Health inspection·June 16, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to appropriately respond to and resolve grievances for 1 of 3 sampled residents, Resident #1. Residents Affected - Few The findings included: Review of the policy titled, Social Services-Grievance Process, with an effective date of 04/01/24, revealed the following: Grievances may be voiced through verbal complaint to a staff member (p.1); the facility shall implement a process whereby when there is grievance, it should be documented on the facility grievance report (p.2). Record review revealed Resident #1 was admitted to the facility on [DATE] and had a resident-initiated discharge on [DATE]. Resident #1's diagnoses included Pulmonary Hypertension, Muscle Wasting and Atrophy, Type 2 Diabetes Mellitus with Peripheral Angiopathy without Gangrene, Atrial Fibrillation, Hypothyroidism, and Chronic Kidney Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], under Section C for the Brief Interview of Mental Status (BIMS) revealed a score of 14, indicating Resident #1 had intact mental cognition. Review of the facility's grievance record for 05/2025 did not include any complaint or concern from Resident #1's son. An interview was conducted with Resident #1's son on 06/18/25 at 12:00 PM who stated he reported complaints to the former and the new Administrators regarding the care of his mother which included medications, falls, non-functioning bed and TV, and resident's rights. The former and the new Administrators did not indicate any updates or progress regarding his complaints. He was very much concerned about Resident #1's medications which were not given until the night before a resident- initiated discharge from the facility. An interview was conducted with Staff A, Social Services, on 06/16/25 at 1:51 PM, who stated she has been working in the facility for 16 years. When asked how she informs residents of the grievance process, responded, A staff would take a grievance, then a management meeting would follow, and a grievance would be assigned to the appropriate person. When asked the usual response time for most grievances, she responded, Two days, if it is a small matter, but for a room change, it might take longer than the usual time. When asked regarding the malfunctioning bed and television (TV), she responded, The Maintenance Director is very responsive. It is very unusual that the TV is not working because the facility buys new TVs to replace the ones that are not working. When asked how she would know Page 1 of 4 106005 106005 06/16/2025 West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446

F 0565 Level of Harm - Minimal harm or potential for actual harm the grievance was resolved, responded, Whoever is interested would know the grievance is resolved. When asked why Resident #1's name was not included in the May 2025 grievance report list, she responded, There were no reported grievances from Resident #1. Residents Affected - Few 106005 Page 2 of 4 106005 06/16/2025 West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure a newly admitted resident received physician ordered medication for immediate care for 1 of 3 sampled residents, Resident #1. Residents Affected - Few The findings included: Record review revealed Resident #1 was admitted to the facility on [DATE] and had resident-initiated discharged on 05/28/25. Resident #1's diagnoses included Pulmonary Hypertension, Muscle Wasting and Atrophy, Type 2 Diabetes Mellitus with Peripheral Angiopathy without Gangrene, Atrial Fibrillation, Chronic Kidney Disease, Age Related Osteoporosis, without current Pathological Fracture and Hypothyroidism. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], under Section C for the Brief Interview of Mental Status (BIMS) revealed a score of 14, indicating Resident #1 had intact mental cognition. Review of the nursing progress notes dated 05/16/25 revealed the admitting diagnoses included weakness and status post fall. Review of the Advanced Registered Nurse Practitioner (ARNP) admission notes dated 05/17/25 revealed the following recommendations: continue current medications and follow fall risk precautions. Review of the Pharmacist progress notes dated 05/19/25 revealed the medication regimen was reviewed, and recommendations were made. Review of the summary of facility's physician orders revealed medications were ordered by telephone on 05/16/25. Further review of physician orders revealed there were no orders for the recommended medications that included Gabapentin, Carvedilol, Calcitriol, Allopurinol, and Sodium Bicarbonate. Review of the nursing progress notes dated 05/20/25, by a Registered Nurse (RN) Unit Manager, revealed a new order that documented medication not available, but did not indicate which medications were not available or what the new order was. Review of May 2025 Medication Administration Record (MAR) revealed Resident #1 received the recommended medications on 05/27/25 (10th day after admission), during the night before a resident-initiated discharge. In an interview with the Assistant Director of Nursing (ADON) on 06/16/25 at 3:42 PM, when she was asked about the process of providing the recommended medications for a newly admitted resident, responded, We follow the recommendations. When asked why the recommended medications were not documented in the physician orders and into Resident #1's MAR until the 10th day of Resident #1's stay in the facility, she stated she would investigate. Until the end of the survey, she did not provide the reason why. During a later interview with the ADON on 06/16/25 at 5:00 PM, she stated the medications were active for Resident #1 since 05/27/25 (the10th day). When she was asked how soon medications would start after a resident's admission to the facility, she responded, As soon as possible or probably the 106005 Page 3 of 4 106005 06/16/2025 West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446

F 0635 next day. When asked why Resident #1 who was admitted on [DATE] did not get the recommended medications until 05/27/25, she did not respond. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106005 Page 4 of 4