Health inspection·June 1, 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 record review, interview, and policy review, the facility failed to report a credible allegation of abuse for 2 of 3 sampled residents no later than 2 hours after the allegation by Resident #7, and no later than 2 hours after a known resident to resident altercation between Residents #4 and #5. The facility also failed to report the results of the investigation of the allegation of abuse by Resident #7 to the State Survey Agency within 5 working days of the allegation. The findings included: Review of the policy Abuse & Neglect Prohibition dated 05/23/17 documented, Investigation: 2. The facility will report such allegations to the state, as per state/federal regulation. The Facility will report immediately but no later than 2 hours after forming the suspicion if the events that cause the allegation involve abuse or result in serious bodily injury. 3. The facility will report reportable investigation findings in accordance with State law, including to the state survey agency within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. 1) Review of the Nursing Home Federal Reporting Five Day Report, revealed the Social Services Director (SSD) became aware of an allegation of abuse by Staff A, Certified Nursing Assistant (CNA), toward Resident #7, on 05/03/23 at 8:30 AM. This report documented the date and time of the incident as 05/03/23 at 1:00 PM. The narrative of this report documented the event took place on 05/02/23 at approximately 10:30 PM, with facility knowledge the following morning. The report was submitted by the SSD. Review of the Status Log corresponding to this report documented the SSD submitted the Immediate Report on 05/03/23 at 2:56 PM, more than 6 hours after becoming aware of the allegation. Further review of the Status Log documented the SSD submitted the Five Day report on 05/12/23 at 11:01 AM, seven working days after the allegation. During an interview on 06/01/23 at 5:35 PM, the SSD agreed with the incorrectly documented date and time of the incident as compared to the narrative. When asked about the failure to submit the allegation of abuse to the State Agency within 2 hours, the SSD stated she thought that meant to call the Abuse Hotline (Department of Children and Families/DCF) within two hours. The SSD also acknowledged the failure to submit the Five Day report within the mandated timeframe. 2) Review of the Nursing Home Federal Reporting Five Day Report, documented a resident to resident Page 1 of 5 105837 105837 06/01/2023 Boynton Beach Rehabilitation Center 9600 Lawrence Rd Boynton Beach, FL 33436

F 0609 Level of Harm - Minimal harm or potential for actual harm altercation, involving Residents #4 and #5 physically hitting on another on 04/15/23 at 1:25 PM. This report was completed by the Social Services Director (SSD). Review of the corresponding Status Log revealed the Immediate Report was submitted on 04/15/23 at 10:29 PM, nine hours after the resident to resident abuse. Residents Affected - Few During an interview on 06/01/23 at 5:07 PM, the SSD confirmed she had completed and submitted the Immediate report at the above mentioned time. 105837 Page 2 of 5 105837 06/01/2023 Boynton Beach Rehabilitation Center 9600 Lawrence Rd Boynton Beach, FL 33436

F 0610 Respond appropriately to all alleged violations. 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 ensure a thorough investigation for 2 of 3 abuse allegations, involving Residents #4, #5, and #7. Residents Affected - Few The findings included: 1) Review of the Nursing Home Federal Reporting Five Day Report documented a resident to resident abuse altercation between Resident #4 and #5, on 05/14/23 at 1:25 PM, under the gazebo in the courtyard. This area was the designated smoking area for the facility, but the incident happened at a non-designated smoking time, when no staff were outside to witness the altercation. As per the report, Resident #4 reported to the Social Services Director (SSD) that he had called a female Resident #6 a name, and Resident #5 got up out of his wheelchair and hit him in the mouth causing a small cut, and causing him to fall backwards in his wheelchair. The report documented, other residents and family members came into the building to get staff for assistance. This report and subsequent investigation lacked any evidence of an interview with Resident #5, the alleged attacker, Resident #6, the female victim of verbal abuse, or any other witness, except the Activity Director, who was the first staff member summoned to the incident, or staff who care for each resident. During an interview on 06/01/23 at 10:20 AM, when asked about and altercation with Resident #4 on 04/15/23 under the gazebo in the courtyard, Resident #5 stated Resident #4 was calling Resident #6, a female friend of his, a name, and I told him that wasn't appropriate. I thought (name of Resident #4) was going to hit her, so I rolled forward to put myself between them and (name of Resident #4) slugged me (pointing to his right jaw). Resident #5 explained he ended up with a bruise. Resident #5 volunteered during the interview that Resident #12 was also there, under the gazebo with them during the incident. Resident #5 denied hitting Resident #4, and stated he even tried to help Resident #4 up off the ground, after he had lost his balance and fell, but he couldn't as the resident kept hitting at him. During an interview on 06/01/23 at 10:37 AM, Resident #12 was asked if she observed the altercation out in the courtyard on 04/15/23. Resident #12 confirmed she had been there and explained that Resident #4 was verbally abusive toward the female Resident #6, started to get up and go toward her, so Resident #5 told Resident #4 to stay away from her. Resident #12 stated Resident #4 stood up and slugged Resident #5 in the face. Resident #12 stated Resident #5 did not hit back. Resident #12 explained that Resident #4 ended up falling to the ground, stating it was wet outside and she thought he had slipped, and Resident #5 tried to assist him back up, but Resident #4 kept swinging at him. Resident #12 stated, All the upper people (referring to management) got upset with (name of Resident #5), but it wasn't him. When asked if any of the staff asked her what happened, Resident #12 stated they had not, but she wished they had so she could tell them what really happened. Review of the record revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 13, on a scale of 0 to 15, indicating she was cognitively intact, as per the annual Minimum Data Set (MDS) assessment dated [DATE]. During an interview on 06/01/23 at 10:51 AM, Resident #6, the female victim of verbal abuse, stated Resident #4 was calling me a name, stood up and looked like he was going to hit me. (Name of Resident #5) got between the two of us and (name of Resident #4) punched him. Resident #6 explained that after Resident #4 threw the punch, he fell backward. Resident #6 stated Resident #5 even tried to help Resident #4 get back up. 105837 Page 3 of 5 105837 06/01/2023 Boynton Beach Rehabilitation Center 9600 Lawrence Rd Boynton Beach, FL 33436

