Health inspection·March 4, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy and procedures review, staff and resident interviews the facility failed to protect residents' rights to be free from verbal and physical abuse for 3 (Residents #700, #650, and #800) of 3 sampled residents. The findings included: The facility policy Abuse, Neglect, Exploitation, Mistreatment and Injury of Unknown Origin issued 8/22 (revised 10/22) documented Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment . Patients with needs and behaviors that might lead to conflict with staff or other residents will be identified by the Interdisciplinary Care Planning Team, with interventions and follow through designed to minimize the risk of conflict . Review of the clinical record revealed Resident #999 was admitted on [DATE]. Diagnoses included Dementia and Major Depressive Disorder. On 12/23/23 the diagnosis list was updated to include adjustment disorder and dementia with behavioral disturbance. The admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 10/21/23 documented Resident #999 had behaviors of wandering occurring one to three days in the last seven days. The MDS noted the resident was rarely/never understood. On 11/1/23 at 12:02 p.m., the nurse's progress note documented, Husband/family alerted this nurse to concerns of increased agitation and sadness/hopelessness. Resident assessed for suicidal ideation by 2 nurses, none noted, resident denied thoughts or plans. The physician was notified and ordered Citalopram (antidepressant) 10 milligrams (mg) a day and a Psychiatry consult. Review of the Psychiatric APRN (Advanced Practice Registered Nurse) note dated 12/1/23 documented, Chief complaint . nursing also reports resident (#999) is having behaviors . Nursing reports resident is having behaviors of being verbally inappropriate, combative towards family and hard to redirect . Recommendation: Resident observed today walking around the unit, alert, confused, uncooperative, hard to redirect . Nurse reports resident is having behaviors to be in [sic] combative towards family, verbally inappropriate and hard to redirect. Resident is unstable. Symptoms are occurring due to exasperated mood disorder, the symptoms are occurring daily and causing severe distress . Psych (psychiatry) started Depakote sprinkles 250 mg (milligrams) by mouth twice daily diagnosis of mood disorder . Staff to continue to monitor and document behaviors . Page 1 of 9 105965 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0600 Level of Harm - Actual harm Residents Affected - Few On 12/21/23 at 1:59 p.m., a nursing progress note documented, It was reported to this writer that the resident is showing increased aggression, cussing at fellow residents, throwing a cookie at a fellow resident. Notified MD (Physician), psych (Psychiatry) notified she will be in Friday. Will redirect resident. On 12/22/23 at 1:33 p.m., a nursing progress note documented Resident #999 had, Agitation and aggressive behaviors reported to psych Advanced Registered Nurse Practitioner (ARNP). On 12/22/23 the Psychiatric APRN documented, Resident being seen for follow-up psych evaluation due to recent medication change. Nursing reports resident having aggressive behaviors, hard to redirect, throwing things, difficult with her care. Patient observed on unit alert confused, no behaviors noted at time of interview . Psych feels the symptoms are occurring due to exacerbation of underlying MOOD Disorder. The symptoms are occurring daily and causing severe distress . Therefore psych decided to increase Depakote sprinkles to 500 mg by mouth twice daily . Staff to monitor and document behaviors . On 12/22/23 at 1:46 p.m., a nursing progress note documented, Resident had violent outburst wrapped a cord around her husbands [sic] throat and attempted to throw monitor at him, hit him in the face and pulled his hair. Yelled for help and nurses were able to intervene and separate. No violence toward any staff or any other resident noted. She did yell at her husband obscenities. The Psych ARNP was notified and new order for Seroquel 25 mg (Antipsychotic) two times a day for 14 days, increase observation, and any other signs of violence notify primary immediately and send to the emergency room for evaluation and treatment for altered mental status. On 12/29/23 the Psychiatric APRN documented, Nursing reports resident's behaviors appear to be slowly resolving since starting Seroquel . Patient behaviors appear to be stable at this time . Psych recommends decrease Depakote Sprinkles to 250 mg by mouth twice daily X3 (for three) days, then 125 mg by mouth twice daily X2 (for two) days, then discontinue . On 1/2/24 the APRN documented seeing the resident for a follow up visit after Resident #999 fell on [DATE], was sent to the emergency room and returned to the facility that evening. The APRN noted Resident #999 was on multiple psychotropic medications with aggressive behavior with her dementia and psychiatry has been working with her medications. The APRN documented the resident was pleasant and cooperative. She spoke with the resident's husband and deferred discussion of her behaviors to Unit Manager. The