Health inspection·March 7, 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, record review, facility policy review, resident and staff interviews and medical record and facility policy review, the facility failed to protect residents' rights to be free from neglect by failing to provide a safe environment for 2 (Residents #243 and #20) of 5 residents reviewed for avoidable falls and accidents. The findings included: The facility policy provided for Fall Prevention and Management created 7/2018 and last revised 1/2023 states: The Fall Risk Evaluation (completed on admission) will determine fall risk factors. 1. Fall risk assessments will be completed for all residents; initially on admission/readmission, quarterly, significant change and after an identified fall; 2. As part of the assessment, the nurse will help identify individuals with a history of falls and risk factors for subsequent falling; Staff will ask the resident and the caregiver about history of falling . staff will record history of one or more recent falls . root causes for fall history will be identified. 3. In addition, the nurse shall assess and document/report vital signs . recent injury, . musculoskeletal function . change in condition . neurological status . pain . meds . active diagnosis; 4. The staff will document risk factors . implement goals and interventions . communicate interventions . provide staff training . revise IDT after an event . educate resident and family as needed. 5. Staff will evaluate and document falls that occur while the individual in in the facility. 6. If interventions have been successful in preventing falling, the staff will continue with current approaches; 7. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. The policy also stated, residents will be referred to therapy for a screen - for indication of need for therapy interventions. Interdisciplinary team should monitor and document on resident's response/success with fall reduction interventions. Residents who continue to fall with interventions in place will be assessed for change in or additions to interventions. All staff shall receive education on the fall prevention program at the time of orientation and annually thereafter. Review of the clinical record revealed Resident #20 was admitted to the facility on [DATE] after a fall at home resulting in a left femur fracture. The Significant change in status Minimum Data Set (MDS) assessment with a reference date of 1/10/24 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13. Page 1 of 22 105995 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0600 Resident #20 required partial/moderate assistance for mobility. Level of Harm - Actual harm On 3/10/24 at 12:20 p.m., in an interview Resident #20 said she fell many times since she had been at the facility, and thought she broke her pelvis. Resident #20 was not able to provide more details but said she has been at the facility for three years. Residents Affected - Few Review of the facility's accident/incident log revealed Resident #20 had multiple falls since 8/11/23. On 8/11/23 Resident #20 was found on the floor and was transferred to the hospital. Resident #20 was diagnosed with fracture of the right acetabular (hip) which required surgery, a closed fracture of right olecranon process (elbow) which required surgery and fractures of pubic rami (pelvis). On 10/5/23, 10/24/23, 11/12/23, 11/23/23, and 12/10/23, Resident #20 sustained additional falls. On 1/3/24, Resident #20's son found her on the floor in her room. The resident complained of back pain. On 1/5/24 an X-ray of the back showed Resident #20 had multiple lumbar vertebral compression fractures. The X-ray report noted the fracture to Lumbar vertebrae 1 was severe and may be acute. The facility investigated and on 1/3/24 noted, After investigation it was noted that the resident was trying to put away items in her room. Going forward the room is to be kept decluttered and items should be put away for the resident. (Resident #20) is requested to ring for assistance but at times she forgets and believes she can walk. Corrective actions included resident room to remain decluttered and hygiene items should be in her drawers if she should need them. Residents are encouraged to use call bell. Hospice and the Interdisciplinary Team (IDT) met and indicated that hospice was going to request a volunteer to come sit with Resident #20 a few times a week and have her more involved in activities. Further review of the accident log showed Resident #20 sustained additional falls on 1/17/24, 1/18/24, and 1/20/24. On 3/5/2024 at 2:00 p.m., in an interview the MDS Coordinator said she had been employed at the facility for approximately six years and had never encountered any resident with so many falls. She said they were scratching their heads wondering what to do next. After reviewing Resident #20's care plan the MDS coordinator said she was not able to see interventions in the care plan to prevent further incidents of falls. On 3/5/24 at 2:45 p.m., in an interview the MDS Coordinator said she updated a couple of days on the care plan to include, move debris and fall mats to the floor. On 3/5/24 at 3:00 p.m., in an interview Certified Nursing Assistant (CAN) Staff E said she has been employed at the facility for 23 years and was familiar with Resident #20. 105995 Page 2 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0600 She said Resident #20 has fall mats that get put out every night when she's in bed. Level of Harm - Actual harm CNA Staff E said no one has told her what to do to prevent Resident #20 from falls. She said she just knows to be extra careful to make sure the resident does not fall since she has Parkinson's. Residents Affected - Few On 3/5/2024 at 3:15 p.m., the MDS Coordinator provided a fall care plan which listed multiple interventions to prevent further falls for Resident #20. She said she could not explain why the original care plan in the clinical record was not correct. Review of the care plan initiated on 4/6/22 and revised on 1/23/24 noted Resident #20 had an actual fall with two fractures to the right upper extremity, the right lower extremity, and the pelvis. Fall on 8/17/23 with major injury. Fall on 10/5/23, no injury; fall on 10/24/23 with hematoma (collection of blood in the tissues) on 10/24/23. Fall on 11/2/23, 11/23/23, 12/10/23, 1/17/24, 1/18/24, and 1/20/24 with no injury. The goal as 6/30/21 was for the resident to resume usual activities without further incidents. The interventions included: Bolster sheet to mattress (1/22/24). Continue interventions on the at-risk plan (6/30/21). Dysom [sic] (non-slip mat) to wheelchair (8/4/22). For no apparent acute injury, determine and address causative factors of the fall (6/30/21). Frequent checks (8/28/23). High back wheelchair (12/13/23). Low bed (11/27/23). Monitor/document /report as needed for 72 hours to doctor for s/sx (signs or symptoms) of pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation (6/30/21). Moved resident's room closer to nurse's desk (12/11/23). Neuro-checks Initiated on 4/06/22 with revision on 5/11/23. Place resident in areas of high visibility (8/16/22). Physical Therapy consult for strength and mobility (8/12/21). 