Health inspection·April 27, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure care planning interventions were implemented related to; 1) Not providing adaptive eating equipment during meal service, and 2) Not offering and assisting with braces/splinting for contracture management for two residents (#83 and #36) out of twenty-two sampled residents. Findings included: 1) On 4/24/2023 at 12:40 p.m. Resident #83's room was approached and from the hallway, the resident could be seen in his room seated in a high-back wheelchair next to his bed, with the over the bed table positioned in front of him. The resident was noted to be alone in the room with his meal tray placed in front of him. The floor beneath him was observed with what appeared to be a puddle of red liquid. The resident was able to confirm he had dropped some liquid on the ground. Resident #83 was interviewed; he was noted to have to take time to answer general questions about his day. The resident was noted to have some food pocketed within his mouth on both sides. While in the room with Resident #83 from 12:40 p.m. through to 12:52 p.m., no staff were observed to enter the room to assist the resident with his meal. The meal tray was observed to be a non divided plate and both of his eating utensils were regular silverware. A review of the meal ticket on the tray, revealed; Resident #83, Diet - No Added Salt Mechanical Soft texture and Nectar Thick liquids, and AE Curved Utensil/Divided plate. No adaptive eating utensils were observed on the meal tray. Photographic evidence was taken. On 4/26/2023 at 12:40 p.m. Resident #83 was noted in his room and seated in his high back wheelchair next to the bedside. The over-the-bed table was positioned in front of him, and he had his lunch meal tray placed on the table. Staff A, Certified Nursing Assistant (CNA) was observed in the room and standing up in front of the resident with a spoonful of food being brought to his mouth. Staff A was asked if the resident had any adaptive equipment and she explained, No they took that away because he now requires assistance with feeding. The resident was not provided with a divided plate and was not provided with any adaptive built-up eating utensils per the current meal ticket. Photographic evidence was taken. Staff A stated she could not remember the last time he had the eating adaptive equipment. She continued to scoop food from his plate and tried to bring the spoon to his mouth, while standing in front of him. Resident #83 shook his head in a yes manner when asked if he could self-feed. Staff A gave him the spoonful of food item and allowed him to grip the spoon and he brought it to his mouth himself. She explained she needs to make sure she has her hand very close to the eating utensil as he really cannot eat on his own and needs assistance. While Resident #83 brought the spoon to his mouth, there was not any immediate concerns. Staff A was asked if speech therapy was working with the resident and she revealed, Yes, but I forgot her name. The resident then said, Staff B was the speech therapy member, and Staff A then confirmed the same name. Page 1 of 14 106030 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 4/26/2023 at 12:55 p.m. Resident #83's was observed seated in his room with his lunch meal tray placed in front of him. He had already started his meal with assistance from Staff A at 12:40 p.m., however, Staff A was not in the room. Resident #83 was not attempting to eat on his own. His meal tray still had approximately 50% uneaten food items on it. Staff A was observed in the room next door, seated in a chair, and assisting another resident with eating needs. At 1:00 p.m. Staff A was observed to get up from assisting the other resident and go over to Resident #83's room and begin to assist him with his meal. She brought forkfuls of food to his mouth, while allowing him to take bites slowly, and then chew and swallow slowly. At 1:15 p.m., Staff A was no longer in Resident #83's room, and she was again noted in the room next door seated in a chair and assisting the other resident with eating needs. There was no other staff member noted to be assisting Resident #83's during the meal. Resident #83 was not observed to try and eat on his own, but his meal tray was still observed with uneaten food items on it. At 1:20 p.m. Staff A stopped assisting the other resident in the next room and walked back to Resident #83's room to continue to assist him with his eating needs. Resident #83 accepted the food that was brought to his mouth. An interview with Staff A revealed, Resident #83 wanted a break so I ran over to start feeding the other resident and then I will go back and assist him. She stated, There are not a lot of staff on this hallway, and I do the best that I can with all those who require eating assistance. She stated the residents who require eating assistance should have staff in the room during the entire time of the meal service, and to not leave to help others. A review of Resident #83's medical