Health inspection·July 1, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, it was determined, the facility failed to report an allegation of abuse. The failure affected 1 of 2 sampled residents, Resident #1.The findings included: Review of the facility policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI), last revised 03/2025, documents Reporting: Allegations of possible ANEMMI will be reported to state agencies per federal regulation time frame. State agencies may include, Abuse Hotline, State Agencies and Local Law Enforcement.Initial reporting: allegations are reported immediately, but no later than two hours .within five working days of the incident, the facility must provide in its report, sufficient information to describe the results of the investigation and indicate any corrective actions taken. Clinical record review revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. Review of the Minimum Data Set admission (MDS) assessment with reference date of 03/13/25 documented the resident was assessed as independent with skills for daily decision making and had no behaviors. The clinical record documented Resident #1 was transferred to the emergency department on 03/30/25, as per the resident request. The clinical record documented Resident #1 was transferred to the emergency department on 03/30/25, as per the resident request. The resident had called 911 alleging the aide hit him over the head, the police and EMS came and the police verified there was no hitting on the video the resident presented. The resident was then taken to the hospital for evaluation. The resident returned the same day, as this is where he was residing at the time.On 07/01/25 at 12:54 PM, the Administrator (NHA) stated that another State Government Agency did not take the case when they called it in, but that then on 04/04/25, the representative showed up to investigate the allegation of abuse for 03/30/25. On 04/04/25, the resident was discharged home, had gone back to the hospital and then to another nursing home facility. Review of the Grievance log documents Resident #1 filed a grievance on 03/31/25, noting the resident states the aide came in the room more than one time to harass him. Review of the Social Worker Assistant note documented the following on the form titled, Resident Interview and Questionnaire Related to Abuse dated 03/31/25 documents as follows:Did you report the alleged abuse? Response, NO.Ask why didn't you report it to the nurse? Response, I called the person that came to mind,Did you report the alleged abuse to any external entities? Response, call 911 and fire rescue arrived. Review of the Police report dated 04/02/25 documents Made contact with Administrator who stated that one of her patients informed her that on 03/30/25, he got hit on the head by a nurse and that she was contacting [another State Government Agency]. The interview with the Administrator conducted on 07/01/25 at 12:54 PM also revealed Resident #1 never reported the allegation of abuse to her. The police came to the facility and reviewed the resident's phone video and determined there was no abuse. The administrator confirmed she contacted [another State Government Agency] for the incident and did not complete the required reporting to the regulatory agency, because she did not feel it met the criteria Page 1 of 5 105762 105762 07/01/2025 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for abuse. The Administrator stated after the fact and researching the hospital records, she was made aware of the open [another State Government Agency] case alleging the resident was neglected at home, involving one of his family members. An interview with the [another State Government Agency] Investigator conducted on 07/01/25 at 2:37 PM confirmed he was at the facility on 04/04/25 to investigate an allegation of physical abuse for Resident #1. The investigation determined the facility failed to report the allegation of abuse to the regulatory agency. 105762 Page 2 of 5 105762 07/01/2025 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined, the facility failed to ensure discharge planning was implemented in a safe manner. The failure affected 1 of 2 sampled residents, Resident #1.The findings included:Clinical record review conducted on 07/01/25 revealed Resident #1 was admitted to the facility on [DATE] with diagnosis of Hemiplegia, Dysphagia, Diabetes, Stroke, and status post Coronary Artery Bypass Graft and Craniotomy.The clinical record documented Resident #1 was transferred to the emergency department on 03/30/25, as per the resident request. The resident had called 911 alleging the aide hit him over the head, the police and EMS (Emergency Medical Services) came, and the police verified there was no hitting on the video the resident presented to them. The resident was then taken to the hospital for evaluation. The resident returned the same day, as this is where he was residing at the time.On 07/01/25 at 12:54 PM, the Administrator (NHA) stated that [another State Government Agency] did not take the case when they called it in, but that on 04/04/25, the representative showed up to investigate the allegation of abuse for 03/30/25.On 04/04/25, the resident was discharged home, had gone back to the hospital that same day (04/04/25), then went to another nursing home facility, and is currently residing at home with family. Review of the Minimum Data Set (MDS) Discharge Assessment, with reference date of 04/04/25, documented the resident required partial to moderate assistance with bathing and dressing, was dependent with transfers and used a manual wheelchair for mobility. The resident was frequently incontinent of bladder and always incontinent of bowel and had an active discharge plan to return to the community. Review of the record documented the resident was alert and oriented to person, place, others, and time. Review of the Physician/Practitioner Progress Notes for service date of 04/02/25 documented: CHIEF COMPLAINT: Need for Assistance with Mobility and ADL's (Activity of Daily Living) secondary to recent caregiver neglect and pneumonia, now with medical debility.PAST MEDICAL HISTORY:CHF (Congestive Heart Failure), CAD (Coronary Artery Disease) with CABG (Coronary Artery Bypass Graft) X 2, HTN (Hypertension) and Brief Psychotic Disorder.HOSPITAL COURSE: . presented to the hospital on [DATE] with heart failure and was admitted to the ICU for Surgical Optimization for planned mitral valve replacement. Post Operative course was complicated by Acute Stroke with subsequent Hemorrhagic conversion, mitral valve thrombus, required emergency decompression craniotomy 2 days later. After rehabilitation, the resident had a readmission to the acute care hospital on 2/17/25 for complaints of caretaker abuse and neglect. Prior Level of Function: Per Family: Patient lived alone and was independent of all ADLs. Current Level of Function per