Health inspection·February 21, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with facility staff and family members, the facility failed to notify the Resident Representative (RR) of a significant change in the resident's health status that resulted in acute care for one (Resident #1) of three residents reviewed. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, major depressive disorder, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An SBAR (Situation Background Assessment Recommendation) form dated 1/14/24 at 8:50 p.m., showed the resident presented with nausea, vomiting, labored or rapid breathing and shortness of breath which had gotten worse. The form did not indicate that family or RR were notified. A physician note dated 01/14/24 9:04 p.m. showed under description: OBC (outbound call to family. I reported the CIC (change in condition and the orders put in place. She (RR) was upset that the facility did not call her. She stated she was visiting her mother earlier and she ate well. Nurses physical exam findings showed cold, clammy, restless, abdomen s/nt. (soft non-tender) lungs with crackles. A transfer form for Resident #1 dated 01/14/24 showed at 9:30 p.m., the [AGE] years old female was found unresponsive. Documentation showed the resident had noted emesis x 3, food and stomach contents, slight SOB (shortness of breath with POX (pulse oximetry) of 86%. Orders had been received and while administering, the resident became unresponsiveness with no heart rate or respirations. CPR (cardiopulmonary resuscitation) was initiated. Resident was transferred to the Emergency Department. An event note dated 01/14/24 showed Resident noted with emesis x 3 this evening around 8:40 p.m. appeared as just stomach contents and food. Resident then noted with mild SOB, POX 86% on RA with crackles noted to BUL. Vitals were obtained: 106/60, 90, 22, 98.2 F, O2 placed at 2 Liters via NC (nasal cannula) and on call ARNP (Advanced Registered Nurse Practitioner) was notified and new orders were received. The note did not indicate that family or RR were notified. An interview was conducted with the Resident Representative (RR) on 2/20/24 at 11:03 a.m. She stated, That day (01/14/24) me and [a family member] were there. We had breakfast with her. [She] ate, she loved pancakes. She was fine. We spent time with her, went home and then in the early afternoon we brought her dinner. She ate, then [the family member] and I left , we went home. I received a call Page 1 of 5 106049 106049 02/21/2024 Life Care Center of New Port Richey 7400 Trouble Creek Road New Port Richey, FL 34653

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 9:14 p.m. from the ARNP which was very shocking because there was nothing wrong with her when we left earlier. The facility did not call to say she had been sick since 5:30 p.m. They were adamant, they kept repeating she was fine and did not have reason to call. After the fact, I became aware she had been sick. I told the nurse practitioner I did not get a call and yet she had vomited 3 times and she had low oxygen. The ARNP said he was going to order an IV (intravenous). I told him I was on my way to the facility. The ARNP said to me, 'I don't know why they did not call you at the onset of the first vomiting' . A little later, a CNA (certified nursing Assistant) called me. The call came in about 9:19 p.m. It was canceled at 9:20 p.m. At 9:33 p.m. she called again and said 'where are you it's a code blue. I said it was 911.' By the time I arrived, they were doing CPR. It was too late. A CNA reported to the RR that the resident had been sick since 5:20 p.m. or 5:30 p.m. she said, .My concerns were and still are the response time to an emergent situation. She was suffering for 4 hours. I still can't get them to tell me why they never called 911 when she showed shortness of breath at the beginning, and this was not her norm. I don't know why they did not call me. I got a call from the ARNP telling what he was about to do . On 2/20/24 at 2:37 p.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN). He stated he worked alongside Staff A, (Registered Nurse, RN) who was assigned the resident. He stated he was there when the RR arrived at the facility. Staff G said, . as I was walking back from unlocking the front door. I told her, her mother had stopped breathing, and we were doing CPR. This was the first time she knew there was a serious problem. She had decided to come and check on her mother because the doctor had called her with new orders. She [the RR] didn't have a response, she was stoic, bland, no reaction at all, she was in shock. I believe it was because she had just been with her mother a few hours earlier. We walked to the hallway together.Regarding contacting the family Staff G said, Anyone can call the family or the physician especially during an emergency. Someone should have called the family to let them know when the vomiting did not stop. I would have called if I knew the nurse had not called. On 2/20/24 at 3:05 p.m., an interview was conducted