record revealed he was admitted to the facility on [DATE]. The advance directives revealed Resident #83 had a Power of Attorney in place to make his medical and financial decisions. A review of the diagnosis sheet revealed diagnoses to include but not limited to: Parkinson's, dementia, seizures, Alzheimer's, dysphagia, depression, cognition communication deficit, and age-related physical debility. A review of the current Minimum Data Set (MDS) Quarterly assessment, dated 3/9/2023, revealed the following. Speech: Speech clarity section revealed - Unclear Speech, usually understood, understands others; Cognition/Brief Interview Mental Score/BIMS score - 15 of 15; Activities of Daily Living/ADL: EATING activities = Limited Assistance with One person assistance; Swallowing/Nutrition: Not checked for holding food, not checked for loss of liquids, not checked for coughing, or choking, not checked for complaints of pain or problem swallowing; Oral/Dental - Not checked for difficulty with chewing. A review of the 4/2023 order sheet, revealed the following but not limited to: - Extend speech therapy for dysphagia, daily x 3 days x one week x four weeks with order date 4/12/2023. - Please ensure additional assistance to self-feed is provided for resident at meal times. Is able to self-feed but very slowly (also wife's request), x shift with order date 3/24/2023. - No Added Salt diet, Mechanical soft texture, Nectar thick liquids with built up curved utensils and divided plate with order date 3/13/2023. - Speech therapy to evaluate and treat as indicated speech therapy to treat daily x 4 days x one week x four weeks for dysphagia therapy. Downgrade liquid to nectar thick liquid. Continue mechanical software, with order date 3/13/2023. 106030 Page 2 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0656 A review of the therapy screen, dated 3/9/2023, revealed the following: Level of Harm - Minimal harm or potential for actual harm Range of Motion/ROM, decreased strength, transfers; Self-care revealed not checked for needing assistance and is self-feed; Safety section revealed - not checked for choking or swallowing. Notes indicated - Recently discontinued from Physical Therapy on 2/14/2023, with no significant change in functional mobility status, no skilled therapy indicated this time. Residents Affected - Few A review of the nurse progress notes revealed the following: 3/9/2023 09:26 mini nutrition - Not suffered psychological stress or acute disease in past three months. Has severe dementia. 3/9/2023 11:44 ADL only - Revealed EATING = Self performance, supervision, support provided and set up help only. 3/14/2023 16:16 Nutrition - Low risk malnutrition. Mech soft and had been eating well +75% some slight decrease in intakes noted past two days. SLP will be working with him. He continues to receive the built-up curved utensil and divided plate and is able to feed self after setting up with minimal assist. 3/19/2023 20:37 - Health status note - CNA updated on oral intake. Able to self-feed his cheesecake on his own but requires assistance to feed any other meals. 3/28/2023 22:14 - Resident has trouble swallowing meds, meds are crushed and placed into pudding to facilitate swallowing, resident holds meds in his mouth until they begin to drool from the mouth. Staff assist with meals, which is very long process related to the time it takes for the resident to swallow. 4/13/2023 19:36 - RD Nutrition note/assessment - Resident had diet downgraded. Diet is NAS mech soft with nectar thick liq. He does receive adaptive equipment for self-feeding efficiency. Has self feeding deficits. 4/21/2023 17:31 Communication with family - Resident requires assist with eating, able to feed self, but slow. A review of the comprehensive care plan, with next review date of 6/7/2023, revealed the following but not limited to problem areas: - Current Functional Performance with interventions in place to include but not limited to: Resident performance EATING - Limited assist/one-person physical assist. - Potential for Aspiration related to diagnosis dysphagia with difficulty chewing and swallowing. Resident is on a modified consistency diet related to history of pocketing food and medication with difficulty swallowing, with interventions in place to include but not limited to: All staff to be informed of special dietary and safety needs, Built up curved utensils and divided plate for all meals. Check mouth after meal for pocketing food and debris. Report to the nurse. Provide oral care to remove debris, Supervise and assist at mealtimes and with nutrition and fluid intake as need, instruct to eat in an upright position, to eat slowly, and to chew each bit thoroughly, Monitor for choking, drooling, holding food in mouth, several attempts at swallowing, appears concerned during meals, 106030 Page 3 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0656 Refer to speech therapist for swallowing eval. Level of Harm - Minimal harm or potential for actual harm - Self Care deficit, needs extensive assist