APRN documented, Will discontinue seroquel for now. On 1/13/24 at 10:15 p.m., the progress note documented Residents #999 and #800 were in their room. Resident #999 started raising her voice stating that Resident #800 was not to be in her room, shouted get out. Resident #999 started throwing salt and sugar packets and individualized snack packets at Resident #800 saying while throwing things, this is my room. Certified Nursing Assistant (CNA) Staff A witnessed Resident #999 pick up a plastic plate cover and toss it at her roommate striking her in the head above left eye. CNA Staff A immediately called for the nurse. Resident #999 was assigned to one to one (1-1) supervision with a CNA and moved to another room. On 1/13/24 at 10:47 p.m., an incident description noted Resident #800 was found sitting on the side of the bed and verbally informed the staff that her roommate (Resident #999) hit her. Resident #999 was seen picking up a broken plate off the floor. When asked how the plate broke Resident #800 105965 Page 2 of 9 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0600 Level of Harm - Actual harm said, She went crazy, look at my head. Resident #800 had a lump above her left eye, with a small laceration. Resident #800 stated her roommate became angry and kept telling her this is her room and that she needed to leave, Her roommate turned evil and became so strong and hit her with the lid of the dinner cover. Residents Affected - Few On 1/13/24 at 10:00 p.m., a nursing progress note documented, notified family of incident, husband states It was no surprise for him, then asked why patient was not moved to memory care. The facility's investigation into the abuse allegation noted a Certified Nursing Assistant (CNA) witnessed Resident #999 pick up a plastic plate cover and toss it at her roommate striking her in the head above the left eye. The CNA immediately called for the nurse to come to the room. The nurse arrived and the residents were immediately separated. Resident #999 was moved to a different room and all potential harmful objects were removed from her room. The facility's investigative findings on 1/18/24 noted, The facility unsubstantiate the allegation of abuse related to the residents being adquately supervised and staff responding immediately. The care plan was updated on 1/15/24 noting Resident #999 had a history of exhibiting the following behaviors: Chronic/frequent refusal of care and/or services, impulsivity, Physical and verbal aggression. The goal was for Resident #999 to have fewer episodes of the identified behavior. The interventions as of 1/15/24 included to administer medications as ordered. Monitor/document for side effects and effectiveness; encourage resident to interact with staff members as tolerated; explain procedures to the resident before starting and allow the resident time to adjust to changes as needed; minimize potential for teh resident's disruptive behaviors by offereing tasks with divert attention/redirect behavior as indicated; one on one with staff as needed. On 2/16/24 the facility added non-pharmacological interventions utilized as needed to redirect resident behavior: offering lower stimulus environment, speaking calming, allowing resident to choose care options as they are able or offer activities to divert resident's attention. The Certified Nursing Assistant (CNA) visual/bedside [NAME] (Provides instructions for care) did not list Resident #999's verbal and physical aggressive behaviors. The [NAME] noted to minimize the potential for the resident's disruptive behaviors by offering tasks which divert attention/redirect behavior as indicated. On 1/16/24 at 4:24 p.m., a nursing progress note documented, Resident continues 1-1 observation due to physically aggressive behavior towards other residents. Administered medication as ordered. Resident complained of having too much medication and stated, It will be their fault if I do something to someone because of all the medication. On 1/19/24 the Psychiatric APRN documented, Resident seen today per nursing request as resident had behaviors of being aggressive including a recent incident with her previous roommate. Pt (Patient) alert with confusion, noted agitation, flat mood, and affect, uncooperative at times during interview. On 2/6/24 the Psychiatric APRN documented Resident #999 reportedly made a comment that her roommate was noisy, and she was going to slit her throat if she was not more quiet. On 2/6/24 Unit Manager Registered Nurse Staff B documented, Resident recent aggressive behaviors and statements demonstrate possible further aggressive events, MD, Psychology, husband, sister, and management notified. Resident will remain in a room without a roommate for safety and possible 105965 Page 3 of 9 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0600 placement at another facility to better suit her needs. Level of Harm - Actual harm On 2/10/24 at 6:18 p.m., the Assistant Director of Nursing documented, This nurse received notification from day shift and evening nurse, other residents and other residents family member that (Resident #999) is being extremely aggressive. She is using vulgar language, using