Health inspection·March 2, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure one resident (#43) received adequate supervision and assistance to prevent at least four falls over twenty-two days resulting in transfer to a higher level of care and diagnoses of fracture of humerus to the right arm out of 21 sampled residents. Findings Included: An observation of Resident #43 on 3/02/22 at 2:07 p.m. while wheeling herself to the bathroom wearing a splint and sling on her right arm revealed Resident #43 sliding her arm out of the sling to wash her hands in the doorway of the bathroom. Then she backed her wheelchair up for an interview and stated she used to go to the bathroom all the time but fell and hurt herself. Resident #43 stated she would use her call light, and no one would come so she would go on her own. Now she said she wears a brief, and her roommate will remind her to use the call light if she needs to be changed or assistance. Review of an incident report dated 12/27/21 at 9:08 a.m. for Resident #43 reflected: Resident observed on the floor in front of the toilet and next to her wheelchair. Resident had full body assessment with no visible injuries or bruising noted. Active range of motion conducted. Resident assisted from floor by multiple staff members to her chair. Relayed to physician that resident had multiple falls this shift. Orders received to send the resident to the hospital. Family and physician notified. Review of a nursing progress note dated 12/27/21 at 2:54 p.m. written by the Director of Nursing (DON), reflected: Hospital called to get information for previous ortho doctor. The Resident reinjured an old humerus fracture and will need to follow up with ortho. admitted overnight for observations. Review of a Fall Risk Evaluation dated 12/30/21 at 8:48 p.m. reflected the resident is a fall risk. Review of an incident report dated 12/11/21 at 3:28 p.m. for Resident #43 reflected: Resident's roommate notified staff that the patient was in the bathroom on the floor. Resident observed sitting on the floor without injury observed. Resident stated she was trying to get on the toilet and slipped and hit her head. Resident was evaluated, no injuries noted. Resident sitting in room watching TV reminded to use call light. Family and physician notified. Review of the post-fall review reflected on 12/11/21 at 3:15 p.m., Resident #43 was found on the floor in the bathroom. Resident stated she was trying to get on the toilet and slipped and hit her Page 1 of 5 105878 105878 03/02/2022 Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712

F 0689 Level of Harm - Minimal harm or potential for actual harm head. Resident assessed by the nurse. No injuries. Resident reminded to use call light for assistance. Interdisciplinary team summary: Resident educated to call for assistance when needed. Medication review sent, therapy referral sent for evaluation. Review of the Fall Risk Evaluation dated 12/11/21 at 3:10 p.m. revealed the resident is a fall risk. Residents Affected - Few Review of an incident report dated 12/6/21 at 6:58 p.m. for Resident #43 reflected: Certified nurse's assistant (CNA) notified the nurse that his resident was on her bedroom floor, nurse went to resident's room, resident on the floor beside bed and denied hitting her head. Resident stated she slid off the bed to the floor when she was trying to climb into bed. Resident assessed, denied pain, no injuries noted. Resident assisted to bed by staff and reminded to use call light for assistance. Review of the post-fall review reflected on 12/6/21 at 6:15 p.m., Resident #43 fell getting into bed unassisted and she said she slid to the ground. No injuries noted. Interdisciplinary note summary: Resident independent with transfers, educated to ask for assistance as needed. Therapy referral sent for evaluation. Review of the Fall Risk Evaluation dated 12/6/21 at 6:15 p.m. revealed the resident is a fall risk. Review of the post-fall review reflected on 12/6/21 at 10:30 p.m., Resident #43 fell in the bathroom. Resident said she was going from her wheelchair to the toilet when she slipped. No injuries noted. Interdisciplinary note summary: Staff to do 30-minute checks to anticipate needs. Resident re-educated to ask for assistance when needed. During an interview with the DON on 3/02/22 at 1:04 p.m. she confirmed she investigates falls if they are considered adverse then she will document and create a file. The DON confirmed she did not do investigations related to the three falls including the one fracture for Resident #43 as she did not consider them to be adverse. The DON stated the resident is non-compliant and although she may have gone to the hospital and re-fractured her arm it was not adverse. The DON read from the incident form the nurse completed for the 12/27/21 fall and was asked about the statement, multiple falls this shift which the nurse documented on the incident form. The DON said she would expect to have seen multiple notes related to the falls and confirmed she never even noticed multiple falls this shift. The DON looked on the computer to recall that day and confirmed she did not get witness statements or investigate the last time the resident was observed or if she had multiple falls that shift. The DON confirmed she did not complete or investigate for a root cause as these were not considered adverse to her and said the resident used to transfer on her own to the toilet and transfer herself prior to the last fall