with ADL related to Parkinson's needs assist with meals and adaptive equipment with interventions in place to include but not limited to: Allow for rest periods between ADL tasks, Divided plate, and built-up curved utensils for all meals, provide physical assistance to resident as needed to complete tasks. Residents Affected - Few - Risk for malnutrition due to dementia, limited mobility and elevated BMI potential for weight variance and decline in intake due to Parkinson's, dementia, Alzheimer's, and depression. Significant wt. loss is noted. Needs assistance with set up help for all meals and feeding. Needs adaptive equipment to assist with self-feeding, with interventions in place to include but not limited to: Allow resident ample time to consume food, provide adaptive equipment as ordered each meal. The above listed care plan problem areas indicated Resident #83 should receive both Eating assistance and also the use of adaptive Eating equipment during meals. However, staff were not consistent with following the care plan interventions. On 4/26/2023 at 2:10 p.m. an interview was conducted with Staff B, Speech Therapist, and the Director of Rehabilitation Services (DOR). Staff B stated she was well acquainted with Resident #83 since his admission and was able to state his primary diagnosis of Parkinson's as a condition that will have periodic changes in presentation for his care. Staff B mentioned Resident #83 as a Foody that loves to eat. Staff B stated the resident would need ques to close his mouth at times in order to remind the patient to swallow. Staff B denied pocketing of food was an issue for the resident, and stated the resident had a strong cough response. Staff B stated assistive devices during meals for Resident #83, such as lipped plate with dividers and built-up eating utensils, was an Occupational Therapy plan and not a Speech Therapy plan. On 4/27/2023 at 9:15 a.m. an interview was conducted with Staff C, MDS Coordinator and Staff D, MDS Coordinator. Both were aware of the resident and needs in relation to care and services. Staff C stated she knew Resident #83 was assessed and care planned for Eating- Activities of Daily Living (ADL) and was coded for Limited Assistance with One-person Assistance. She stated a resident who was coded for Limited Assistance with One person Assistance would mean the staff member would indeed need to be present in the room or dining room during the entire time the resident was eating. Staff C and Staff D confirmed Resident #83 was on swallowing and chewing precautions and was being seen on case load from Speech Therapy. Staff C stated Resident #83 should be provided with Limited Assistance with Eating but also should be supervised at all times during his meal service. Staff C and Staff D confirmed Resident #83 was ordered, and care planned for Adaptive Eating equipment to include Built Up Eating utensils and a Divided Plate. They were not aware he did not receive adaptive equipment and he should have and still should receive the equipment with meals. 2) On 4/26/2023 at 7:40 a.m. Resident #36 was observed in his room. lying in bed with Head Over Bed (HOB) approximately 25 degrees, with his head on a pillow. The bed covers were pulled up to his neckline but both hands were exposed. There were no splints or braces on either of his hands. The room was visually free from any splints/braces. On 4/26/2023 at 9:40 a.m. Resident #36 was noted in his bed and lying under the covers with both his hands and arms exposed. Resident #83 was awake and alert. He was not observed with any type of splint or brace on his left hand. Resident #36 was asked about his left hand and if he had any pain. He denied any pain and said, I'm fine. He was asked if he had any special device he wears on his hand 106030 Page 4 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and he said, I'm fine. It was noted that the resident had cognitive deficits and could not be interviewed with relation to his care and services. The room was not observed with any type of splints/braces out in the open, nor placed on his Left hand. On 4/26/2023 at 11:35 a.m. the resident was observed in his room and was in bed. His eyes were observed closed and both of his hands were exposed. He was not observed wearing splint/brace on his Left or Right hand. On 4/26/2023 at 1:30 p.m. and 2:40 p.m. Resident #36 was noted in room and lying in bed. He was not wearing a splint/brace on his Left hand. There were no visible signs of a brace/splint in his room. On 4/27/2023 at 8:10 a.m. Resident #36 was again observed in his room and lying in bed. He was not observed with any splint/brace on his Left hand. The resident was not able to speak with relation to his medical care and services. A brace or any type of splints were not visible within the resident's room. On 4/27/2023 at 9:57 a.m. Resident #36 was noted in his room and seated upright in bed with the covers pulled up to his neckline. An interview was conducted with Staff F, CNA who was assigned to Resident #36. Staff F