105995 Page 3 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0600 Repair patient's bed (1/18/24). Level of Harm - Actual harm Resident education on asking for assistance prior to transfer, an ambulation (6/30/21). Residents Affected - Few Resident education on keeping wheelchair brakes locked (6/30/21). Resident education to wait for staff to assist with supplies (1/5/24). Reviewed care plan. All interventions remain appropriate (5/7/23). Staff education to use leg rests on wheelchair (5/16/23). Urine analysis, culture, and sensitivity (5/11/23). On 3/7/24 at 11:30 a.m., in an interview the Administrator said the only root cause for Resident #20's multiple falls was her Parkinson's disease. She stated, I think I counted 25 falls that she has had since her admission. She said Resident #20's last fall was in January 2024. She stated, this is the longest she has ever gone without falling. She said the facility has implemented every intervention they could think of except one-on-one supervision. She said Resident#20 never had one-on-one supervision or monitoring of any kind, and no documentation such as a log of any monitoring or supervision. The Administrator said she started a PIP (Performance Improvement Project) on 12/5/23 to address a problem area of falls to address the frequency of falls and interventions not immediately put in place. Review of the PIP dated 12/5/23 showed the goal was for, care plans will be updated by nursing personnel upon a fall. The root cause was, Not a thorough investigation when a fall happens to find out why and place an appropriate intervention. Barrier was, MDS typically adds items to care plan but she is not always at the center. The comments noted improvements of falls for January and February 2024 The Administrator said no changes were made to the PIP after Resident #20 sustained three additional falls, including a second fall at the facility resulting in injury/fracture on 1/5/24. She said education was provided to nursing staff for fall prevention, but she was unsure if the CNAs had any training. She said she was not sure how the Director of Nursing (DON) conducted the education or if it was, Train who was there or stick to the staffing roster to ensure all staff were educated. On 3/6/24 at 8:30 a.m., Resident #20 was observed in a wheelchair in the lobby by the nurse's nurses' station. On 3/7/24 at 2:20 p.m., in an interview the Physical Therapy Director said they would not do a therapy screen when Resident #20 falls since she was receiving hospice services. The clinical record showed a physician's order dated 9/15/23 for hospice services. 105995 Page 4 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0600 Level of Harm - Actual harm Residents Affected - Few 2. Review of the clinical record for Resident #243 revealed an admission date of 12/6/23 for Rehabilitation services after a fracture of the right femur (thigh bone). Diagnoses included Transient Ischemic Attacks (TIA), Dementia and Cerebral Infarction. The admission MDS assessment with a target date of 12/13/23 noted Resident #243's cognition was moderately impaired with a BIMS score of 11. Resident #243 used a manual wheelchair for mobility and was dependent on staff to wheel 50 feet. On 12/13/23 the elopement risk review form noted the criteria: Resident is able to maneuver his wheelchair independently. Resident has a diagnosis of dementia, hallucination and/or delusions. Resident has a history of wandering. Resident verbalizes desire to leave the facility. The facility determined the resident was at risk for elopement and placed a wander guard (alarms staff when a resident leaves a safe area) to the left ankle. The care plan initiated on 12/13/23 noted the resident was an elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, and impaired safety awareness. The goal was to maintain the resident's safety. The interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist: Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Wander alert to the left ankle. Review of the progress notes showed on 12/23/23 at 12:05 p.m., Resident #243 was outside in the wheelchair. The resident's son stated that he found him in the parking lot, bringing him back inside very upset, and wanted to be discharged from the facility. The resident had been wandering in the hallway and the nurse kept redirecting him several times. The nurse saw the wander guard around his left ankle before he took his morning medications. On 12/23/23 at 12:10 p.m., the nursing progress note documented that the nurse could not find the wander guard on the resident's ankle. They searched for the wander guard, and could not find it in the resident's room, or in the trash. On 3/4/24 at 11:02 a.m., in a telephone interview with Resident #243's son, he said on 12/23/23 he came with his mother to visit his father (Resident #243). When they pulled into the parking lot, his father was in his wheelchair on the edge of a ditch that was four to five feet deep. He raced to 105995 Page 5 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0600 Level of Harm - Actual harm Residents Affected - Few get him and brought him inside the facility. He said, Two nurses were just sitting there doing nothing. He told them he was checking his father out. They gathered his father's belongings and took him home. He said his father was just as confused as when he was admitted to the facility and has episodes of being aggressive. His father fell, broke his hip, and came to the facility for rehabilitation. He has Alzheimer's or Dementia, and also had three strokes. He took his father home because he did not feel his father was safe at the facility. On 3/6/24 at 1:25 p.m., in an interview the Administrator said on 12/23/223 Resident #243 was wearing a wander guard in the morning but somehow got outside where the son found him and brought him back in. She said the wander guards work by locking the doors