Health inspection·June 11, 2021

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and a review of the facility policy, the facility failed to ensure allegations related to verbal, physical, and sexual abuse were reported immediately to the governing agency in accordance with the State law for five residents (#133, #72, #3, #56 and #7) out of the sampled 40 residents. Findings included: 1. A review of the admission Record revealed that Resident #133 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, and bipolar disorder with current episode manic severe with psychotic features. Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #133 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired. Section E Behaviors indicated that the resident had verbal behavioral symptoms directed toward others for one to three days per week. A review of the progress notes revealed the following: 04/08/21 17:29 (5:29 p.m.) The police arrived to take the resident because she was a danger to other resident; 04/08/21 16:26 (4:26 p.m.) The police were contacted to [NAME] Act the resident due to behavior problems; 04/08/21 12:22 [Resident #133] was using her walker to try to push another resident down. She made two attempts; 04/08/21 12:05 [Resident #133] was observed nudging another resident with her walker; 04/07/21 14:56 (2:56 p.m.) The resident was noted yelling out to the gentleman across the hall to come into her room several times and she was also noted in room [ROOM NUMBER] sitting on the bed kissing the resident; 04/05/21 13:48 (1:48 p.m.) [Resident #133] was observed in hallway and took her walker and started ramming it into another resident; 04/04/21 15:23 (3:23 p.m.) The resident appeared to be showing interest in one of the male Page 1 of 9 106033 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0609 residents on the unit and another resident who was walking down to the restorative area; Level of Harm - Minimal harm or potential for actual harm 03/02/21 15:19 (3:19 p.m.) [Resident #133] was standing over her roommate (#72) yelling at her. Residents Affected - Some The care plan initiated 04/06/21 indicated that Resident #133 displayed episodes of inappropriate sexual behaviors of attempting to touch staff and/or residents' private areas and sexual comments to staff and/or residents. The interventions included but were not limited to provide for the safety of other residents. The Certificate of Professional Initiating Involuntary Examination dated 04/08/21 revealed that Resident #133 had erratic behaviors and impulses that escalated over the last few weeks. The resident was aggressive and had pushed down an elderly patient. Resident #133 was also trying to touch a male resident in private areas. The resident had been hypersexual. Resident #133 was also pushing her walker into others. On 06/11/21 at 5:07 p.m., the Director of Nursing (DON) stated that Resident #133 was manic schizophrenic. Resident #133 shared a room with Resident #72. Resident #72 stated she opened her eyes and Resident #133 was standing over her yelling and using profanity. On the day Resident #133 was baker acted (4/08/21) she tried to ram a resident with her walker. There was a staff member that stopped Resident #133 from hitting the resident. She was also baker acted because she attempted to touch Resident #3's private area. Resident #133 would get up and pace up and down the hallway daily. Resident #3 was in the restorative area. Resident #133 liked Resident #3 and she thought that they were a couple. Resident #133 attempted to touch Resident #3's private area, but she did not touch him. There was a restorative aide that came over and stopped her and asked her to go to her room. Resident #3 just laughed and smiled about it. The DON reported that while a staff member was on the medication cart, Resident #133 passed by her and touched her on the bottom and breasts. Resident #133 was trying to push her walker into others. The DON stated she did not report the incidents because Resident #133 didn't touch the residents that she only attempted too. A review of the admission Record revealed that Resident #72 was admitted to the facility on [DATE] with diagnoses of legal blindness and major depressive disorder. Section C Cognitive Patterns of the MDS dated [DATE] indicated that Resident #72 had a BIMS score of 12 out of 15, indicating the resident was moderately impaired. A review of the admission Record revealed that Resident #3 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, anxiety disorder, and schizophrenia. Section C Cognitive Patterns of the MDS dated [DATE], indicated that the resident had a BIMS score of 05 out of 15, indicating severe impairment. On 06/11/21 at 5:26 p.m., Staff F, Physician Assistant, reported that Resident #133 was starting to show signs of manic episodes. She was concerned she would