stated she was familiar with Resident #36 but normally works on another floor stating, I know of Resident, but I work on a different floor. Staff F was able to say Resident #36 was on a Nectar diet and was total care. She stated she was not aware Resident #36 had a contracture. Staff F stated she was not aware of Resident #36 requiring a splint on his left hand. Upon entering Resident #36's room, Staff F greeted the resident and demonstrated that a splint was on his left hand. Staff F did not remember if the splint was on or not when she came on shift this a.m. She also did not know who offered and donned the splint or when it was placed on. Staff F was unable to answer the schedule for splint. Staff F stated the therapy team notifies the nursing staff when a splint is needed. On 4/27/2023 at 10:04 a.m. an interview with Staff E, CNA who also worked with Resident #36 was conducted. She stated she was not aware of who assisted Resident #36 with the split this a.m. She stated perhaps the previous shift placed it on. The resident was observed on 4/27/2023 from 8:10 a.m. through 9:50 a.m. without any splints on his left hand. A review of Resident #36's medical record revealed he was admitted to the facility on [DATE]. A review of the advance directives revealed the resident had a Power of Attorney/POA in place to make his medical and financial decisions. A review of the diagnosis sheet revealed diagnoses to include but not limited to dementia, dysphagia, depression, Alzheimer's, contracture left hand, and peripheral vascular disease. A review of the current Minimum Data Set (MDS) Quarterly assessment, dated 3/30/2023 revealed the following; Cognition/Brief Interview Mental Status/BIMS score - 3 of 15 which indicated the resident would not have been able to speak with relation to his care and services; Activities of Daily Living/ADL - BED MOBILITY = Extensive assist with one person, TRANSFERS = Extensive assist with Two person, EATING = Extensive assist with one person, TOILET USE = Extensive assist with one person, PERSONAL HYGIENE = Extensive assist with one person; Health Condition - Not checked for falls prior to or upon admission; Active dx. Contracture Left hand; Nutrition - not documented for wt. loss, has mechanically altered diet. A review of the current Physician's Order Sheet for the month of 4/2023, revealed the following but 106030 Page 5 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0656 not limited orders: Level of Harm - Minimal harm or potential for actual harm Skin tear to Left elbow cleanse with wound wash, pat dry. Xeroform to wound bed and cover with foam dressing x night shift for wound care with order date 4/26/2023. Residents Affected - Few Skin tear on left arm-Betadine swab to wound bed x evening shift for wound care 7 days with original order 4/26/2023. OT to treat QD x 2 days per week for 30 days for contracture management, orthotics/subsequent, therapeutic exercises, ROM/Strength, patient/caregiver education with original order date 3/30/2023. Resident to wear left hand functional position splint up to 4 hours daily on day shift as tolerated to prevent further contractures with original date 9/13/2022. A review of the nurse's progress notes revealed the following: - 3/23/2023 14:28 - Health Status Note - Resident noted to be having some contractures to bilateral hands, having difficulties in picking up items and needs help with other ADLs and feeding, referral made to OT. - 3/26/2023 11:58 Order note - Resident to wear left hand functional position splint up to 4 hours a day during day shift as tolerated and then palm protector all other times, excluding bathing/hygiene every day shift A review of the nurse's progress notes dating back from 1/30/2023 through to current notes on 4/27/2023, did not indicate any documentation that reflected Resident #36 ever refusing the use of a Left-hand splint. Nor were there any notes reflecting Resident #36 was not comfortable wearing the device. A review of the Occupational Therapy Certification period of 3/29/2023 through to 4/26/2023 assessment and plan of treatment revealed Resident #36 had a preexisting Left-hand contracture and that OT had a plan of treatment for. The assessment revealed treatment approaches may include Subsequent encounter, orthotics/prosthetics use. The goal revealed Resident #36 will improve ability to safely and efficiently perform eating tasks with supervision or touching assistance with use of built-up utensils to ensure adequate nutrition and hydration. The Plan of Treatment section Functional Skills Assessment revealed under Eating; Partial/moderate assistance is able to feed self, however, has difficulty holding regular utensils due to decreased joint flexibility and coordination. The Musculoskeletal System Assessment section Test/UE strength revealed use of Left-hand grip strength, NT due to contracture. The assessment summary revealed; Patient has presence of multiple joint contractures in left hand, elbow, right elbow, wears a palm protector daily which applies. The summary also indicated that Splint/Orthotic Recommendations are to continue with replacement splint for left hand, combined with hand hygiene to maintain skin integrity. The Occupational Therapy Discharge summary, dated [DATE], revealed the resident had been seen on case load for contracture management for the left hand. The Discharge summary revealed the resident met the highest practical level, with interventions to include Contracture management, staff is educated on providing adequate hand hygiene and to don/doff palm protector which is least aggressive to provide partial ROM and maintain skin integrity of left hand to prevent skin breakdown. 