with Staff B, CNA. She stated she was not the assigned CNA. She went to help Staff E who was the CNA assigned. She said, I went there with dinner tray. I found she was throwing up. It was around 5:20 p.m. [Staff E] asked me to pass trays as she cleaned her up. After that first incident, she started going up and down, on the bed and on the chair. She could not sit still. She was still throwing up. [Staff E] notified the nurse. The nurse [Staff A] came checked vitals. I had never seen the resident like that before. Her face was sweating, and she was cold. I talked to her. She said, 'I don't feel good.' She did not eat her food. This was not like her. She continued to throw up and gag. Staff E notified Staff A. [Staff A] came and did vitals. She said to put her back to bed. She said she will call the doctor. I told the nurse you should call the daughter and let her know she is throwing up. The daughter will tell you what to do. The nurse said she will take care of it. Staff B confirmed between her and Staff E, the resident threw up 3-4 times starting at approximately 5:20 p.m., and each time they changed and notified Staff A. On 2/21/24 at 2:15 p.m., an interview was conducted with Staff E, CNA. Who was assigned to the resident. She said, I remember around 4:00 p.m. to 4:30 p.m. the family came with food, and she ate. At first it was a normal routine. When I went to pass trays in my hall, around 5 p.m., [Staff B, CNA) who was helping me pass trays said she was vomiting. [Staff B] continued to pass trays while I took care of her. I cleaned her hair and everything. I told the nurse. I told her that she said she was not feeling good, and she was vomiting. For the next, maybe 2 hours, she [Resident #1] vomited several times. I remember I changed her at least 3 times. I was concerned because she started to show confusion. She did not understand me when I spoke with her. We normally talk all the time. She was out of control. She was 106049 Page 2 of 5 106049 02/21/2024 Life Care Center of New Port Richey 7400 Trouble Creek Road New Port Richey, FL 34653

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shaking. She said she felt terrible. I tried to get her comfortable. She kept going back to chair and bed. I, [Staff A] and [Staff B] kept an eye on her. She was weak and restless. The nurse was informed. We were scared she would vomit and slide on her vomit and fall and hurt herself. I kept redirecting her to chair. She was not able to stop herself. I told the nurse myself like maybe 2-3 times. I kept telling the nurse of her symptoms, like she was cold and then sweating. She was up and down. I told her she does not feel good. The nurse kept saying to check vitals. I would not have called family, it is the nurse's job. I tried to give her the best care. I tried my best. I had 12 patients, so I went back and forth. I was very sad. On 2/21/24 at 12:02 p.m., an interview was conducted with Staff L, LPN. She stated a change in condition was anything that changed in the resident's mental or physical status. She said if there was anything related to a fall, skin condition, not eating, sick, or a change in mental status, change in the usual response, they would take vitals, and then contact physician and family. She stated this should be followed with documentation, a progress note and complete the CIC form in the [electronic record]. An interview was conducted with the Regional Nurse Consultant (RNC) on 2/21/24 at 1:55 p.m. She stated the nurse should have notified the family when the first emesis was reported. She stated the nurse could have alerted the family that the resident was throwing up the food they had given her. Yes, this was the beginning of the change. The nurse should have called them. On 2/21/24 at 3:21 p.m., an interview was conducted with the Director of Nursing (DON). She stated, A Change in Condition (CIC) meant the nurse should document a CIC form in the resident's record when there was changes in the resident's status. She stated it should show changes that the resident had experienced or was experiencing. It should show anything that was out of their norm. Examples included abnormal labs, abnormal vitals, if they are not eating/sleeping if they are sick. The DON said, Yes, if they are throwing up. The DON confirmed the nurse should have reached out to the family when she was notified of the change. She stated she had educated the one nurse, and they were doing education for all nursing staff. Review of a facility policy titled, Changes in Resident's Condition or Status, revised on 08/09/23, This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the residence condition or status. Notifications of changes included . (B). A significant change in the residence physical, mental, or psychosocial status.(that is, deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications.) 106049 Page 3 of 5 106049 02/21/2024 Life Care Center of New Port Richey 7400 Trouble Creek Road New Port Richey, FL 34653