lash out at someone. Staff F reported that Resident #133 had touched a staff member inappropriately. She touched the nurse's breast. She kept lingering around the male residents. Resident #133 was showing behaviors like she was sexually promiscuous. On 06/11/21 at 6:15 p.m., the DON stated she was not made aware of Resident #133 kissing another resident. She stated that she did not do an investigation and did not report it. On 06/11/21 at 6:20 p.m., Staff G, Licensed Practical Nurse (LPN), reported the resident (#133) was 106033 Page 2 of 9 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some doing fine and suddenly, she walked up behind her and asked her if she could feel or touch her breast. Staff G stated she told her that it was inappropriate. Resident #133 came back down the hall and grabbed her buttocks and she told her that that was inappropriate and not to touch her again. Staff G stated that Resident #133 likes to take over the hallway with her walker. Staff G reported that Resident #133 was sitting in the restorative room with a male resident (Resident #3) and kissed him. She stated that she probably reported it to a supervisor. Staff G stated she reported it to someone but was not sure who she reported it to. 2. The Grievance/Concern Report dated 05/02/21 revealed that Resident #56 stated he woke up with his roommate next to him touching his leg. He asked Resident #7 to step away and he stepped away. He was not sure if he was trying to wake him up. On 06/11/21 at 12:49 p.m., Resident #56 reported that he was asleep and woke up to his roommate's hand on his upper thigh. The resident stated he told Resident #7 to get away from him. Resident #56 stated that Resident #7 did not say anything and just walked away. A review of the admission Record revealed that Resident #56 was admitted into the facility on [DATE] with diagnoses that included a history of traumatic brain injury and cognitive communication deficit. Section C Cognitive Patterns of the annual Minimum Data Set (MDS) dated [DATE] indicated that Resident #56 had a BIMS score of 14 out of 15 indicating the resident was cognitively intact. Section E Behaviors indicated that the resident did not have any behaviors. A Psychiatric Evaluation completed on 05/05/21 indicated that staff requested the resident to be seen due to recent a grievance made. Patient (#56) reported that another resident (#7) inappropriately touched him. Staff reports no behavioral issues, agitation, or aggression. There are no reported signs of psychosis including delusions, hallucinations, paranoia, or self dialogue. Patient stated he feels better now that he is in a different room from his previous roommate. A review of the admission Record revealed that Resident #7 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and bipolar disorder. Section C Cognitive Patterns of the annual MDS dated [DATE] indicated that Resident #7 had a BIMS score of 14 out of 15, indicating the resident was cognitively intact. On 06/11/21 at 10:49 a.m., the Social Services Director (SSD) reported that she was made aware of the grievance filed by Resident #56. The grievance was initiated by Staff H, Registered Nurse (RN), Weekend Supervisor. The SSD reported that she was informed that Resident #56 requested a room change because Resident #7's roommate touched his leg while he was sleeping. The Administrator and DON conducted the investigation. On 06/11/21 at 11:03 a.m., the DON reported that the incident happened on the weekend. Resident #56 reported that he felt a touch on the thigh that woke him up. Resident #56 stated he thought the roommate touched him. The DON reported that Resident #7 gets up through the night and paces and does not sleep. Resident #56 stated he was uncomfortable and wanted to change his room. The DON reported that she did not speak with any other residents because he does not go to other patients' rooms, and he does talk to any other residents. The DON stated that she did not report the incident to the governing agencies in accordance with State Law. 106033 Page 3 of 9 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 06/11/21 at 1:21 p.m., Staff F, Physician Assistant, stated that Resident #56 reported to her that when he woke up Resident #7's hand was on his leg. Staff F stated that Resident #56 stuck to his story and did not change his story. On 06/11/21 at 3:53 p.m., the Administrator reported if Resident #56 stated that the touching was inappropriate, he would have called it in and notified the family. On 6/11/21 the Assistant Director of Nursing provided the reportable logs for review from January 2021 to March 2021 and confirmed the facility had no reportables since March 2021. The policy titled, Abuse Investigation and Reporting revised July 2017 indicated the following: All reports of resident abuse, neglect exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman c. The Resident's Representative of Record; d. Adult Protective Services; e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: a. Two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b. Twenty-four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. 