106030 Page 6 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0656 A review of the current care plans with next review date 6/8/2023 revealed the following areas: Level of Harm - Minimal harm or potential for actual harm (1.) Impaired mobility and self-care deficit related to weakness, cognitive impairment due to dementia, decreased balance and endurance left hand, with interventions in place to include but not limited to: Palm protector and splint to right hand as tolerated. Residents Affected - Few Note: It was clarified through interview with the Director of Nursing and Interview with the MDS/Care Plan Coordinator Staff C, that the care plan should have indicated the Left hand, not Right hand as the problem area. (2.) Risk for skin impaired skin integrity related to decreased mobility, muscle weakness, incontinence, depression, psychotropic med use, cognitive impairment, repeated falls, Malignant neoplasms right forearm and left dorsal hand, declines further biopsy, contracture left hand, with interventions to include but not limited to: Palm protector and splint to Right hand as ordered. Note: It was clarified through interview with the Director of Nursing and Interview with the MDS/Care Plan Coordinator Staff C, the care plan should have indicated the Left hand, not Right hand as the problem area. On 4/27/2023 at 9:15 a.m. Minimum Data Set/Care Plan Coordinators Staff C and D were interviewed with relation to Resident #36, and both confirmed he had a left-hand contracture and has been seen on case load from OT/PT. Staff C and Staff D the resident does utilize a left hand/palm splint orthotic, and it is the responsibility of the aide to don and doff per the order and care plan. Staff C and Staff D confirmed if a resident refuses to wear the device, it should be noted in progress notes and brought to the attention of the nurse and then ultimately to MDS/Care Planning staff, so they can update with relevant interventions. They were not aware Resident #83 was not offered or assisted with his left-hand splint. Staff C and Staff D confirmed the resident did not currently have any care plan problem areas with regards to refusal of care and treatment, specifically with relation to his contracture management device. On 4/27/2023 at 11:00 a.m. the Director of Nursing provided the Comprehensive Care Plan policy and procedure with a revised date 4/2022, for review. The policy revealed the following: It is the policy of this facility to develop and implement comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under the Policy Explanation and Compliance Guidelines section of the policy revealed, (3) The Comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. (8) Qualified staff responsible for carrying out interventions specified in the care plan will be 106030 Page 7 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0656 notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106030 Page 8 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 review, the facility failed to ensure eating assistance and adaptive eating equipment was provided for one resident (#83) out of twenty-two sampled residents. Residents Affected - Few Findings included: On 4/24/2023 at 12:40 p.m. Resident #83's room was approached and from the hallway, the resident could be seen in his room seated in a high-back wheelchair next to his bed, with the over the bed table positioned in front of him. The resident was noted to be alone in the room with his meal tray placed in front of him. The floor beneath him was observed with what appeared to be a puddle of red liquid. The resident was able to confirm he had dropped some liquid on the ground. Resident #83 was interviewed; he was noted to have to take time to answer general questions about his day. The resident was noted to have some food pocketed within his mouth on both sides. While in the room with Resident #83 from 12:40 p.m. through to 12:52 p.m., no staff were observed to enter the room to assist the resident with his meal. The meal tray was observed to be a non divided plate and both of his eating utensils were regular silverware. A review of the meal ticket on the tray, revealed; Resident #83, Diet - No Added Salt Mechanical Soft texture and Nectar Thick liquids, and AE Curved Utensil/Divided plate. No adaptive eating utensils were observed on the meal tray. Photographic evidence was