racial slurs, refusing to leave other resident's rooms . Residents Affected - Few On 2/25/24 a nursing progress note documented Resident #999 was moved in a room with Resident #650. On 2/29/24 at 9:45 a.m., in an interview the Administrator said Resident #999 came to them without a psychiatric background and only dementia as a diagnosis. Resident #999's first roommate Resident #800 was hit in the head with a plate/tray. We removed Resident #800. Resident #999 stayed in the two person room alone for several weeks, but we could not keep her in a double room alone forever. Resident #999 was placed in a room with Resident #700. Resident #999 said she was going to slit her new roommate's throat and made racial slurs to her and her family who were visiting. We moved the roommate out of the room. Both residents reside on the same floor but in different halls. The Administrator said resident #999 was very distant, easily upset and on one occasion she attempted to strangle her spouse with a cord, we had to get staff to get her off of him and still she is here. Right now, Resident #999 is in a room with a friend, another resident who is alert and oriented and kind of looks out for her and can handle her. They agreed to be roommates. On 2/29/24 at 10:15 a.m., Resident #999 was observed ambulating with a rolling walker past other residents in the hallway. She walked up and down the hallway and to the nurse's desk unsupervised by staff. On 2/29/24 at 11:15 a.m., in an interview Registered Nurse (RN) Staff B said Resident #999 had memory problems and behavior issues. During a care plan meeting she had threatened to Jump out of the window. She is very territorial. One day her family member brought in candy for her to share with her friends at the dining room table and when the other ladies asked for a piece of candy, she threw the candy at them. She is very negative and aggressive. On 2/29/24 at 12:00 p.m., Resident #999 was observed ambulating with a rolling walker in the hallway unsupervised. She ambulated to the small seating room and declined to sit. Licensed Practical Nurse (LPN) Staff C approached and explained to Resident #999 that she had a visitor who wanted to speak with her. Resident #999 made an angry face and said what do you want?. She was noted to have a mask like face with angry expressions. She was not able to recall any incidents of abuse toward her spouse or other residents. She became easily agitated when asked questions and walked away. On 2/29/24 at 1:15 p.m., an attempt was made to interview Resident #700. She did not respond appropriately to interview questions. She continues to reside on the same unit as Resident #999. On 2/29/24 at 2:20 p.m., in a telephone interview Resident #999's Primary Care Physician said she knew the resident had some behaviors prior to her admission but she was doing okay, All of a sudden, she began displaying aggression. I know psych was involved and they were adjusting her medications. I became more involved when the family requested to meet with me because they felt the psych medications she was on were not effective and they wanted to try medications she had used in the past. I 105965 Page 4 of 9 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0600 said let's try it then because whatever they were trying was not working. Level of Harm - Actual harm On 2/29/24 at 3:05 p.m., in an interview Certified Nursing Assistant (CNA) Staff D said if Resident #999 was having behaviors, she would call for help if she could not calm her. She would offer her something to eat, take her to activities or talk with her. She said she had not seen her hit anyone but, She walks all the time. She can be mean; she yells at you and does not want you to touch her for care. Residents Affected - Few On 2/29/24 at 4:22 p.m., in a telephone interview the Psychiatric APRN said she was initially asked to see Resident #999 for aggressive behavior. She had aggressive behavior, difficult to redirect and she was refusing care. She said,I don't think a skilled nursing facility is appropriate for her, she needs a psychiatric facility that can manage her behaviors and adjust her medications as needed. This is just my opinion. On 2/29/24 at 5:07 p.m., in an interview Licensed Practical Nurse (LPN) Staff C said they monitor Resident #999 by observation, charting, documentation, and report one shift to the next. She is unpredictable so I guide her and try to be positive with her, so she feels more comfortable. I give her lots of encouragement. I have not seen her physically aggressive but verbally yes. She refuses care, and you must approach her slow, and calm, she startles easily. I have seen her refuse care and refuse redirection. The new room change has been a challenge for her. She walks a lot, and she does not stay in her room. She wanders a lot and most of the time you can redirect her. For her safety and everyone involved with the recent room change we tried to ease her into it. Redirection is difficult sometimes. Observation is a big thing for her, you must know where she is at all times, I encourage activities. I have never seen her verbally aggressive with other residents. When she can't be redirected, we