to prevent the resident from exiting. She said when the resident came back in that his wander guard was gone and it was never found. The facility did not have surveillance cameras and was not certain where the resident was found. The family took the resident home, the doors were checked after the incident and were working properly. Review of the Elopement investigation noted the Incident apparent Cause was, Resident appeared more confused today and was aggressive. This was not like the resident's behavior. His spouse did want him to come home and will tell him that daily. Resident was set to discharge on [DATE]. The actions taken after incident included: Check wander guard transmitters to ensure they are working; check function of doors; missing elopement drill held; ensure all residents are accounted for; check the placement of the other two identified residents who have a wander guard; skin check on Resident #243 no injury found; pain assessment on Resident #243 denied pain; contact doctor for directives; Resident #243 dressed appropriately for Florida weather. On 3/7/2024 at 11:30 a.m., in an interview the Administrator said she considered the root cause of the elopement was a change in Resident #243's behavior. She said that no changes were made to the elopement process since Resident #243's elopement on 12/23/23. She said there was nothing to fix because the doors were working when they tested them afterwards. Education regarding elopement was provided to staff. On 3/6/2024 at 2:30 p.m., in an interview the DON said the parking lot was observed, the resident was halfway up the middle of the parking lot but could not say exactly where because no staff saw him outside and no one questioned the family. The Administrator present during the interview said the maintenance director tested the wander guard system and it was working just fine. She said the resident had somehow removed the wander guard so the alarms did not work. They searched the facility but could not find the missing wander guard. The wander guard is checked daily to ensure it is applied and working. That documentation is on the Treatment Administration Record. On 3/7/2024 at 12:30 p.m., in an interview the Director of Maintenance said he has been employed at the facility for three weeks and is trying to learn and figure out everything that needs to be done. He said they check the doors/alarms every week but was only able to provide documentation of door check for skilled side for 12/23/23. He said there have not been any consistent checks that he was 105995 Page 6 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0600 aware of but he is trying to change that and the Administrator has asked him to do routine checks. Level of Harm - Actual harm On 3/8/2024 at 12:40 p.m., in an interview the Administrator said maintenance was checking the doors but they don't document that it was done. She is currently trying to get them to do that. Residents Affected - Few 105995 Page 7 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

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 staff and resident interview, medical record review, and review of facility policies, the facility failed to have documentation of a thorough investigation for 1 (Resident #243) of 1 resident reviewed for elopement. Residents Affected - Few The findings included: The facility's event investigation guidelines (undated) for suspected neglect noted to include time frame date, shift, and time of report or discovery of the event, including specific individuals involved . Elopement: Investigation should begin immediately. Summarize what was done in the investigative process and your conclusion with supportive evidence to support the root cause of the incident. Include all details of when, what etc. Include facts of evidence obtained. Consistencies in consistencies, effect on resident, staff involved. Review of the clinical record for Resident #243 revealed an admission date of 12/6/23 for Rehabilitation services after a fracture of the right femur (thigh bone). Diagnoses included Transient Ischemic Attacks (TIA), Dementia and Cerebral Infarction. The admission MDS assessment with a target date of 12/13/23 noted Resident #243's cognition was moderately impaired with a BIMS score of 11. Resident #243 used a manual wheelchair for mobility and was dependent on staff to wheel 50 feet. On 12/13/23 the elopement risk review form noted the criteria: Resident is able to maneuver his wheelchair independently. Resident has a diagnosis of dementia, hallucination and/or delusions. Resident has a history of wandering. Resident verbalizes desire to leave the facility. The facility determined the resident was at risk for elopement and placed a wander guard (alarms staff when a resident leaves a safe area) to the left ankle. The care plan initiated on 12/13/23 noted the resident was an elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, and impaired safety awareness. The goal was to maintain the resident's safety. The interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 105995 Page 8 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Identify pattern of wandering: Is wandering purposeful, aimless, or escapist: Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Wander alert to the left ankle. Review of the progress notes showed on 12/23/23 at 12:05 p.m., Resident #243 was outside in the wheelchair. The resident's son stated that he found him in the parking lot, bringing him back inside very upset, and wanted to be discharged from the facility. The resident had been wandering in the hallway and the nurse kept redirecting him several times. The nurse saw the wander guard around his left ankle before he took his morning medications. On 12/23/23 at 12:10 p.m., the nursing progress note documented that the nurse could not find the wander guard on the resident's ankle. They searched for the wander guard, and could not find it in the resident's room, or in the trash. On 3/4/24 at 11:02 a.m., in a telephone interview Resident #243's son said on 12/23/23 he came with his mother to visit his father. When they pulled into the parking lot, his father was in his wheelchair on the edge of a ditch that was four to five feet deep. He raced to get him and brought him inside the facility. He said, Two nurses were just sitting there doing nothing. He told them he was checking his father out. They gathered his father's belongings and took him home. He said his father was just as confused as when he was admitted to the facility and has episodes of being aggressive. His