taken. On 4/26/2023 at 12:40 p.m. Resident #83 was noted in his room and seated in his high back wheelchair next to the bedside. The over-the-bed table was positioned in front of him, and he had his lunch meal tray placed on the table. Staff A, Certified Nursing Assistant (CNA) was observed in the room and standing up in front of the resident with a spoonful of food being brought to his mouth. Staff A was asked if the resident had any adaptive equipment and she explained, No they took that away because he now requires assistance with feeding. The resident was not provided with a divided plate and was not provided with any adaptive built-up eating utensils per the current meal ticket. Photographic evidence was taken. Staff A stated she could not remember the last time he had the eating adaptive equipment. She continued to scoop food from his plate and tried to bring the spoon to his mouth, while standing in front of him. Resident #83 shook his head in a yes manner when asked if he could self-feed. Staff A gave him the spoonful of food item and allowed him to grip the spoon and he brought it to his mouth himself. She explained she needs to make sure she has her hand very close to the eating utensil as he really cannot eat on his own and needs assistance. While Resident #83 brought the spoon to his mouth, there was not any immediate concerns. Staff A was asked if speech therapy was working with the resident and she revealed, Yes, but I forgot her name. The resident then said, Staff B was the speech therapy member, and Staff A then confirmed the same name. On 4/26/2023 at 12:55 p.m. Resident #83's was observed seated in his room with his lunch meal tray placed in front of him. He had already started his meal with assistance from Staff A at 12:40 p.m., however, Staff A was not in the room. Resident #83 was not attempting to eat on his own. His meal tray still had approximately 50% uneaten food items on it. Staff A was observed in the room next door, seated in a chair, and assisting another resident with eating needs. At 1:00 p.m. Staff A was observed to get up from assisting the other resident and go over to Resident #83's room and begin to assist him with his meal. She brought forkfuls of food to his mouth, while allowing him to take bites slowly, and then chew and swallow slowly. At 1:15 p.m., Staff A was no longer in Resident #83's room, and she was again noted in the room next door seated in a chair and assisting the other resident with eating needs. There was no other staff member noted to be assisting Resident #83's during the 106030 Page 9 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal. Resident #83 was not observed to try and eat on his own, but his meal tray was still observed with uneaten food items on it. At 1:20 p.m. Staff A stopped assisting the other resident in the next room and walked back to Resident #83's room to continue to assist him with his eating needs. Resident #83 accepted the food that was brought to his mouth. An interview with Staff A revealed, Resident #83 wanted a break so I ran over to start feeding the other resident and then I will go back and assist him. She stated, There are not a lot of staff on this hallway, and I do the best that I can with all those who require eating assistance. She stated the residents who require eating assistance should have staff in the room during the entire time of the meal service, and to not leave to help others. A review of Resident #83's medical record revealed he was admitted to the facility on [DATE]. The advance directives revealed Resident #83 had a Power of Attorney in place to make his medical and financial decisions. A review of the diagnosis sheet revealed diagnoses to include but not limited to: Parkinson's, dementia, seizures, Alzheimer's, dysphagia, depression, cognition communication deficit, and age-related physical debility. A review of the current Minimum Data Set (MDS) Quarterly assessment, dated 3/9/2023, revealed the following. Speech: Speech clarity section revealed - Unclear Speech, usually understood, understands others; Cognition/Brief Interview Mental Score/BIMS score - 15 of 15; Activities of Daily Living/ADL: EATING activities = Limited Assistance with One person assistance; Swallowing/Nutrition: Not checked for holding food, not checked for loss of liquids, not checked for coughing, or choking, not checked for complaints of pain or problem swallowing; Oral/Dental - Not checked for difficulty with chewing. A review of the 4/2023 order sheet, revealed the following but not limited to: - Extend speech therapy for dysphagia, daily x 3 days x one week x four weeks with order date 4/12/2023. - Please ensure additional assistance to self-feed is provided for resident at meal times. Is able to self-feed but very slowly (also wife's request), x shift with order date 3/24/2023. - No Added Salt diet, Mechanical soft texture, Nectar thick liquids with built up curved utensils and divided plate with order date 3/13/2023. - Speech therapy to evaluate and treat as indicated speech therapy