106033 Page 4 of 9 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the plan of care for one resident (#61) out of 40 sampled residents was updated to reflect the use of a mechanical lift for transfers. Findings included: An observation was conducted on 06/09/21 at 2:05 p.m. in Resident #61's room of Staff E, Certified Nursing Assistant (CNA) transferring Resident #61 into bed using a mechanical lift. The resident was suspended in the air by a sling and being moved to his bed from his wheelchair, which was positioned a few feet away from the foot of his bed. Staff E was the only staff member in the room and was performing the transfer alone. Staff E said that she knew she was supposed to have two staff members present to perform transfers with a mechanical lift but, said she had been in the middle of weighing the resident using the lift when he requested to go to bed. Staff E confirmed that she had also performed the task of weighing the resident using the lift by herself without assist of another person and stated, because I work alone. Staff E confirmed that she had been trained by the facility that two trained staff members were required to perform transfers using a mechanical lift. Review of Resident #61's medical record revealed that he had been admitted to the facility on [DATE] with diagnoses that included hemiplegia (loss of strength or paralysis on one side of the body following a stroke. The most recent Minimum Data Set (MDS) completed 05/07/21 revealed a Brief Interview for Mental Status (BIMS) of 13, which meant that the resident was cognitively intact. The MDS also revealed that the resident was totally dependent on the physical assist of two or more persons for all transfers. The CNA task list revealed only the following information regarding transfer status: Res. (resident) has rt (right) sided weakness .Res. needs assist with bed mobility and transfers. Resident #61's care plan initiated on 2/23/21, revealed a focus area for fall risk that included only the following interventions related to transfers: Supervise during transfers .assist as needed .Provide hands on assist with transfers . Physical Therapy documentation dated 6/10/21 revealed that the resident was Dependent for transfers. An interview was conducted with the facility Director of Nursing (DON) on 06/11/21 at 12:33 p.m. Regarding Resident #61's transfer status and she said, I think he's a two people transfer. She consulted the medical record and said, I see here he's a [mechanical] transfer .no wait .here it's saying requires staff assist to transfer, what I'm not seeing is how many staff or lift. The DON confirmed that the plan of care did not reveal that a mechanical lift should be used to transfer the resident, and that it was not listed on the CNA informational task list and should have been. She said, when they weigh him, they use the [mechanical] lift because it has a scale on it .should always be two people when using the lift because anything can happen. The DON said, if lift is being used it needs to be reflected in the record .why it is being used, needed .that is something they (CNAs) need to let the nurse know so we can see if change in condition and update it in the care plan. The DON stated that the process should have been for a CNA to tell a nurse that a lift was needed to transfer Resident #61 which would have triggered a Physical Therapy evaluation of his transfer status, a change to the Minimum Data Set (MDS), update to the CNA task list, and update to the care plan. The DON confirmed this process should have happened for Resident #61. A review of facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016 106033 Page 5 of 9 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed, 13. Assessments of residents are ongoing and care plans are revised as information about the resident s and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition . A review of the facility policy titled, Lifting Machine, Using a Mechanical revised 07/2017 revealed: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 106033 Page 6 of 9 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-eight medications were observed administered and two errors were identified for two residents (#2 and #51) of three residents observed. These errors constituted a medication error rate of 7.14% percent. Residents Affected - Few Findings included: An observation of second floor medication administration on 6/10/2021 at 8:15 a.m., resulted in Staff A, Licensed Practical Nurse (LPN), not providing Resident #2 with water to rinse her