father fell, broke his hip, and came to the facility for rehabilitation. He has Alzheimer's or Dementia, and also had three strokes. He took his father home because he did not feel his father was safe at the facility. Review of the facility's investigation and root cause dated 1/4/24 noted on the morning of 12/23/23 Resident #243 appeared more agitated and unsettled. The licensed Registered Nurse (RN) on duty and Certified Nursing Assistant (CNA) had a difficult time getting the resident ready for the day as he was more assertive. RN on duty did note wander guard was in place while she was assisting with care. RN on duty noted that the resident was propelling himself on the different hallways in the skilled unit and needed to be redirected on several occasions. RN say the resident at approximately 12:10 p.m. around the from to the 70's hall which was in perimeter of the front door. She went to take care of a resident. At approximately 12:13 p.m., she saw Resident #243 entering back in the skilled unit's main entrance being pushed by his son. The wander guard was missing. The nurse and family looked for the wander guard but could not find it. The corrective actions implemented were: Check wanderguard transmitters to ensure they are working. check function of doors. Missing elopement drill held. Ensure all residents are accounted for. Check the placement of the other two identified residents who have a wanderguard. Skin check on Resident #243, no injury. 105995 Page 9 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0610 Pain assessment: No pain. Level of Harm - Minimal harm or potential for actual harm Contact physician for directives. Resident was dressed appropriately for Florida weather. Residents Affected - Few The investigation included statements from staff on duty but did not include a statement of the resident's son who found Resident #243 in the parking lot. On 3/6/24 at 1:25 p.m., in an interview the Administrator said on 12/23/23 Resident #243 was wearing a wander guard in the morning but somehow got outside where the son found him and brought him back in. She said the wander guards work by locking the doors to prevent the resident from exiting. She said when the resident came back in that his wander guard was gone and it was never found. The facility did not have surveillance cameras and was not certain where the resident was found. The family took the resident home, the doors were checked after the incident and were working properly. Review of the Elopement investigation noted the Incident apparent Cause was, Resident appeared more confused today and was aggressive. This was not like the resident's behavior. His spouse did want him to come home and will tell him that daily. Resident was set to discharge on [DATE]. The investigation did not include how Resident #243 was able to remove the wanderguard and steps taken to prevent other residents from removing the wanderguards. On 3/7/2024 at 11:30 a.m., in an interview the Administrator said she considered the root cause of the elopement was a change in Resident #243's behavior. She said that no changes were made to the elopement process since Resident #243's elopement on 12/23/23. She said there was nothing to fix because the doors were working when they tested them afterwards. Education regarding elopement was provided to staff. On 3/6/2024 at 2:30 p.m., in an interview the DON said the parking lot was observed, the resident was halfway up the middle of the parking lot but could not say exactly where because no staff saw him outside and no one questioned the family. The Administrator present during the interview said the maintenance director tested the wander guard system and it was working just fine. She said the resident had somehow removed the wander guard so the alarms did not work. They searched the facility but could not find the missing wander guard. The wander guard is checked daily to ensure it is applied and working. That documentation is on the Treatment Administration Record. 105995 Page 10 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the baseline care plan was developed and implemented for 1(Resident #196) of 6 baseline care plan reviewed to ensure it includes the instructions/interventions needed to provide effective and person-centered plan of care that meet the professional standards of quality of care. The findings included: On 3/4/24 at 11:09 a.m., during an interview with Resident #196, he said he has a displaced fracture of his left ulna, and the orthopedic surgeon told him when he was discharged from the hospital, Resident #196 needed to see him in his office to determine what the next course of action, needed to be taken, to address the left ulna fracture. Resident #196 said since his admission on [DATE], no one had explained to him the plan of care related to his left ulna fracture and why he had not seen the orthopedic surgeon in 3 days after his admission to the facility as he was told by the orthopedic surgeon when he was in the hospital. A review of Resident #196's medical record revealed he was admitted to the facility on [DATE] with a diagnosis of a displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for closed fracture. Review of the physician's orders dated 2/29/24 revealed an order to follow up with the orthopedic surgeon in 3 days and keep the soft cast in place until Resident #196 was seen by the orthopedic surgeon. On 3/5/24 a review of Resident #196's baseline care plan dated 2/28/24 noted an acute fracture to the left ulna with a goal of no complications. In the section for interventions to ensure there were no complications to the left ulna fracture nothing was checked and/or written as intervention(s) to ensure there were no complications to Resident #196's left ulna fracture. On 3/7/24 at 9:10 a.m., in an interview with the Director of Nursing (DON), she said the admitting nurse or someone from the nursing staff was required to complete each resident's baseline care plan upon admission to ensure all areas of concerns were addressed immediately with an interim goal and interventions. The DON reviewed Resident #196's handwritten (dated 2/28/24) and electronic (dated 2/29/24) interim baseline care plans and confirmed the interim care plan did not contain goals and interventions related to Resident #196's left ulna fracture and soft cast to the left arm. By failing to identify interventions the facility staff had no guidance to assure effective and person centered care for Resident #196's left ulna fracture and the soft cast to his left arm as required. On 3/7/24 at 9:38 a.m., in an interview with the Minimum Data Set (MDS) Coordinator, she said she was responsible to initiate, review and update each resident's plan of care during their stay at the facility. She said the admitting nurse or someone from the nursing staff were required to initiate a baseline interim plan of care for all newly admitted residents to ensure there were no delays in implementing interventions to ensure all areas of concerns were addressed immediately after their admission to the facility. The MDS Coordinator said, after she reviewed Resident #196's interim baseline care plan dated 105995 Page 11 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0655 2/28/24 and 2/29/24, nursing staff did not put interventions in place upon admission, to ensure Resident #196's left ulna fracture and his left arm soft cast had no complications as required. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105995 Page 12 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation interview and record review the facility failed to ensure they had a physician's order for the continuation, flushing and dressing change of an intravenous peripheral catheter (IVPC) for 1 Resident (#197) of 1 resident reviewed with an IVPC as related to facility's policy IVPC care and in accordance with the professional standard of care for IVPC. Residents Affected - Few The findings included: On 3/4/24 at 11:32 a.m., an observation revealed the IVPC dressing located on Resident #197's right forearm was not dated with the time it was inserted or the last time the IVPC site dressing was changed. On 3/4/24 at 11:32 a.m., during an interview with Resident #197, she said a facility nurse inserted the IVPC last week so she could receive a bag of intravenous (IV) fluid due her lab results. She said since the insertion of the IVPC no one had flushed the IVPC until today or changed the IVPC dressing to her right forearm. She said the IVPC site does not hurt but she didn't know why the nurse did not remove the IVPC after she had received the IV fluids ordered by the physician. On 3/4/24 at 12:38 p.m., in an interview with Staff D, she said she had inserted Resident #197's IVPC several days ago to infuse IV fluids ordered by Resident #197's physician due to abnormal laboratory values. She said when the IV fluid was completed, they did not remove the IVPC from Resident #197's forearm just in case Resident #197's physician wanted Resident #197 to receive more IV fluids. Staff D confirmed she had flushed Resident #197's IVPC that morning and the IVPC dressing to Resident #197's right forearm was not dated. She further said she did not know if Resident #197's IVPC dressing was changed from when she inserted the IVPC a couple of days ago. She said the resident was required to have orders related to the insertion, maintenance, and discontinuation of an IVPC. She said she was unaware of the facility's policy related to insertion, maintenance, and discontinuation of an IVPC. On 3/5/24 a review of the Peripheral Line Dressing Change #C-IV-3 policy dated 7/2018 stated the peripheral catheter insertion site was a potential entry site for bacteria that could produce a catheter-related infection. If the patient was sensitive to the transparent semipermeable membrane (TSM), gauze and tape dressings could be used. The policy stated in the procedure section that the transparent dressing should be changed every 72 hours with site rotation, or sooner if the integrity of the dressing was compromised. Assessment of the peripheral catheter site were performed at the following times: during dressing changes, every 2 hours during continuous therapy, before and after administration of intermittent intravenous medications, and at least every eight hours when maintained for access only. Assessment was to include the absence or presence of erythema, drainage, swelling, induration, skin temperature at site, or complaint of tenderness at the site or along the vein tract. A review of the Peripheral Catheter Flushing #C-IV-2 policy dated 7/2018 stated a specific flush order must be documented. Flushing was performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. The policy stated in the procedure section, a physician's order was required to flush a peripheral 105995 Page 13 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0684 catheter. The order must include the flushing agent, the amount, and the frequency. Level of Harm - Minimal harm or potential for actual harm On 3/5/24 review of Resident #197's medical record revealed an active physician's order for the insertion of an IV into Resident #197's left forearm with a 20-gauge needle dated 2/28/24. Further review revealed no physician order to flush the IVPC and change the IVPC inserted into Resident #197's right forearm as required by the facility's policies and procedures. Residents Affected - Few On 3/6/24 at 10:56 a.m., during an interview with the Director of Nursing (DON), said she had discovered on 3/5/24 Resident #197 had an IVPC inserted into their right forearm on 2/28/24 to receive a one-time dose of IV fluids related to an abnormal laboratory result. She said upon further investigation she discovered the facility did not obtain a physician order to continue the IVPC after the resident received the IV fluid ordered by the physician to include the specific flushing agent, the amount, the frequency of the flushes and how frequent the IVPC site dressing was required to be changed as required per their peripheral catheter policies and to ensure their residents receive treatment and care in accordance with professional standard of care and practice. 105995 Page 14 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, resident and staff interviews and medical record and facility policy review, the facility failed to implement adequate supervision to prevent accidents for 2 (Residents #20 and #243) of 5 residents reviewed for accidents. The findings included: 1. The facility policy provided for Fall Prevention and Management created 7/2018 and last revised 1/2023 stated: The Fall Risk Evaluation (completed on admission) will determine fall risk factors. 1. Fall risk assessments will be completed for all residents; initially on admission/readmission, quarterly, significant change and after an identified fall; 2. As part of the assessment, the nurse will help identify individuals with a history of falls and risk factors for subsequent falling; Staff will ask the resident and the caregiver about history of falling . staff will record history of one or more recent falls . root causes for fall history will be identified. 