to treat daily x 4 days x one week x four weeks for dysphagia therapy. Downgrade liquid to nectar thick liquid. Continue mechanical software, with order date 3/13/2023. A review of the therapy screen, dated 3/9/2023, revealed the following: Range of Motion/ROM, decreased strength, transfers; Self-care revealed not checked for needing assistance and is self-feed; Safety section revealed - not checked for choking or swallowing. Notes indicated - Recently discontinued from Physical Therapy on 2/14/2023, with no significant change in functional mobility status, no skilled therapy indicated this time. A review of the nurse progress notes revealed the following: 106030 Page 10 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0676 Level of Harm - Minimal harm or potential for actual harm 3/9/2023 09:26 mini nutrition - Not suffered psychological stress or acute disease in past three months. Has severe dementia. 3/9/2023 11:44 ADL only - Revealed EATING = Self performance, supervision, support provided and set up help only. Residents Affected - Few 3/14/2023 16:16 Nutrition - Low risk malnutrition. Mech soft and had been eating well +75% some slight decrease in intakes noted past two days. SLP will be working with him. He continues to receive the built-up curved utensil and divided plate and is able to feed self after setting up with minimal assist. 3/19/2023 20:37 - Health status note - CNA updated on oral intake. Able to self-feed his cheesecake on his own but requires assistance to feed any other meals. 3/28/2023 22:14 - Resident has trouble swallowing meds, meds are crushed and placed into pudding to facilitate swallowing, resident holds meds in his mouth until they begin to drool from the mouth. Staff assist with meals, which is very long process related to the time it takes for the resident to swallow. 4/13/2023 19:36 - RD Nutrition note/assessment - Resident had diet downgraded. Diet is NAS mech soft with nectar thick liq. He does receive adaptive equipment for self-feeding efficiency. Has self feeding deficits. 4/21/2023 17:31 Communication with family - Resident requires assist with eating, able to feed self, but slow. A review of the comprehensive care plan, with next review date of 6/7/2023, revealed the following but not limited to problem areas: - Current Functional Performance with interventions in place to include but not limited to: Resident performance EATING - Limited assist/one-person physical assist. - Potential for Aspiration related to diagnosis dysphagia with difficulty chewing and swallowing. Resident is on a modified consistency diet related to history of pocketing food and medication with difficulty swallowing, with interventions in place to include but not limited to: All staff to be informed of special dietary and safety needs, Built up curved utensils and divided plate for all meals. Check mouth after meal for pocketing food and debris. Report to the nurse. Provide oral care to remove debris, Supervise and assist at mealtimes and with nutrition and fluid intake as need, instruct to eat in an upright position, to eat slowly, and to chew each bit thoroughly, Monitor for choking, drooling, holding food in mouth, several attempts at swallowing, appears concerned during meals, Refer to speech therapist for swallowing eval. - Self Care deficit, needs extensive assist with ADL related to Parkinson's needs assist with meals and adaptive equipment with interventions in place to include but not limited to: Allow for rest periods between ADL tasks, Divided plate, and built-up curved utensils for all meals, provide physical assistance to resident as needed to complete tasks. - Risk for malnutrition due to dementia, limited mobility and elevated BMI potential for weight variance and decline in intake due to Parkinson's, dementia, Alzheimer's, and depression. Significant 106030 Page 11 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wt. loss is noted. Needs assistance with set up help for all meals and feeding. Needs adaptive equipment to assist with self-feeding, with interventions in place to include but not limited to: Allow resident ample time to consume food, provide adaptive equipment as ordered each meal. The above listed care plan problem areas indicated Resident #83 should receive both Eating assistance and also the use of adaptive Eating equipment during meals. However, staff were not consistent with following the care plan interventions. On 4/26/2023 at 2:10 p.m. an interview was conducted with Staff B, Speech Therapist, and the Director of Rehabilitation Services (DOR). Staff B stated she was well acquainted with Resident #83 since his admission and was able to state his primary diagnosis of Parkinson's as a condition that will have periodic changes in presentation for his care. Staff B mentioned Resident #83 as a Foody that loves to eat. Staff B stated the resident would need ques to close his mouth at times in order to remind the patient to swallow. Staff B denied pocketing of food was an issue for the resident, and stated the