let her walk and calm down. We work as a team. We let her express herself in a safe manner. On 3/4/24 at 10:18 a.m., in an interview CNA Staff E, said she has observed Resident #999 be aggressive with other residents, She yells at them, curses at them and will throw things at them. She tries to pick a fight. On 3/4/24 at 10:45 a.m., in an interview Resident #800, said she remembered the incident with Resident #999. It was in the evening and the curtain was pulled between us. I was in bed and had just eaten. She came over to my side and she was angry, her face was mad and she told me you better not take anything of mine. She started to shake the bedside table and my dinner tray was still on it. She threw the whole thing at me, and the plate warmer fell at the foot of the bed. It was dome shaped. She picked it up and hit me with it, she did not throw it, she hit me. I was yelling and a CNA came in and then two more came in. My left eye was black, black as could be after that. On 3/4/24 at 12:22 p.m., in an interview the Medical Director said he was not the primary care physician for Resident #999 but has discussed the resident because, We have been discussing the risks, so she was always being discussed and managed. She has a psych history of her behaviors. Her primary care physician was not in agreement with psych medications, and he was in constant communication with the family and the facility was in constant communication. We felt this was not the facility for her, but the family wanted her to remain here. They did one to one care, she was not aggressive, so it was discontinued. She was deemed safe and not a danger to herself and others. The family wants the resident to remain here. The staff are constantly monitoring her. Her history of psych behaviors are aggression. Aggression with her own husband, she had hostile behavior with the husband. We are constantly monitoring but not doing one to one, that is what we have in place and monitoring her medications. She becomes more hostile when you try to do something with her. She did not want to be on one 105965 Page 5 of 9 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0600 to one. The staff are always asking the roommate if there are any problems. I am not her doctor, but I know all about her. Level of Harm - Actual harm Residents Affected - Few On 3/4/24 at 9:20 a.m., in an interview Resident #650, current roommate of Resident #999, said she makes me uneasy. She stands at the foot of my bed staring at me and cursing under her breath. I don't know her, but I know of her behaviors. She comes in and out of the room and walks to the foot of my bed, stares at me and curses. I have asked to see the Director of Nursing twice, but he has not come. I don't feel 100% safe, that's for sure. On 3/4/24 at 1:00 p.m., in an interview the Medical Director said, Resident #999 was not a threat to others. When informed of Resident #650's interview complaining about Resident #999 staring at her, cursing, and not feeling safe, the Medical Director said, Well, that's not threatening, she is just looking at her. 105965 Page 6 of 9 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview the facility failed to report significant changes in behaviors to the appropriate state agencies for a level II Preadmission Screening and Resident Review (PASRR) for 1 (Resident #999) of 3 residents reviewed with newly diagnosed psychiatric disorder. The findings included: Review of the clinical record revealed Resident #999 was admitted to the facility on [DATE] with diagnoses including Dementia and Major Depressive Disorder. A level I PASRR screen form dated 10/13/23 documented No diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. On 11/1/23 at 12:02 p.m., the nurse's progress note documented Husband/family alerted this nurse to concerns of increased agitation and sadness/hopelessness. Resident assessed for suicidal ideation by 2 nurses, none noted, resident denied thoughts or plans. The physician was notified and ordered Citalopram (Antidepressant) 10 milligrams (mg) a day and a Psychiatric consult. Review of the Psychiatric APRN (Advanced Practice Registered Nurse) note dated 12/1/23 documented, Chief complaint . nursing also reports resident (#999) is having behaviors . Nursing reports resident is having behaviors of being verbally inappropriate, combative towards family and hard to redirect . Recommendation: Resident observed today walking around the unit, alert, confused, uncooperative, hard to redirect . Nurse reports resident is having behaviors to be in [sic] combative towards family, verbally inappropriate and hard to redirect. Resident is unstable. Symptoms are occurring due to exasperated mood disorder, the symptoms are occurring daily and causing severe distress . Psych (psychiatry) started Depakote sprinkles 250 mg (milligrams) by mouth twice daily diagnosis of mood disorder . Staff to continue to monitor and document behaviors . On 12/21/23 at 1:59 p.m., a nursing progress note documented, It was reported to this writer that the resident is showing increased aggression, cussing at fellow residents, throwing a cookie at a fellow resident. Notified MD, psych notified she will