3. In addition, the nurse shall assess and document/report vital signs . recent injury, . musculoskeletal function . change in condition . neurological status . pain . meds . active diagnosis; 4. The staff will document risk factors . implement goals and interventions . communicate interventions . provide staff training . revise IDT after an event . educate resident and family as needed. 5. Staff will evaluate and document falls that occur while the individual in in the facility. 6. If interventions have been successful in preventing falling, the staff will continue with current approaches; 7. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. The policy also stated, residents will be referred to therapy for a screen - for indication of need for therapy interventions. Interdisciplinary team should monitor and document on resident's response/success with fall reduction interventions. Residents who continue to fall with interventions in place will be assessed for change in or additions to interventions. All staff shall receive education on the fall prevention program at the time of orientation and annually thereafter. On 3/10/24 at 12:20 p.m., in an interview Resident #20 said she fell many times since she had been at the facility, and thought she broke her pelvis. Resident #20 was not able to provide more details but said she has been at the facility for three years. Review of the clinical record revealed Resident #20 was admitted to the facility on [DATE] after a fall at home resulting in a left femur fracture. The Significant change in status Minimum Data Set (MDS) assessment with a reference date of 1/10/24 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13. Resident #20 required partial/moderate assistance for mobility. Review of the facility's accident/incident log revealed on 8/11/23 Resident #20 was found on the floor and was transferred to the hospital. 105995 Page 15 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0689 Resident #20 was diagnosed with fracture of the right acetabular (hip) which required surgery, a closed fracture of right olecranon process (elbow) which required surgery and fractures of pubic rami (pelvis). Level of Harm - Actual harm Resident #20 was admitted to the hospital and returned to the facility on 8/17/23. Residents Affected - Few Review of the care plan initiated on 4/6/22 and revised on 1/23/24 noted Resident #20 had an actual fall with two fractures to the right upper extremity, the right lower extremity, and the pelvis. Fall on 8/17/23 with major injury. Fall on 10/5/23, no injury; fall on 10/24/23 with hematoma (collection of blood in the tissues) on 10/24/23. Fall on 11/2/23, 11/23/23, 12/10/23, 1/17/24, 1/18/24, and 1/20/24 with no injury. The goal as 6/30/21 was for the resident to resume usual activities without further incidents. The interventions prior to 8/17/23 included: Continue interventions on the at-risk plan (6/30/21). Dysom [sic] (non-slip mat) to wheelchair (8/4/22). Monitor/document /report as needed for 72 hours to doctor for s/sx (signs or symptoms) of pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation (6/30/21). Place resident in areas of high visibility (8/16/22). Physical Therapy consult for strength and mobility (8/12/21). Resident education on asking for assistance prior to transfer, an ambulation (6/30/21). Resident education on keeping wheelchair brakes locked (6/30/21). Reviewed care plan. All interventions remain appropriate (5/7/23). Staff education to use leg rests on wheelchair (5/16/23). Urine analysis, culture, and sensitivity (5/11/23). Review of the progress note dated 8/11/23 at 3:15 p.m., showed Resident #20 was found on the floor by activity personnel lying on the floor facing her front door. The fall was unwitnessed. The resident was alert and oriented and stated she was trying to go to bed. Resident complained of right hip pain and was sent to the hospital via Emergency Medical Services (EMS) for further evaluation. The care plan was not updated with new interventions to prevent further falls upon the resident's return to the facility. On 8/28/23 the care plan was updated with, Frequent checks. 105995 Page 16 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0689 Review of the progress notes revealed Resident #20 sustained additional falls on 10/5/23, 10/24/23, 11/12/23, and 11/23/23. Level of Harm - Actual harm On 11/27/23 the care plan was updated with, Low bed. Residents Affected - Few On 12/10/23 at 11:01 a.m., a progress note documented the nurse heard someone yelling for help. The nurse ran to help in the dining room and found Resident #20 sitting on the floor. The resident said she hit her head on the wheelchair. No injuries or bruising noted. On 12/11/23 the care plan was updated with , Moved resident's room closer to nurse's desk, and High back wheelchair on 12/13/23. On 1/3/24 at 6:03 p.m., a progress note showed Resident #20 was found into floor sitting position. The resident's son was at bedside and stated he found the resident in the floor. No injuries were noted and the resident denied any pain. The facility investigated and on 1/3/24 noted, After investigation it was noted that the resident was trying to put away items in her room. Going forward the room is to be kept decluttered and items should be put away for the resident. (Resident #20) is requested to ring for assistance but at times she forgets and believes she can walk. Corrective actions included resident room to remain decluttered and hygiene items should be in her drawers if she should need them. Residents are encouraged to use call bell. Hospice and the Interdisciplinary Team (IDT) met and indicated that hospice was going to request a volunteer to come sit with Resident #20 a few times a week and have her more involved in activities. On 1/5/24 at 2:17 p.m., the Advanced Practice Registered Nurse documented Resident #20 reported lower back pain after the fall. The practitioner ordered an X-Ray of the lumbar area. The radiology report dated 1/5/24 noted multiple lumbar vertebral compression fractures involving Lumbar 1(L1), Le and L4. The fracture at L1 is severe and may be acute. Correlation with patient history and location of symptoms is recommended. On 1/5/24 the care plan was updated with, Resident education to wait for staff to assist with supplies. On 1/18/24 at 2:41 a.m., a progress note documented Resident #20 was found on the floor on the right side of the bed on the mat. Resident was not able to explain what happened. No injuries noted. On 1/18/24 