on 12/27/21. The DON then stated the investigation was completed but not documented and did not have witness statements to the last time the resident was observed. The DON confirmed the resident fractured her right arm at an old fracture site but was unsure if the fracture was from the 12/27/21 fall or prior. The DON stated the resident was picked up for therapy when she returned from the hospital for strengthening and transfers. The DON confirmed the resident is still non weight bearing on her right arm since her fall 12/27/21. The DON stated the resident had been transferring on her own and going to the bathroom since she was admitted as she was continent and knew when she needed to go the bathroom, so she did not update her care plan related to toileting or start a bowel and bladder program because the resident self-propels around the facility in her wheelchair. 105878 Page 2 of 5 105878 03/02/2022 Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During the interview with the DON the Rehabilitation Program Manager joined on 3/2/22 at 1:18 p.m. to confirm therapy picked up the resident on 12/8/21 after her fall from 12/6/21 and kept her on therapy until 2/24/22. The Rehabilitation Manager stopped the DON when the DON said the resident transferred and toileted herself and reiterated to the DON the resident was not safe and should not have been transferring and ambulating without assistance since 12/8/21 when therapy started working with the resident. She was an assist of one during ambulation and transfers. The Rehabilitation Manager stated she is still in therapy and non-weight bearing with her right arm but is non-compliant since she continues to self-propel in the facility. Review of the 12/11/21 fall at 3:10 p.m., the DON read notes from the computer and stated the resident fell in the bathroom trying to use the toilet. The DON confirmed they did not put interventions in place and that no witness statements were taken to see when the resident was last observed or taken to the bathroom. Review of the 12/6/21 fall at 6:15 p.m., the DON read notes from the computer reflected the resident fell transferring from her wheelchair to the toilet when she slipped. No injuries noted and the resident was placed on every 30-minute checks. The DON stated the resident was continent, and she did not consider placing her on a toileting program. The DON confirmed she did not do an investigation related to the fall to see when the resident was last taken to the bathroom or last seen. During an interview on 3/02/22 at 2:00 p.m. with Staff C, CNA he stated the resident doesn't stand and needs help with everything. Staff C confirmed the resident used to go to the bathroom on her own and yell for help. Now, she can't stand and wears a brief since she came back from the hospital. She tells us when she needs to be changed now. She has tried to use bathroom with therapy but now her legs are too weak. During an interview on 3/02/22 at 2:03 p.m. with Staff A, Licensed Practical Nurse (LPN), she stated the resident would toilet herself and not ask for assistance and was obsessed with the bathroom and her bowels and would go in the bathroom on her own. The resident was never placed on a bowel protocol. She would constantly want to go to the bathroom. She drinks a lot of water and is more incontinent now than before. She can't move around as well as she did before she fractured her arm. During an interview on 3/02/22 at 1:44 p.m. with Staff B, LPN he stated he was working on 12/27/21 and was given report the resident had multiple falls that night or morning but could not remember the nurse who gave the report. Staff B stated the resident was observed on the bathroom floor not long after his shift started. She was sitting on her bottom in the bathroom. Staff B, LPN confirmed he filled out the report on the computer and called the physician to let him know he was given a report she had multiple falls prior to his shift then called the family to let them know she was going to the hospital. Staff B, stated the process after a fall is to assess the resident, call the physician and family and if the resident needed a higher level of care they would get the order and transfer documents ready and fill out an incident form on the computer. Staff B would then alert the supervisor or DON and would get statements if needed which are documented in the computer. Staff B said he did not remember witness statements being documented on the 12/27/21 fall. Review of the [NAME] reflected the resident requires assist of one for transfers and toileting. Staff to assist with toileting upon arising, before and after meals, at bedtime and as needed. Review of restorative notes dated 12/14/21 at 6:58 p.m. reflected the resident was on a restorative nursing program to ambulate with four wheeled walker and gait belt for safety, gait was steady but 105878 Page 3 of 5 105878 03/02/2022 Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712

