Health inspection·June 19, 2023

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. Based on staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that all alleged violations involving injuries of unknown origin were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in Long-Term Care facilities) in accordance with State law through established procedures for one (Resident #1) in a sample of three residents. The findings include: A review of Resident #1's medical record revealed a nursing progress note written on 05/19/2023 at 7:10 a.m., which read: Resident slept good. Alert, oriented and verbally responsive. Around 6:00 a.m., when staff assigned to her were doing B/B (bowel and bladder) incontinent care, writer noticed right lower side of leg with discoloration and also right breast. At 7:00 a.m., informed DON (Director of Nursing)/management and in the building. Dr. (doctor's) answering service called . and waiting for call back. At 7:05 a.m., responsible party informed and thankful to writer. She wants her mother to have a pillow as protection because her mother is leaning to the right side. Give report to incoming nurse. A review of facility grievances revealed that a grievance was filed on 05/19/2023 on behalf of Resident #1 by her daughter. The grievance read: Describe the grievance as provided by resident/individual: Unexplained severe hematoma to R (right) breast, R side of back, R side of arm, R lateral leg from knee to ankle, L (left) upper lower arm, L leg, chest. My mother alleges two people, one white girl and one black man were helping her to the toilet without a lift or sit-to-stand from her wheelchair. My mother can't walk or stand. Describe the grievance as seen/heard by witness: N/A. In an interview with the Administrator on 06/19/2023 at 12:00 p.m., she was asked if she investigated the grievance from 05/19/2023 concerning Resident #1. She stated yes. She was asked whether an Immediate Federal Report and a 5-Day Federal Report for injury of unknown origin were completed. She stated, No, because we know where the injuries came from. She had been transferring with the sit-to-stand mechanical lift and was also on a blood thinner, Eliquis. The bruising came from being transferred when she could no longer bear the weight needed for the sit-to-stand lift. The daughter is who discovered the bruising and she alleged her mom had fallen, but she had not fallen. There was no fall. The bruising was all on her right side, and she leans to her right side in her wheelchair. She had X-rays done which were all negative. All staff were re-educated on the use of mechanical lifts. Page 1 of 3 105834 105834 06/19/2023 North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a second interview with the Administrator on 06/19/2023 at 2:50 p.m., she was asked if there were any other investigations conducted other than the grievance investigation from 05/19/2023 for Resident #1. She stated no. She was asked when this grievance investigation was concluded. She stated, We notified the daughter on 5/25/23 of the resolution. She was asked to clarify who was caring for Resident #1 when the bruising occurred. She stated, I don't know who was caring for her. The grievance form was based on the daughter's feedback and the resident's feedback. She was asked if staff were attempting to transfer the resident to the toilet without a sit-to-stand device or were they using a transfer device. She stated, I'm not sure. I believe they were using the sit-to-stand device. She stated she did not know when this incident occurred. She did not know which staff were involved. When asked how the bruising was discovered, she stated, She did not have the discoloration a day prior to. The daughter comes in and provides hands-on care and there was no discoloration the day prior. The daughter discovered the bruising. She came in a couple of days after Mother's Day and she brought it to our attention. The daughter notified me personally. She came down to the office and told me and I started the grievance. The staff were already addressing it. The daughter said it supposedly occurred on the 14th. I don't know how or where she got that date from. The Administrator stated she observed the bruising the day it was reported. When asked to describe what she observed, she stated, It was discoloration below her right breast and on her side. There was nothing on the left side. When asked whether the source of the injury was observed by anyone, she stated no. She was asked if the injuries were discovered by another person. She stated, Yes, it was discovered a couple days after using the lift. It took a couple days for the discoloration to show up. She was asked if the source of the injury could be explained by the resident. She stated, No, the resident was not able to really give us what happened. In an interview with Employee A on 06/19/2023 at 3:05 p.m., she was asked when she was first notified about the bruising discovered on Resident #1. She stated May 19, 2023. When asked whether the event was reported to her by staff or family, she replied, By staff. By the floor nurse. She no longer works here. When asked whether she observed the bruises, she replied, At that time, no. When asked when she observed the resident's bruises, she stated, It was either that evening or the next morning. When asked to describe what she observed, she stated, Her breast was bruised from the bottom of her right breast and across the right breast to her side, and a long lateral bruise on the lower part of her right lateral leg. When she was asked what she did when the event was reported to her, she stated, I informed [Administrator] and [Regional Nurse]. I was also the Interim Director of Nursing (IDON) at that time and I wasn't really sure what to do, so I called them. She was asked what their response was. She stated, I think we had to report it to do the investigation to interview the staff. Because it was such an odd location, we had to rule out that anything happened. Just to find out how the bruising happened. My thought process was how would she get bruising like that outside of a physical assault. She was asked if the source of the injury was observed by any person. She stated no. She was asked if the injury was discovered by another person. She stated, Yes, by the nurse. She was asked if the source of the injury could be explained by the resident. She stated, No, she wasn't able to say what happened. She was asked if the injury was suspicious because of the extent of the injury or the location of the injury. She stated yes to both. A review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation (undated) revealed: Policy: It is the policy of this facility to take appropriate steps to prevent abuse, neglect, exploitation, misappropriation and the occurrence of an injury of unknown source, and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the 105834 Page 2 of 3 105834 06/19/2023 North Bank Center for Rehabilitation and Healing 333 E Ashley St Jacksonville, FL 32202

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator, the Risk Manager, The Social Service Director, and the Director of Nursing. The Abuse Coordinator/Designee shall report any alleged violations of abuse or serious bodily injury immediately but the local law enforcement if they feel a crime has occurred. If the alleged violation involves neglect, misappropriation of resident property, exploitation, or injuries of an unknown source and involves no serious bodily injury, it must be reported no later than 24 hours. 6. Reporting: Upon initial investigation, where suspicion that Abuse/Neglect/Exploitation may have occurred, the Abuse Coordinator/designee shall immediately report the alleged violation to AHCA (for Federal report), Adult Protective Services, and local law enforcement when appropriate. The Risk Manager/Designee will file the Immediate Federal Report with AHCA and then submit the summary and findings of the investigation with the 5-day Federal Report. . 105834 Page 3 of 3