at 8:25 a.m., a progress note noted the nurse was called to the resident's room by an Occupational Therapist who stated the resident was lying on the floor next to the bed. The sheet was wrapped around the resident and the bed was in the lowest position. Resident stated she did not know what happened. Upon inspection of the bed, it was noted the headboard was loose which caused the mattress to be unstable. No injuries observed. On 1/18/24 the care plan was updated with, Repair patient's bed. 105995 Page 17 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0689 Level of Harm - Actual harm Residents Affected - Few On 1/20/24 at 3:37 a.m., a progress note documented during rounds Resident #20 was observed lying on the floor mat on the left side. The resident stated she was sleeping when she rolled onto the left side. The resident denied pain or hitting her head. On 3/5/2024 at 2:00 p.m., in an interview the MDS Coordinator said she had been employed at the facility for approximately six years and had never encountered any resident with so many falls. She said they were scratching their heads wondering what to do next. After reviewing Resident #20's care plan the MDS coordinator said she was not able to see interventions in the care plan to prevent further incidents of falls. On 3/5/24 at 2:45 p.m., in an interview the MDS Coordinator said she updated a couple of days on the care plan to include, move debris and fall mats to the floor. On 3/5/24 at 3:00 p.m., in an interview Certified Nursing Assistant (CAN) Staff E said she has been employed at the facility for 23 years and was familiar with Resident #20. She said Resident #20 has fall mats that get put out every night when she's in bed. CNA Staff E said no one has told her what to do to prevent Resident #20 from falls. She said she just knows to be extra careful to make sure the resident does not fall since she has Parkinson's. On 3/5/2024 at 3:15 p.m., the MDS Coordinator provided a fall care plan which listed multiple interventions to prevent further falls for Resident #20. She said she could not explain why the original care plan in the clinical record was not correct. On 3/7/24 at 11:30 a.m., in an interview the Administrator said the only root cause for Resident #20's multiple falls was her Parkinson's disease. She stated, I think I counted 25 falls that she has had since her admission. She said Resident #20's last fall was in January 2024. She stated, this is the longest she has ever gone without falling. She said the facility has implemented every intervention they could think of except one-on-one supervision. She said Resident#20 never had one-on-one supervision or monitoring of any kind, and no documentation such as a log of any monitoring or supervision. The Administrator said she started a PIP (Performance Improvement Project) on 12/5/23 to address a problem area of falls to address the frequency of falls and interventions not immediately put in place. Review of the PIP dated 12/5/23 showed the goal was for, care plans will be updated by nursing personnel upon a fall. The root cause was, Not a thorough investigation when a fall happens to find out why and place an appropriate intervention. Barrier was, MDS typically adds items to care plan but she is not always at the center. The comments noted improvements of falls for January and February 2024 The Administrator said no changes were made to the PIP after Resident #20 sustained three additional falls, including a second fall at the facility resulting in injury/fracture on 1/5/24. She said 105995 Page 18 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0689 Level of Harm - Actual harm Residents Affected - Few education was provided to nursing staff for fall prevention, but she was unsure if the CNAs had any training. She said she was not sure how the Director of Nursing (DON) conducted the education or if it was, Train who was there or stick to the staffing roster to ensure all staff were educated. On 3/6/24 at 8:30 a.m., Resident #20 was observed in a wheelchair in the lobby by the nurse's nurses' station. On 3/7/24 at 2:20 p.m., in an interview the Physical Therapy Director said they would not do a therapy screen when Resident #20 falls since she was receiving hospice services. The clinical record showed a physician's order dated 9/15/23 for hospice services. 2. Review of the clinical record for Resident #243 revealed an admission date of 12/6/23 for Rehabilitation services after a fracture of the right femur (thigh bone). Diagnoses included Transient Ischemic Attacks (TIA), Dementia and Cerebral Infarction. Review of the progress notes showed on 12/23/23 at 12:25 p.m., Resident family keeps packing up all resident belongings. Resident's son took resident into his car, left. On 12/23/23 Resident #243's son signed a release of responsiblity for discharge against medical advice for his father. On 3/4/24 at 11:02 a.m., in a telephone interview with Resident #243's son, he said on 12/23/23 he came with his mother to visit his father (Resident #243). When they pulled into the parking lot, his father was in his wheelchair on the edge of a ditch that was four to five feet deep. He raced to get him and brought him inside the facility. He said, Two nurses were just sitting there doing nothing. He told them he was checking his father out. They gathered his father's belongings and took him home. He said his father was just as confused as when he was admitted to the facility and has episodes of being aggressive. His father fell, broke his hip, and came to the facility for rehabilitation. He has Alzheimer's or Dementia, and also had three strokes. He took his father home because he did not feel his father was safe at the facility. Review of the admission Minimum Data Set (MDS) assessment with a target date of 12/13/23 noted Resident #243's cognition was moderately impaired with a BIMS score of 11. Resident #243 used a manual wheelchair for mobility and was dependent on staff to wheel 50 feet. On 12/13/23 the elopement risk review form noted the criteria: Resident is able to maneuver his wheelchair independently. Resident has a diagnosis of dementia, hallucination and/or delusions. Resident has a history of wandering. Resident verbalizes desire to leave the facility. The facility determined the resident was at risk for elopement and placed a wander guard (alarms staff when a resident leaves a safe area) to the left ankle. 