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure timely assistance was provided for ADLs (Activities of Daily Living) for one (Resident #2) of two sampled residents reviewed. Residents Affected - Few Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses to include emphysema and unspecified dementia. A review of the care plan for Resident #2 showed a goal revised on 2/16/23, indicating the resident required ADL assistance and therapy services needed to maintain or attain highest level of function. Interventions included: assist with mobility and ADL's as needed, therapy services as ordered. During a facility tour on 02/20/24 at 11:15 a.m., the hall outside Resident #2's room was noted with a strong bowel (BM) movement odor. Resident #2 did not respond to the interview. An attempt to locate the Certified Nursing Assistant (CNA) or the Nurse assigned to this hall was unsuccessful. On 02/20/24 at 11:18 a.m., an interview was conducted with Staff M, Licensed Practical Nurse ( LPN.) She was observed across the hall. She stated she was not assigned to this hall but would take care of the problem. Staff M walked with surveyor to the area and confirmed a strong BM odor. She stated their expectation was to ensure their residents were changed in a timely manner. She stated she was not sure where the odor was coming from. She said, it could be one of the residents here who have a colostomy bag. It could be, we will check. Yes, the resident needs to be changed and cleaned up. On 2/21/24 at 11:38 a.m., an interview was conducted with Resident #2's family member. She stated she had care concerns for [Resident #2]. She said, a couple days ago she came in and noticed he had spilled soup on himself and was not cleaned up. It had started to dry on him. Yesterday, 02/20/24, no one changed him. You could smell bowels on him. The family member stated she left the facility before 2:00 p.m. and the resident was soiled. She stated she spoke to a staff member. The staff member said she would take care of it. The family member stated she believed the staff member was the CNA (Certified Nursing Assistant) in the hall. She stated when she returned to the facility around 5:30 p.m., he was still soiled. She stated he could hardly eat. She stated she spoke to another staff member and left shortly after 6:00 p.m. The family member stated no one had come to the room at the time. A review of the CNA task log for Resident #2 for 02/20/24 showed concerns with toileting. There was no documentation to show the resident was checked or changed from 1:16 p.m. to 9:33 p.m. On 2/21/24 at 3:24 p.m., an interview was conducted with Staff K, CNA. She stated she was assigned to Resident #2 on 02/20/24. She stated upon arrival on her shift she conducted rounds to see if the residents needed to be changed. She said, If they do, I clean them up. I usually document as I go. Yesterday, I did not get a chance. I was running behind. I think I checked on him probably around 4:30 pm. He had large BM. I changed him. He had loose stools. He was with his family member at dinner time. I did not go in there. [The family member] left around 5:15 p.m. I usually change the residents every 2 hours. I should document each check and change. I know it looks bad. 106049 Page 4 of 5 106049 02/21/2024 Life Care Center of New Port Richey 7400 Trouble Creek Road New Port Richey, FL 34653

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/21/24 at 2:30 p.m., an interview was conducted with Staff J, LPN. She stated she worked with him on 2/20/24 on the 7:00 a.m. to 3:00 p.m. shift. She stated she worked with him when the aide was doing vitals and he had become combative with the aide. She stated the appropriate response was to get gentle with him. She stated the CNAs document each check and change. Staff J reviewed the Electronic Medical Record (EMR) for the resident. She confirmed toileting was documented at 8:02 a.m., 11:57 a.m. and 13:16. and then 21:33. There was no evidence the resident was toileted from 1:16 p.m. to 9:33 p.m. The nurse said, I can't speak to an 8 hour the gap. They should document each incident of toileting or even checking. The facility expectation was to check residents every 2 hours and more often if needed. She said she could not remember if she noted foul odors or not. She said, I just don't remember. I think I would. On 2/21/24 at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). She reviewed the resident's documentation. There was no evident the resident was toileted for more than 8 hours. She said, We have started education with the CNA over the telephone and face to face when she gets here. The CNAs should clean up the resident and then document right after. She stated she reviewed the task log and did not see evidence of care. She said, I do know that CNAs sometimes wait to chart at the end of their shift. I can't prove it. She should have documented if she provided the care. Review of a facility policy titled, Activities of Daily Living (ADLs, Revised 02/12/24, showed the resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform will be reported to the nurse. 106049 Page 5 of 5