mouth after she was administered Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH, after she took one puff from the inhaler. An immediate interview was conducted at 8:29 a.m., with Staff A who stated, She (Resident #2) usually drinks water after I give her the medication. The medication label printed by the pharmacy read Rinse mouth after use. Record review of the active physician orders for June 2021 for the Resident #2 read, Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG, 1 Puff inhale orally one time a day. A further record review for Resident #2 indicated she was admitted on [DATE] with multiple diagnoses that included Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (COPD). On 06/10/2021 at 9:38 a.m., an observation was conducted of Staff B, LPN administering medication to Resident #51. During the administration late medication of Humalog Solution (Insulin Lispro) Inject 3 ml (milliliters) subcutaneously with meals for Diabetes to be administered at 08:00 a.m. the screen on Electronic Medication Record (EMAR) was red denoting a late medication in the EMAR. Staff B was asked why the medication was not administered, and she indicated that she arrived at the facility for assignment at 9:00 a.m. and could not sign into the computer until 9:15 a.m. She further revealed that she would mark on the EMAR a hold noted by code 5, for the insulin medication, and call the physician. During an immediate record review and reconciliation of medications observed to be administered to Resident #51 by Staff B, it was determined that the following medication was not administered; Humalog Solution (Insulin Lispro), To Inject three (3) ml subcutaneously with meals for Diabetes to be administered at 08:00 a.m. with meals, which was not provided and administered during breakfast meal for Resident #51. An interview was conducted with the Assistant Director of Nursing (ADON), and Staff C, LPN/Unit Manager (UM) on 06/10/2021 at 11:17 a.m. The ADON and UM were notified of the medication administration observations made of Staff A, LPN for Resident #2, and of Staff B, LPN for Resident #51. The UM stated, The instructions on the medications need to be read a little more carefully. The ADON revealed that the facility needs to educate the nursing staff further related to medication administration. The ADON further stated, My expectation is that all medications are to be given on time. On 6/11/2021 at 1:05 p.m., a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated, All meds (medications) are to be given on time and the insulin medication should have been given with meals. 106033 Page 7 of 9 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0759 A facility provided policy titled, Administering Medications, revision date April 2019, read under Policy Heading, Medications are administered in a safe and timely manner, and as prescribed. Level of Harm - Minimal harm or potential for actual harm Policy Interpretation and Implementation Residents Affected - Few 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.) 106033 Page 8 of 9 106033 06/11/2021 Vivo Healthcare St Petersburg 521 69th Ave N Saint Petersburg, FL 33702

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based upon observation, interview, and record review the facility failed to appropriately secure medications in two medication carts (2W and 2E) of four medication carts. Findings included: A review of the facility's policy and procedure titled, Storage of Medications, effective November 2020, included under Policy Heading: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Under Policy Interpretation and Implementation was included: 2. Drugs and biologicals shall be stored in the packaging containers or other dispensing systems in which they are received. On 06/10/21 at 3:47 p.m. an observation of the medication cart on 2W included one loose white pill, and a clear gel capsule located in the second drawer from the top of the medication cart. Staff B, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured tablets. On 06/10/21 at 4:00 p.m. an observation of the medication cart on 2E included one white loose tablet in the second drawer, and one yellow round tablet in the third drawer from the top of the medication cart. Staff D, LPN confirmed the presence of the unsecured medications. (Photographic Evidence Obtained) On 06/10/21 at 4:23 p.m., an interview with the Director of Nursing (DON) was conducted, and the DON was informed of the observations made of the medication carts located on the second floor of the facility. She stated, There should be no loose medications in the med carts. On 06/11/21 at 1:05 p.m., a telephone interview was conducted with the pharmacy consultant. During the interview, the Pharmacy Consultant stated, The nurses are supposed to be checking medication carts for loose pills. 106033 Page 9 of 9