be in Friday. Will redirect resident. On 12/22/23 at 1:33 p.m., the progress note documented Resident #999 had Agitation and aggressive behaviors reported to psych Advanced Registered Nurse Practitioner (ARNP). On 12/22/23 at 1:46 p.m., the progress note documented, Resident had violent outburst wrapped a cord around her husband's throat and attempted to throw monitor at him, hit him in the face and pulled his hair. Yelled for help and nurses were able to intervene and separate. No violence toward any staff or any other resident noted. She did yell at her husband obscenities. The Psych ARNP was notified and new order for Seroquel 25 mg two times a day for 14 days, increase observation, and any other signs of violence notify primary immediately and send to emergency room (ER) for eval and treatment for altered mental status (AMS). On 12/23/23 the diagnosis list was updated to include adjustment disorder and dementia with behavioral disturbance. 105965 Page 7 of 9 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/13/24 at 10:15 p.m., the progress note documented Residents #999 and #800 were in their room. Resident #999 started raising her voice stating that Resident #800 was not to be in her room, shouted get out. Resident #999 started throwing salt and sugar packets and individualized snack packets at Resident #800 saying while throwing things, this is my room. Certified Nursing Assistant (CNA) Staff A witnessed Resident #999 pick up a plastic plate cover and toss it at her roommate striking her in the head above left eye. CNA Staff A immediately called for the nurse. Resident #999 was assigned to 1-1 with a CNA and moved to another room. On 1/14/24 the diagnosis list was updated to include psychotic disorder. On 1/19/24 the Psychiatric ARNP documented Resident seen today per nursing request as resident had behaviors of being aggressive including a recent incident with her previous roommate. Pt alert with confusion, noted agitation, flat mood, and affect, uncooperative at times during interview. On 2/6/24 the Psychiatric ARNP documented Resident #999 reportedly made a comment that her roommate was noisy, and she was going to slit her throat if she was not more quiet. On 2/6/24 Unit Manager Registered Nurse Staff B documented, Resident recent aggressive behaviors and statements demonstrate possible further aggressive events, MD, Psychology, husband, sister, and management notified. Resident will remain in a room without a roommate for safety and possible placement at another facility to better suit her needs. On 2/29/24 at 9:45 a.m., in an interview the Administrator said Resident #999 came to us without a psychiatric background and only dementia as a diagnosis. Resident #999's first roommate Resident #800 was hit in the head with a plate/tray. We removed Resident #800. Resident #999 stayed in the 2-person room alone for several weeks, but we could not keep her in a double room alone forever. Resident #999 was placed in a room with Resident #700. Resident #999 said she was going to slit her new roommate's throat and made racial slurs to her and her family who were visiting. The Administrator said resident #999 was very distant, easily upset and on one occasion she attempted to strangle her spouse with a cord, we had to get staff to get her off of him and still she is here. Right now, Resident #999 is in a room with a friend, another resident who is alert and oriented and kind of looks out for her and can handle her. They agreed to be roommates. On 2/29/24 at 11:15 a.m., in an interview RN Staff B said Resident #999 had memory problems and behavior issues. During a care plan meeting she had threatened to Jump out of the window. She is very territorial. One day her family member brought in candy for her to share with her friends at the dining room table and when the other ladies asked for a piece of candy, she threw the candy at them. She is very negative and aggressive. On 2/29/24 at 4:22 p.m., in a phone interview the Psych ARNP said she was initially asked to see Resident #999 for aggressive behavior. She had aggressive behavior, difficult to redirect and she was refusing care. I don't think a skilled nursing facility is appropriate for her, she needs a psychiatric facility that can manage her behaviors and adjust her medications as needed. This is just my opinion. On 3/4/24 at 9:20 a.m., in an interview Resident #650, current roommate of Resident #999, said she makes me uneasy. She stands at the foot of my bed staring at me and cursing under her breath. I 105965 Page 8 of 9 105965 03/04/2024 Capri Health and Rehabilitation Center 1450 East Venice Avenue Venice, FL 34292

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few don't know her, but I know of her behaviors. She comes in and out of the room and walks to the foot of my bed, stares at me and curses. I have asked to see the Director of Nursing twice, but he has not come. I don't feel 100% safe, that's for sure. On 2/29/24 at 5:45 p.m., a record review revealed a level II PASRR was not completed. In an interview, the Administrator said a Level II screening was not completed because she did not know a Level II screen was necessary. 105965 Page 9 of 9