Health inspection·March 30, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and facility record review, the facility failed to maintain a clean, sanitary and homelike environment related to 1. unclean surfaces and resident equipment in two community shower rooms (first floor and second floor) of two community shower rooms, 2. a stained privacy curtain, an unclean floor and air conditioning vent as well as missing caulking in one resident room and bathroom (room [ROOM NUMBER]), and 3. broken and missing floor and wall tiles in one out of one laundry room for four days (3/27/2023, 3/28/2023, 3/29/2023, and 3/30/2023) of four days observed. Findings included: 1. The first-floor community shower room was observed on 3/30/2023 at 9:20 a.m. and 12:00 p.m. with black bio growth along the tile grout lines on all three sides of the floor. The floor tiles leading to the drain on one side were cracked and had black bio growth on them. The shower chair had a brown oxidized area around the white plastic tubing joints of the shower chair on four of four wheels. The joints on the shower chair had pink bio growth around them. The bathtub had a large yellowish colored ring on the inside of the tub wall under the faucet, and within that spot was a large ring and a brown substance that ran from the drain up about half the side of the wall, under the faucet. In addition, surrounding the drain a green hairy bio growth was observed. (Photographic Evidence Obtained) The second-floor community shower room was observed on 3/30/2023 at 9:30 a.m. and 12:15 p.m. and revealed the shower stall floor had numerous spots of black bio growth in the grout, especially where the floor meets the wall tiles. The drain had a porous surface with black bio growth around the outside edge. The four shower chair wheels had an oxidized brown substance where the wheels met and connected. All of the joints of the chair had pink bio growth surrounding them. The shower bed cushion was raised and underneath this cushion was a mesh area that held the cushion in place. Approximately three feet of this mesh area had pink, yellow and brown substances along the mesh, and areas of the mesh had clumps of hair and hair strands throughout the mesh base. The bathtub had a white expandable tube, which had hair and black bio growth on it. A hair pic and other miscellaneous resident equipment were observed covered in dust. (Photographic Evidence Obtained) 2. Resident room [ROOM NUMBER] was observed on 3/27/2023 at 10:50 a.m., 3/28/2023 at 2:30 p.m., 3/29/2023 at 11:00 a.m., with black bio growth on the outside vents to the air conditioner window unit, directly next to the bed B. The room privacy curtain in between bed A and B was stained with several lines of a yellowish liquid, the call light and phone cord were laying on floor and had dirt/dust on them. The room floor between bed A and B had a sticky substance that had no color. A floor mat was observed up against the wall in between bed A and B with dirt and drops of a liquid over the Page 1 of 31 106103 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some entire surface. In addition, the bathroom floor had missing tile(s) and the caulking at the toilet bowl base was cracked and absent in some areas. (Photographic Evidence Obtained) On 3/30/2023 at 11:30 a.m. an interview was conducted with Staff F, Housekeeper. She stated she cleans (sweeps and mops) the shower and resident rooms one time per day. She stated resident equipment is cleaned on a weekly basis. If they are unable to get a mark up, they utilize a degreaser and other chemicals. If something needs repair, I will notify my supervisor. On 3/30/2023 at 11:31 a.m. an interview was conducted with Staff G, Housekeeping Account Manager. Staff G stated his expectation for the cleaning of the shower and resident rooms is that they are completed daily, and weekly for cleaning of resident equipment. He stated the certified nursing assistants (CNAs) complete the cleaning of resident equipment, after each resident's use. If repair is needed for something, an entry is placed in the maintenance log book for follow up. On 3/30/2023 at 11:32 a.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She stated the expectation for resident equipment cleaning is after each resident use with a disinfectant. On 3/30/2023 at 11:33 a.m. an interview was conducted with Staff H, CNA. She stated she cleans the shower chair after each use with bleach wipes. If there is an issue, we report it in the maintenance book. Staff H went into the second floor shower room and stated, It always looks like this. She indicated they (CNAs) wipe off the equipment after resident usage. A review of the facility's policy and procedure titled, Housekeeping In-Service 5-step Daily Patient Room Cleaning, dated 1/1/2000 revealed: To show housekeeping employees the proper cleaning method to sanitize a patient's room or any area in the healthcare facility. The 5-Step patient cleaning procedure consisted of: 1. Empty Trash 2. Horizontal Surfaces to include work clockwise around the room hitting all surfaces. Clean tabletops, headboards, windowsills, chairs - should all be done. 3. Spot Clean walls 4. Dust mop areas to include the entire floor, especially behind dressers and beds, all corners and along all baseboards must be dust mopped to prevent buildup. 