therapists, the resident requires maximal assistance for bed mobility; dependent for transfers and ambulation. Review of the Social Service Notes dated 04/02/25 documented, Met with resident and spoke with [family member-X] via phone to discuss details of requested discharge on [DATE]. Family member requested I speak with [family member-Y]. Detailed message left requesting return phone call. Referral faxed to home health agency for nursing, therapy and home health aide. Referral faxed for a hemi-walker. Family to provide transport. Review of the Social Service Notes dated 04/04/25 documented, Resident did not discharge on [DATE] as his [family member-X] had his house keys and was not responding to phone calls. The [family member] came by today and dropped off the house key. I inquired if she would be at the house, she stated the other [family member] handles that. Spoke with the veteran's home health and they arranged for 30-35 hours per week, per resident request to advise discharge is for today and resident would like to resume services. [Family member] agreed she would check on him but is not available 24/7. Transportation arranged with [company] transport. A message left for [family member] advising her transportation will pick him up between 4:30 to 5 PM, 105762 Page 3 of 5 105762 07/01/2025 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requesting she be at the house. Resident advised. Review of the Discharge Planning/Summary Notes dated 04/04/25 documented, Resident is alert and oriented. Discharge instructions given by writer resident verbalized understanding. Resident left facility with [company] transport, all personal belongings in resident's possession confirmed. Resident escorted out of building via wheelchair by staff and transporter. All safety measures met. Review of the Home Health documentation revealed they were unable to reach the resident or family members on 04/03/25, 04/04/25 and 04/07/25. The facility staff wrote on 04/10/25 that the home health agency would not take Resident #1' s case due to high liability and the facility staff questioned why they did not notify the facility. An interview with the Social Worker (SW) conducted on 07/01/25 at 12:04 PM revealed that upon discharge, Resident #1 already had services set up from the veteran's association, in addition she set up home health services for therapy and nursing follow up. The resident wanted to go home and there was an issue with the [family member], who had the keys to his home, at some point he was living with the [family member] but now he wanted to go back to his own home. The facility set up transportation and two staff members accompanied the resident. The social worker recalled leaving a message with the [family member] to advise her of the time the resident was being transported so she could be present. The SW doesn't know if the family was at home when he arrived but recalls the Medicare agency was having a hard time getting hold of him and that he eventually ended up at the hospital. An interview with the Transporter conducted on 07/01/25 at 1:14 PM revealed himself and another staff followed the transport company to assist with getting Resident #1 home. Upon arrival, they knocked on the door and no one responded then the resident gave him the keys to open the door, and he requested to go into the bed. The bed was very high, and he suggested he sit in the recliner. The resident agreed and the resident was assisted to the recliner and the staff confirmed there was no one else at the house at the time. They left and closed the door. An interview with the Labor Coordinator, conducted on 07/01/25 at 1:20 PM revealed she accompanied the transporter to the resident's home but did not enter the house. An interview with the Director of Nursing and the Administrator conducted on 07/01/25 at 1:54 PM clarified that on 04/04/25, the [another State Government Agency] Investigator came into the facility to review an allegation of unsafe discharge. The family member did not want him home, but Resident #1 wanted to go home and did not appeal the discharge notice. The facility added that the resident was discharged to the same home, that he was previously discharged from another nursing facility. The Administrator was aware the resident was left by himself at the home. An interview with the [another State Government Agency] Investigator conducted on 07/01/25 at 2:37 PM confirmed the visit to the facility on [DATE]. The visit was due to an allegation of abuse, at the same time, he received a notice for unsafe discharge and asked the facility to hold the discharge until he was able to assess the resident. Upon completion of his visit, he asked the facility not to discharge the patient home alone as it was not safe. The [another State Government Agency] Investigator partnered with the local fire rescue to monitor the resident's discharge and also advised the family members that if the patient was discharged home by himself, they could call fire rescue for assistance. The [another State Government Agency] Investigator explained Resident #1 was home alone for over an hour, the family had to call fire rescue to enter the property and was subsequently transferred to a local hospital. Resident #1 was not able to care for self, transfer himself and the family was not willing to care for him. The [another State Government Agency] investigation determined the facility arranged for Resident #1, a vulnerable adult with physical limitations, to be discharged to home with home health services. The resident required maximum assistance with wheelchair mobility, was dependent for transfers in and out of a chair and bed and required substantial assistance with activities of daily living (ADLs). 105762 Page 4 of 5 105762 07/01/2025 Prosper Health and Rehabilitation Center 11375 Prosperity Farms Road Palm Beach Gardens, FL 33410

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Per the [another State Government Agency] Investigator and the Administrator, Resident #1 had a documented history of caregiver abuse and neglect related to his two family members. The facility staff set up transportation to the home, and was aware of the family dynamics, and subsequently instructed two staff members to follow the resident's transport to home to ensure his safety. Resident #1 was assisted into his home by the facility staff and the transportation company and left alone with no supervision. The facility failed to determine whether appropriate and adequate support was in place, including the capacity and capability of the resident's caregivers at home. There was no evidence that family members, significant others or the resident's representative that should have been involved in this determination, with the resident's permission, were willing participants of the discharge process. The facility actions posed a risk to the resident's wellbeing. 105762 Page 5 of 5