F 0689 slow, ambulated 100 feet. Level of Harm - Minimal harm or potential for actual harm Review of restorative notes dated 12/15/21 at 1:45 p.m. reflected the resident was discontinued from restorative to work with physical therapy. Residents Affected - Few Review of the care plan focus area for self-care deficits and requires assistance with activities of daily living initiated on 3/17/20, revised on 5/22/21 revealed interventions of toileting using one person assist initiated on 3/17/20 revised on 5/22/21, transfers require one person assist, initiated on 8/22/20 and revised on 12/31/21. Staff to assist with toileting upon arising, before and after meals, at night and as needed, initiated on 1/26/22 and created on 2/7/22. Review of care plan focus area at risk for falls initiated on 3/17/20 revealed a focus area initiated on 3/17/20 for staff assist as needed. Focus area of fall identified with no injury, initiated on 12/6/21 revealed an intervention to educate to ask for assistance, if cognitively intact. Medication review initiated on 12/13/21. Review of the Minimum Data Set (MDS) completed on 1/26/22, review of Section C Cognitive status, a Brief Interview for Mental Status (BIMS) of 10, indicating moderate impairment. Review of Section G. Functional status, revealed transfer requires extensive assistance of one-person physical assist, walk in room occurred once or twice in room with one-person physical assist, toilet use requires total dependence with one-person physical assist. Section G0300, balance during transitions and walking revealed moving from seated to standing position was not steady, but able to stabilize with staff assistance, walking with assistive device is used was not steady, but able to stabilize with staff assistance, moving on and off the toilet was not steady, but able to stabilize with staff assistance. On 3/2/22 at 3:00 p.m. the DON brought in completed documents called an investigation checklist and a fishbone diagram. The DON stated these documents were dated 12/27/21 but were just completed by the Corporate [NAME] president on 3/2/22. and that she did not complete any the documents on 12/27/21. She confirmed she did not complete any investigations in writing and did not feel the falls were adverse including the fall on 12/27/21 that required a higher level of care and refracture of the right arm. Review of facility policy, Incident reporting for residents or visitors revised 1/17, five pages, reflected: All accidents and unusual occurrences involving a resident or visitor will be documented and reported so as to meet all regulatory and insurance carrier requirements. Unusual occurrence or event: any event reportable to federal and state agencies as defined by those agencies. An event or happening involving a resident with unintended, undesirable, or unexpected results or outcomes. 1. When an unusual occurrence is discovered, the employee making the discovery will notify his or her immediate supervisor of the discovery. The supervisor will notify the Administrator and DON immediately. 4. The facility risk manager or designee must notify the appropriate state agency as required by state regulations. 5. The administrator or DON must notify the regional vice president and regional clinical director for any potential state or federal reportable events. Documentation: 1. Record the facts surrounding the incident or accident on an incident/accident report. Keep the original occurrence report on file at the facility. 3. Record the relevant facts regarding the resident in the interdisciplinary progress notes: where the resident was found, assessment conducted, care provided, follow-up care provided. 105878 Page 4 of 5 105878 03/02/2022 Pinellas Point Nursing and Rehab Center 5601 31st St S Saint Petersburg, FL 33712

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 one resident (#52) had orders for the use of oxygen continuously for three (2/28, 3/1, and 3/2) of three days observed for three residents on continuous oxygen. Residents Affected - Few Findings Included: Observation and interview with Resident #52 on 2/28/22 at 10:16 a.m. revealed the resident was wearing oxygen at 2 liters via nasal cannula. The resident stated she never wore oxygen at home unless she was in bed. During the day at the facility if she takes it off the staff say to put it back on. Observation of Resident #52 on 3/1/22 at 8:15 a.m. revealed the resident was wearing oxygen at 2 liters via nasal cannula sitting up in bed. Observation of Resident #52 on 3/2/22 at 9:50 a.m. was wearing oxygen at 2 liters while sitting in her wheel chair. During an interview with Staff A, Licensed Practical Nurse (LPN) on 3/2/22 at 9:51 a.m. she confirmed the resident needed oxygen all the time and should have an order for continuous oxygen. An interview with Staff B, LPN on 3/02/22 at 10:01 a.m. reflected the resident on oxygen all the time but confirmed she did not have an order for the oxygen. Review of the electronic medical record revealed Resident #52 was admitted on [DATE], re-admission on [DATE] and diagnoses of shortness of breath, pulmonary embolism, and chronic obstructive pulmonary disease (COPD). Review of current active physician orders did not reveal any oxygen setting orders. The orders did include to check temperature and oxygen saturation every shift dated 2/3/22. Review of the care plan did not reflect oxygen use for Resident #52. Review of the Minimum Data Set (MDS) Section O, Special Treatments reflected oxygen therapy was not checked as using oxygen during stay. During an interview with the Director of Nursing (DON) on 3/2/22 at 10:07 a.m. she confirmed anyone on oxygen should have an order and confirmed Resident #52 did not have an order for oxygen since the last admission. Review of the facility policy titled Oxygen Administration, two pages, revised 5/18 revealed: Procedure: 1. Check physician's order, 11. Turn the unit on to the desired flow rate and assess equipment for proper functioning. 105878 Page 5 of 5