Health inspection·September 21, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on policy review, interview, and record review, the facility failed to act upon a grievance voiced by a resident regarding care for 1 of 2 sampled residents (Resident #266). Residents Affected - Few The findings included: Policy titled complaints/grievances of resident/family member. Revised date January 2018. Department approval: Director of social services. The objective included: to ensure that all residents have complaints addressed to their satisfaction; to provide a mechanism for residents to access a grievance process. The procedure included: Complaints received by social services or staff member: 1.the staff member brings the complaint to their department manager immediately. 2.the social service director or department manager arranges a meeting with the involved discipline and the resident and/or family member where attempts shall be made to resolve the issues. 3.a resident/family complaint/grievance resolution form is completed and forwarded to the director of social services who will present the data at the quality assurance/performance improvement committee meeting. Record review revealed Resident #266 was admitted to the facility on date 09/07/23. The admission Minimum Data Set (MDS) assessment, reference date 09/18/23 documented a brief interview for mental status score (BIMS) of 15, indicating Resident #266 was cognitively intact. This MDS documented no mood and behavior issue. The MDS revealed Resident # 266 required total assistance from the staff with activities of daily living (ADLs), including: bed mobility, locomotion on and off unit, toilet use and personal hygiene. Review of the comprehensive care plan dated 09/14/23 revealed Resident #266 needed total assistance in almost all aspects of care. Interventions included: to anticipate and meet her needs, explain plan of care, and Promote dignity by ensuring privacy. Review of the grievance log dated for September 2023 revealed no documented evidence of grievance for Resident #266. Review of progress note dated 09/18/23 (a late entry note) written by the social worker, the note indicated, on Friday 09/15/23 I (social worker) received a message from Resident (#266's) daughter that Resident (#266) was complaining that she needed to be changed. Upon speaking to nursing staff, the attending nurse advised that (Staff A) was Resident (#266's) certified nursing assistance (CNA). The attending Nurse stated that Staff A was with another resident giving care and had already spoken with Resident (#266) and told her that she would change her when she's done giving care to the other resident. It was explained to Resident (#266) that CNA had other residents and would provide care to her when finished. Resident (#266) verbalized understanding. Page 1 of 3 106018 106018 09/21/2023 Glades Health Care Center 230 South Barfield Highway Pahokee, FL 33476

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/18/23 at 9:31 AM an interview was held with Resident #266, she revealed that she's been at the facility for 2 weeks, for rehabilitation, status post stroke, and she can't walk, she depends on the staff for all aspects of her care. During the interview, Resident #266 explained that last Friday, September 15, she needed help changing her soiled adult depends, she couldn't find the call light, it was on the floor, therefore she called the front desk via her cell phone and ask for her CNA. The assigned CNA, who was (Staff A), came in the room and scolded Resident #266, yelling at her, stating why you had to call the front desk!? In a rude manner. Then Staff A continued to state she has other residents to care for, she then left the room and did not help Resident #266. Subsequently, Staff A returned to the room and started arguing with Resident #266. Staff A accused Resident #266 of cursing her out. Resident #266 explained, Staff A voiced to her that the attending nurse had informed her (Staff A) that Resident #266 had cursed her out when Staff A had left the room. Resident #266 further explained, Staff A stated, you're not going to disrespect me! and continued to argue with her. Resident #266 voiced, ever since the altercation with Staff A, she has been having headaches, because Staff A upset her. When inquired if she reported the incident to anyone in the facility? Resident #266 voiced she think her daughter may have reported the concern to someone in the facility, she's not sure. On 09/21/23 at 9:16 AM, an interview process was started with the Director of Nursing (DON), regarding Resident #266, when inquired about how the facility addressed Resident #266's concern regarding her care and concern with Staff A, the DON was oblivious about the incident, she revealed she had no knowledge of the incident (after the surveyor had explained what Resident #266 had reported). The DON advised the surveyor to speak with the Social Worker (SW) about the concern. On 09/21/23 at 9:55 AM, a subsequent interview was held with Resident #266 in the presence of the SW. During that time, Resident #266 explained the same concern she had reported to the surveyor on Monday (09/18/23 at 9:31 AM) to the SW. On 09/21/23 at 10:01 AM, an interview was held with the SW, the SW voiced she knows Resident # 266 well, the resident used to be her co-worker, she speaks to Resident #266 often. The SW voiced, she knew about the concern, she said Resident #266 had reported the exact same concern to her on Friday September 15. The SW explained, she documented a note and placed it in the resident's chart, she voiced she did not treat the concern as a grievance, she didn't know she needed to treat it as a grievance. She did not initiate any grievance process/investigation. On 09/21/23 at 10:28 AM, a subsequent interview was held with the DON, again she voiced she had no knowledge of this concern, because the SW never brought the concern to the morning meetings with the interdisciplinary team (IDT). The DON voiced that had she knew about the concern, she would have started a grievance process, she would have brought the involved CNA in, obtain her statement, and provide education. The DON agreed a grievance process and investigation should have started. 106018 Page 2 of 3 106018 09/21/2023 Glades Health Care Center 230 South Barfield Highway Pahokee, FL 33476

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on interview and record review, the facility failed to offer residents Binding Arbitration Agreements in a manner that the residents or their representatives would be able to make an informed decision. Residents Affected - Many The findings included: During the entrance conference, on 09/18/23 at 9:11 AM, when the Administrator was asked if the facility offered Binding Arbitration Agreement to residents as a means for dispute resolution, the Administrator stated that the facility did. The Administrator stated that the facility had not had any disputes resolved using the Binding Arbitration Agreement. Record review revealed the admission Packet documented, Optional Arbitration Clause: if the parties of this Agreement do not wish to include the following arbitration provision, please indicate so by marking an X through this clause. Both parties shall also initial that X to dignify their agreement to refuse arbitration. Any controversy or claim arising out of or relating to the Agreement or the breach thereof, shall be settled in arbitration in accordance with the provisions of the Florida Arbitration Code found at Chapter 682, Florida Statutes, and judgement upon the award rendered by the arbitrator (s) may be entered in any court having jurisdiction thereof. Further review of the admission Packet revealed that there was no other reference to the Agreement in the admission packet and the acknowledgement form in the admission packet was a blanket form that did not make reference to the Binding Arbitration Agreement. During an interview, on 09/20/23 at 2:40 PM, with the Director of Social Services/Admissions Coordinator, when asked for a copy of the Agreement, the Director of Social Services/Admissions Coordinator was not able to provide the document. When asked to provide details of the Agreement, she stated that she was not familiar with the Agreement and was not able to demonstrate knowledge of the Agreement. 106018 Page 3 of 3