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/01/23 at 2:53 PM, Staff B, Licensed Practical Nurse (LPN), stated she was not working the day of the incident, but she is the regular nurse for Resident #5. The LPN stated Resident #5 has a female friend (Resident #6), and that Resident #5 had told her Resident #4 was calling the female resident names and asked for a cigarette, and Resident #5 was trying to defend her. She did not know who hit who, but stated Resident #4 is very aggressive and started punching at her one day when he wanted cigarettes. When asked about the temperament of Resident #5, the LPN stated he does get vocal and aggressive, especially if he gets alcohol, explaining that there had been instances of someone sneaking alcohol into the facility for him to consume. During an interview on 06/01/23 at 3:02 PM, Staff D, Certified Nursing Assistant (CNA), stated she did not see the incident, but the next day she noted Resident #5 had a bruise to his right jaw. The CNA stated Resident #5 told her that Resident #4 was calling his friend Resident #6 a name, and that was why Resident #4 hit him. During an interview on 06/01/23 at 3:06 PM, Staff C, CNA, stated she did not see the incident, but after the event Resident #5 said that Resident #4 hit him. During an interview on 06/01/23 at 3:48 PM, when asked what happened on 04/15/23 out in the courtyard, the Activity Director explained she was in the dining room finishing up the lunch service, when she was summoned to the courtyard. Upon arrival she saw Resident #4 swinging and fall, then saw Resident #5 swinging. The Activity Director confirmed she saw both residents swinging at each other and fighting. The Activity Director stated she then went to get the nurses of both residents and the weekend supervisor. When asked if there were any other residents under the gazebo at the time of the event, the Activity Director stated Resident #6 (the victim of the verbal abuse), Resident #12, and another resident who was currently in the hospital. When asked if Resident #12 was a credible witness, the Activity Director stated she was. When asked about the other resident who was currently in the hospital, the Activity Director stated she would not remember the event now, but at the time she could have been interviewed. When asked if she was involved in any other way, the Activity Director explained she was present when three police interviewed Residents #4 and #5, separately. Resident #4 informed the police that Resident #5 swung at him and then he swung back. Resident #5 denied the incident to the police at first, then stated Resident #4 hit him, but he did not hit back. The Activity Director stated she and the police then went to the SSD and explained what each resident had said. Further review of the written statement from the Activity Director and the investigation lacked the interviews by the police. Further review of the investigation revealed the witness statement from the Activity Director documented she was called from the main dining room by a family member, the two residents were fighting, and she went to get the nurse and supervisor. The only other written statement was by the SSD, that documented she had spoken to multiple residents that stated they were on the patio, and heard yelling, but did not see any physical contact. Review of a progress note in the clinical record of Resident #5, dated 04/15/23 and written by a direct care nurse documented, Resident had altercation - resident to resident altercation. No observation of altercation between the two residents were noted by staff and only reported. Head to toe assessment were provided to resident. Resident denied any pain or discomfort from the punches thrown from fellow resident. One and one care and continuous supervision initiated immediately every shift. The clinical record of Resident #4 lacked any documentation of the altercation. 105837 Page 4 of 5 105837 06/01/2023 Boynton Beach Rehabilitation Center 9600 Lawrence Rd Boynton Beach, FL 33436

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/01/23 at 5:07 PM, the SSD confirmed she was the staff member who completed this resident to resident abuse investigation. The SSD confirmed she had written that she spoke with multiple residents who did not see any physical contact. When asked if she interviewed the three involved residents and had any documented evidence of this, the SSD stated she talked with them all just after the event, as she was called into the facility. The SSD stated the documentation in the report was her interviews. When asked if there were any other residents in the gazebo at the time of the event, she mentioned the resident who was currently in the hospital and one other. When asked if she interviewed either of them she stated she had not. When asked if she interviewed Resident #12, who was identified by Resident #5 and the Activity Director as having been in the gazebo at the time of the incident, the SSD stated she had not. The SSD confirmed both residents were interviewed by the police, who told her they had smelled alcohol on the breath of Resident #5. When asked if she obtained the report from the police and or had documented what they had reported, the SSD stated she had not. 2) Review of the Nursing Home Federal Reporting Five Day Report documented an allegation of abuse by Staff A, Certified Nursing Assistance (CNA) toward Resident #7. This report documented the incident as 05/03/23 at 1:00 PM, but the narrative documented the event took place on 05/02/23 at about 10:30 PM, and the Social Services Director (SSD) was made aware of the incident by her assistant on 05/03/23 at 8:30 AM. Review of the report and the investigation lacked interviews with any other CNA's who worked with the alleged perpetrator. This investigation also documented on an Event/Interview Statement that was not signed nor dated, Writer spoke with other residents able to participate with interviews and had care provided to them by (name of Staff A). All residents denied any problem with the CNA. All residents had good things to say about CNA. During an interview on 06/01/23 at 5:35 PM, the SSD confirmed she had completed this investigation and that she had written the note about the other resident interviews. The SSD confirmed she did not document the specific residents who were interviewed. The SSD confirmed the information provided was the entire investigation. 105837 Page 5 of 5