demonstrate competency related to the provision of nursing assessments and reporting changes in condition. This failure affected 2 of 2 sampled residents, Residents #1 and #2. The findings included: 1. Clinical record review conducted on 10/03/23 revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. The resident's diagnosis included Cerebrovascular Accident (CVA/stroke) with severe deficits. The Minimum Data Set (MDS) admission assessment with reference date 06/29/23 revealed the resident was assessed as moderately impaired for skills of daily decision making, required extensive assistance with activity of daily living (ADLs) and had no skin conditions. The baseline plan of care dated 06/22/23 and comprehensive plan initiated on 07/13/23 documented the resident has altered cardiovascular status related to Atrial Fibrillation, High Cholesterol and Hypertension. The interventions included: Notify Medical Doctor of significant abnormalities and changes as ordered / indicated. Review of the Progress Notes dated 08/01/23 documented the following: the resident was found to have left lower extremity swelling; the family at bedside had concerns; and the physician was notified and gave an order for a doppler study. Further review of the record failed to provide evidence of a detailed assessment, including relevant and pertinent information about the resident's condition, to ascertain the level of the change of condition. Interview with Staff A, Licensed Practical Nurse on 10/03/23 at 11:30 AM, revealed she was the nurse caring for Resident #1 on 08/01/23. The staff recalled the family had concerns that the resident's leg was swollen, could not remember which leg but she went to the room and assessed the resident. The staff verified the resident's leg was swollen and she had not noticed the swelling before. Staff A did not recall the temperature of the leg, degree of edema or if she checked pedal pulses, but told the family she was calling the doctor and obtained an order for a Doppler as requested. In an interview with the Director of Nursing (DON), conducted on 10/03/23 at 1:20 PM, the DON explained that on 08/01/23 she went to assess Resident #1, and touched both legs and asked the resident if she was in pain, the family was there and the resident kept saying pain, no matter where she touched, when she touched her left arm, her right hand, she was very repetitive in her words. The DON then obtained an order for an x-ray of the right leg based on the resident's complaint of pain. Interview with the DON, Administrator and Regional Nurse Consultant on 10/03/23 starting at 3:45 PM revealed the DON clarified she assessed the resident after the family voiced concerns and denied the resident had any swelling to her legs. The DON again stated the resident complained of pain when touched, even though she complained of pain in all areas touched, this was her typical behavior, repeating the word pain over and over. They decided to do an x-ray of the right leg, to ensure there was 105762 Page 6 of 9 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no injury. After the x-ray was negative, they did the Doppler to the left leg since the family complained about the swelling. Interview with the DON, Administrator and Regional Nurse Consultant on 10/04/23 at 2:23 PM confirmed the DON assessed the resident after the family voiced concerns of swelling to leg, and restated she did not see swelling. The DON acknowledged she did not document the assessment and findings, stating she thought the primary nurse was going to document. The investigation determined the nursing staff did not show competency in prompt identification of changes in condition; the facility nursing staff failed to identify the change in condition prior to family notification; the nursing staff failed to conduct a detailed and pertinent assessment of the resident's condition, including the degree of the edema, skin color, sensation, temperature, presence or absence of pulses and degree and location of pain to ensure pertinent information was relayed to the physician for appropriate treatment. 2. Review of the facility policy, titled, Change in a Resident's Condition or Status, revised May 2017, documented, in part, the following: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical / mental condition and/or status (e.g., changes in level of care, billing / payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: 105762 Page 7 of 9 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0726 a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting); Level of Harm - Minimal harm or potential for actual harm b. Impacts more than one area of the resident's health status; Residents Affected - Few c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse or designee will notify the resident's representative by phone when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status; c. There is a need to change the resident's room assignment; d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. 7. In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition of a resident with a mental disorder or intellectual disability. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. 10. The business office manager or designee will verify the address and telephone number of the resident's family or representative (sponsor) on a quarterly basis. Any noted changes will be reported to the Director of Nursing Services to ensure that such information is changed in the resident's medical record. 105762 Page 8 of 9 105762 10/04/2023 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0726 11. A representative of the business office will notify the resident, his/her family, or representative (sponsor), when: Level of Harm - Minimal harm or potential for actual harm a. There is a change in the resident's billing; Residents Affected - Few b. There is a change in the resident's level of care status; c. There is a change in resident rights under federal or state law or regulations; and/or d. There is a change in the rules of the facility that affects the rights or responsibilities of the resident. Observation of care conducted on 10/03/23 at 12:50 PM, revealed Staff B, Certified Nursing Assistant (CNA), providing incontinence care for Resident #2. After the completion of care, it was noted Resident #2 had swelling to bilateral ankles and feet. The CNA was asked to remove the resident's nonskid socks, as the socks were tight around the ankle. The aide removed the socks and an imprint of the pattern of the socks was visible to bilateral ankles. Staff B was asked if the resident always had swollen ankles and feet, who replied she is not the permanent aide, but 'floats' and was not sure. Observation of care conducted on 10/03/23 at 3:00 PM revealed the Director of Nursing (DON) accompanied the surveyor to Resident #2's room and was asked to check the resident's feet. The DON did so and was asked if the resident's ankles and feet were swollen. After touching the feet multiple times, the DON stated yes, maybe plus one edema, and explained the resident was up in the chair, and that could be the reason why. The DON proceeded to cover up the resident and was asked if the resident had palpable pedal pulses. The DON then checked for pulses and replied yes, she does. The DON was made aware of the observation and interview with the aide and proceeded to walk to the nurse's desk. The surveyor asked Staff C, Licensed Practical Nurse (LPN), assigned to care for Resident #2, if she was aware of the resident's swelling to her ankles and feet, who stated 'no, the resident was up in the chair most of the day, and she did not notice it' Staff C confirmed the aide did not report it to her. Record review conducted on 10/03/23 verified the nursing staff has not documented the resident had swelling and in addition, the most recent physician's notes dated 09/23/23 document the resident had no swelling. The investigation validates the nursing staff did not display competency in identifying and reporting a change in condition, and performing a pertinent nursing assessment. 105762 Page 9 of 9