resident had a strong cough response. Staff B stated assistive devices during meals for Resident #83, such as lipped plate with dividers and built-up eating utensils, was an Occupational Therapy plan and not a Speech Therapy plan. On 4/27/2023 at 9:15 a.m. an interview was conducted with Staff C, MDS Coordinator and Staff D, MDS Coordinator. Both were aware of the resident and needs in relation to care and services. Staff C stated she knew Resident #83 was assessed and care planned for Eating- Activities of Daily Living (ADL) and was coded for Limited Assistance with One-person Assistance. She stated a resident who was coded for Limited Assistance with One person Assistance would mean the staff member would indeed need to be present in the room or dining room during the entire time the resident was eating. Staff C and Staff D confirmed Resident #83 was on swallowing and chewing precautions and was being seen on case load from Speech Therapy. Staff C stated Resident #83 should be provided with Limited Assistance with Eating but also should be supervised at all times during his meal service. Staff C and Staff D confirmed Resident #83 was ordered, and care planned for Adaptive Eating equipment to include Built Up Eating utensils and a Divided Plate. They were not aware he did not receive adaptive equipment and he should have and still should receive the equipment with meals. On 4/27/2023 at 10:00 a.m. the Director of Nursing (DON) provided the Activities of Daily Living (ADL) policy and procedure with a revised date of 4/2022 which revealed the following: The Policy stated, the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. (#4) of the policy revealed; Eating to include meals and snacks. The Policy Explanation and Compliance Guidelines revealed the following but not limited to: (#1) Conditions which may demonstrate unavoidable decline in ADLs include: a. Natural progression of the resident's disease state with known functional decline, b. Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities, c. Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment; counsel and/or offer alternatives to the resident or representative. 106030 Page 12 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0676 (#3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal oral hygiene. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106030 Page 13 of 14 106030 04/27/2023 Westminster Point Pleasant 1533 4th Ave W Bradenton, FL 34205

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide care consistent with professional standards of practice related to following physician orders for oxygen therapy for one resident (#52) out of two sampled residents for respiratory care. Residents Affected - Few Findings included: A review of the admission Record for Resident #52 showed she was initially admitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation and chronic respiratory failure with hypercapnia. A review of the Minimum Data Set (MDS) assessment, dated 04/11/23, revealed in Section C Cognitive Patterns, Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 out of fifteen indicating cognitively intact. Section O Special Treatments, Procedures, and Programs indicated Resident #52 was on oxygen while a resident. A review of the Order Summary Report with active orders as of 04/27/23 revealed the following order: -continuous oxygen at 2 liters per minute via nasal cannula every shift (01/17/23). A review of the Treatment Administration Record (TAR) for 04/01/23 to 04/30/23 revealed continuous oxygen was administered at 2 liters per minute via nasal cannula every shift. A review of the care plan for oxygen therapy initiated 12/13/22 showed an intervention to apply oxygen as ordered. On 04/24/23 at 11:52 a.m., Resident #52 was observed in bed in her room with the oxygen nasal cannula below her nose. She adjusted the nasal cannula when asked if she was breathing ok and stated no. The oxygen concentrator was observed at 3.5 liters per minute. On 04/25/23 at 1:56 p.m., Resident #52 was observed in bed in her room. She was wearing the oxygen nasal cannula appropriately and the oxygen concentrator was observed at 3.5 liters per minute. On 04/26/23 at 11:26 a.m., Resident #52 was observed in bed in her room. She was wearing the oxygen nasal cannula appropriately and the oxygen concentrator was observed at 3.5 liters per minute. On 04/26/23 at 11:28 a.m., Staff G, Licensed Practical Nurse (LPN), stated the oxygen concentrator should be set at 2 liters per minute per orders. She had never observed the resident adjusting the oxygen concentrator. Staff G, LPN, went into the room and confirmed the oxygen concentrator was set at 3.5 liters per minute and should have been set at 2 liters per minute. 04/27/23 09:15 a.m., the concern was presented to the Director of Nursing (DON). She did not state her expectations when asked but voiced that it would be fixed immediately. On 04/27/23 at 9:20 a.m., a policy related to following physician orders was requested, but not provided. 106030 Page 14 of 14