105995 Page 19 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0689 The care plan initiated on 12/13/23 noted the resident was an elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, and impaired safety awareness. Level of Harm - Actual harm The goal was to maintain the resident's safety. Residents Affected - Few The interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist: Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Wander alert to the left ankle. Review of the progress notes showed on 12/23/23 at 12:05 p.m., Resident #243 was outside in the wheelchair. The resident's son stated that he found him in the parking lot, bringing him back inside very upset, and wanted to be discharged from the facility. The resident had been wandering in the hallway and the nurse kept redirecting him several times. The nurse saw the wander guard around his left ankle before he took his morning medications. On 12/23/23 at 12:10 p.m., the nursing progress note documented that the nurse could not find the wander guard on the resident's ankle. They searched for the wander guard, and could not find it in the resident's room, or in the trash. Review of the facility's investigation and root cause dated 1/4/24 noted on the morning of 12/23/23 Resident #243 appeared more agitated and unsettled. The licensed Registered Nurse (RN) on duty and Certified Nursing Assistant (CNA) had a difficult time getting the resident ready for the day as he was more assertive. RN on duty did note wander guard was in place while she was assisting with care. RN on duty noted that the resident was propelling himself on the different hallways in the skilled unit and needed to be redirected on several occasions. RN say the resident at approximately 12:10 p.m. around the from to the 70's hall which was in perimeter of the front door. She went to take care of a resident. At approximately 12:13 p.m., she saw Resident #243 entering back in the skilled unit's main entrance being pushed by his son. The wander guard was missing. The nurse and family looked for the wander guard but could not find it. The corrective actions implemented were: Check wanderguard transmitters to ensure they are working. check function of doors. Missing elopement drill held. Ensure all residents are accounted for. Check the placement of the other two identified residents who have a wanderguard. Skin check on Resident #243, no injury. 105995 Page 20 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0689 Pain assessment: No pain. Level of Harm - Actual harm Contact physician for directives. Residents Affected - Few Resident was dressed appropriately for Florida weather. On 3/6/24 at 1:25 p.m., in an interview the Administrator said on 12/23/223 Resident #243 was wearing a wander guard in the morning but somehow got outside where the son found him and brought him back in. She said when the resident came back in that his wander guard was gone and it was never found. The facility did not have surveillance cameras and was not certain where the resident was found. The family took the resident home, the doors were checked after the incident and were working properly. On 3/7/2024 at 11:30 a.m., in an interview the Administrator said she considered the root cause of the elopement was a change in Resident #243's behavior. She said that no changes were made to the elopement process since Resident #243's elopement on 12/23/23. She said there was nothing to fix because the doors were working when they tested them afterwards. Education regarding elopement was provided to staff. The investigation did not include a root cause for the missing wander alarm. On 3/6/2024 at 2:30 p.m., in an interview the DON said the parking lot was observed, the resident was halfway up the middle of the parking lot but could not say exactly where because no staff saw him outside and no one questioned the family. The Administrator present during the interview said the maintenance director tested the wander guard system and it was working just fine. She said the resident had somehow removed the wander guard so the alarms did not work. They searched the facility but could not find the missing wander guard. The wander alarm is checked daily to ensure it is applied and working. That documentation is on the Treatment Administration Record. On 3/7/2024 at 12:30 p.m., in an interview the Director of Maintenance said he has been employed at the facility for three weeks and is trying to learn and figure out everything that needs to be done. He said they check the doors/alarms every week but was only able to provide documentation of door check for skilled side for 12/23/23. He said there have not been any consistent checks that he was aware of but he is trying to change that and the Administrator has asked him to do routine checks. 105995 Page 21 of 22 105995 03/07/2024 Adviniacare at Naples 7801 Airport Pulling Road N Naples, FL 34109

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on facility policy review, employee file review and interview it was determined that the facility failed to ensure infection control management staff had the proper infection prevention education and training as required. The findings include: On review of facility policy titled, Infection Control Program Policy IC-2 last revised 2/2023 indicates that the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Procedure: Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). b. The qualifications and job responsibilities of infection Preventionist are outlined in the infection Preventionist Job Description. During an interview on 3/6/24 at 3:10 p.m., Director of Nursing (DON) acknowledged that she was the infection control nurse for the facility. DON stated that she had not taken any formal education to become the facilities infection preventionist. She stated that she was not aware that she needed any specific training for it. She stated she was not aware of the proper credentials and/or training needed. During an interview on 3/07/24 at 12:23 p.m., the Administrator stated that she was aware of the regulation that the person in charge of infection control for the facility needed to have specific training as an infection preventionist. The administrator said she never asked the DON if she had the training before asking her to take the position. On review of the Director of Nursing's personnel file there was no certification indication she had completed the required training for an infection preventionist. On review of facilities job description for Director of Nursing and Staff development/Infection control employee, neither of the job description noted the regulation for the proper training for infection preventionist in the facility. 105995 Page 22 of 22