5. Damp map areas to include the floor and most important area of a patient's room to disinfect the floor. A review of the facility's policy and procedure titled, Housekeeping In-Service 7-step Daily Washroom Cleaning, dated 1/1/2000 revealed: To show Housekeeping employees the proper method to sanitize a washroom bathroom in a long-term care facility. The 7-Step patient Washroom Cleaning procedure consisted of: 1. Check Supplies 106103 Page 2 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0584 2. Empty Trash Level of Harm - Minimal harm or potential for actual harm 3. Dust mop floor, as with the trash, always dust mop the floor before you bring any water into a room. A dust mop will stick to the floor if you spill or drip water when cleaning sinks. Residents Affected - Some 4. Clean and Sanitize Sink and Tub, 5. Clean and Sanitize Commode 6. Spot Clean Walls and or Partitions 7. Damp Mop Floor, use proper mop and germicide solution to disinfect the floor, be sure to run mop along edges and never push dirt into corners, using a figure 8 motion, work your way out of the door. 2. A tour of the facility's laundry room was conducted on 03/30/2023 at 10:38 a.m. and the washing side of the laundry room was observed to have broken wall tiles with exposed wall. The floor of the washing side of the laundry room was observed to have broken, and loose tiles on the floor with exposed, dirty concrete floors. (Photographic Evidence Obtained) An interview was conducted with Staff M, Laundry Aide and he stated he washes resident clothes and linens in the washing room and transports their clean clothes into the drying room. He stated the floor and the walls have been in that condition for a long time. He was unable to recall exactly how long. An interview was conducted with the Nursing Home Administrator (NHA) and the Maintenance Director on 3/30/2023 at 10:50 a.m. The Maintenance Director stated he was aware of the walls and the floor in the laundry room, but his priority was the resident rooms, then move out to the laundry room. Review of the facility's policy and procedure titled, Infection Control-Cleaning and Disinfecting/Non-Critical Care and Shared Equipment, undated, revealed: Intent: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedure: 1. Cleaning and disinfecting of the facility, including resident rooms is completed in accordance with environmental services policies and procedures. 2. Resident rooms, including rooms of residence on transmission-based precautions, are clean daily . 106103 Page 3 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for one resident (#39) of three residents sampled for PASARR Level II. Findings included: Review of Resident #39's Face Sheet revealed he had a current admission on [DATE] and a latest return on 9/25/22 with diagnoses to include major depressive disorder, recurrent, mild admission diagnosis, other specified depressive episodes diagnosis date of 10/19/2020, generalized anxiety disorder dated 10/19/2020, mood disorder due to known physiological condition with major depressive-like episode, schizotypal disorder 6/17/2022, psychotic disorder with hallucinations due to known physiological condition. dated 2/26/21, major depressive disorder, single episode, moderate dated 2/9/21, anxiety disorder due to known physiological condition dated 1/7/21, other psychotic disorder not due to a substance or known physiological condition. dated 10/19/2020, depression dated 10/15/2020, and schizophreniform disorder dated 10/19/2020. Review of Resident #39's Preadmission Screening and Resident Review (PASARR) dated 6/10/22 revealed a qualifying mental health diagnosis of depression only and that no PASARR Level II was required. Further PASARR review was conducted and revealed Resident #39 had another PASARR dated 2/7/22 and revealed a qualifying mental health diagnosis of anxiety and depression disorders and that no PASARR Level II was required. Review of the admission Minimum Data Set (MDS), dated [DATE], Section I - Active Diagnoses revealed diagnoses of anxiety and depression. Further MDS review of Section I - Active Diagnoses revealed the Quarterly MDS, dated [DATE] and 8/30/22, as well as a significant change MDS, dated [DATE], all revealed medical diagnoses of anxiety, depression, psychiatric disorder (other than schizophrenia), and schizophrenia. Review of the medical record revealed the resident was not assessed for a PASARR Level II. An interview was conducted on 03/29/23 at 3:53 p.m. with the Social Services Director. He stated he does not have anything to do with PASARRs, usually admission handles them when a resident first comes in. An interview was conducted on 3/30/23 at 9:57 a.m. with the Director of Nursing (DON), she indicated PASARRs are the responsibility of the Social Services Director, but she confirmed Resident #39's PASARRs do not indicate a diagnosis for schizophrenia. She confirmed for a new qualifying mental health diagnosis, PASARRs should be updated. Then a Level II PASARR should be completed. Review of the facility's Coordination- Pre-admission Screening and Resident Review (PASRR) Program, policy, undated, revealed: .5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for 106103 Page 4 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0644 resident review. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106103 Page 5 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure one resident (#47) with an indwelling catheter received treatment and care in accordance with professional standards of practice related to not administering an antibiotic for five days after receiving a positive lab result for a Urinary Tract Infections (UTI) of seven residents with indwelling catheters. Findings included: The Resident Face Sheet revealed Resident #47 was readmitted into the facility on [DATE] with diagnoses that included obstructive and reflex uropathy, unspecified urethral stricture, UTI, unspecified abnormal findings in urine, and benign prostatic hyperplasia without lower urinary tract symptoms. Section C Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], indicated Resident #47 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating severe impairment. A review of the Physician Order Report dated 02/28/23 to 03/30/23 revealed the following orders: 02/20/23 supra pubic catheter size 12 Fr (French) 10 ml (milliliter) balloon DX (diagnosis): urinary retention, every shift; Day 07:00 - 15:00 (3:00 p.m.), Evening 15:00 - 23:00 (11:00 p.m.), Night 23:00 - 07:00; 03/11/23 ammonia; urine culture and sensitivity if indicated; urinalysis; 03/13/23 complete blood count with differential platelets; urinalysis; urine culture; 03/21/23-03/31/23 cipro tablet 500mg (milligrams) for diagnosis of UTI twice a day; and 03/20/23-03/31/23 contact isolation: remove isolation cart when antibiotic is completed. A review of the Medication Administration Record (MAR) dated 03/01/23 to 03/23/23 revealed the following: ammonia; urine culture and sensitivity if indicated; urinalysis was completed on March 11th ; complete blood count with differential platelets; urinalysis; urine culture was completed on March 13th ; cipro tablet 500mg for diagnosis of UTI twice a day was administered on March 21st to March 30th ; and contact isolation was started on March 20th and continued to March 30th . The lab results dated 03/14/23 indicated the resident had an organism of Escherichia coli and was positive for ESBL (extended spectrum beta-lactamase). Resident Progress Notes revealed the following: 106103 Page 6 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0690 02/27/23- The resident had dark yellow urine; Level of Harm - Minimal harm or potential for actual harm 03/14/23 Urinalysis ordered and obtained via catheter; 03/16/23- Lab result received was positive for UTI. Oncoming to follow up with result; Residents Affected - Few 03/20/23- Urine culture and sensitivity result received. The doctor in the facility reviewed the results. Verbal order received for by mouth antibiotics related to extended spectrum beta-lactamase (ESBL). Repeat urinalysis on day 12th. Contact isolation initiated. Suprapubic catheter not leaking. Dark urine in bag and fluids encouraged; and 03/23/23- The resident returned from the hospital with a diagnosis of UTI. The care plan created on 2/22/23 for an Indwelling Catheter revealed a goal as, Resident will remain free of infection as evidenced by normal vital signs and absence of pain or retention. The Approaches included: monitor characteristics of urine (odor, color, blood in urine), provide catheter care as ordered. There was no care plan or approaches initiated related to a UTI. On 03/30/23 at 11:46 a.m., the Director of Nursing (DON) reported the doctor should be contacted as soon as the results are received for labs. The DON stated the progress note written on 03/16/23 was written by the ADON (Assistant Director of Nursing) and that she could provide more information about when the doctor was contacted. On 03/30/23 at 11:49 a.m., the ADON reported she contacted the doctor on 03/16/23 and the doctor was supposed to call back after she reviewed the labs. The ADON reported the doctor stated she wanted to review the labs before deciding what medication she would put the resident on. The doctor was in another facility at this time. The doctor did not call back on that day. The ADON confirmed the resident did not start the antibiotic for the UTI until 03/21/23. 106103 Page 7 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide medications as ordered for one resident (#39) out of five residents reviewed for unnecessary medications. Findings included: An interview was conducted on 03/27/23 at 10:05 a.m. with Resident #39. He was observed to be in his wheelchair sitting in the doorway to his room. Resident #39 stated .sometimes they run out of my Parkinson medication. It happened a week and a half ago. For the last week I haven't been getting my sleeping pill either. On 03/27/23 at 10:10 a.m. the Nursing Home Administrator was overheard stating to Resident #39 she's calling the pharmacist to get you something and I'll figure out what the deal is. Review of Resident #39's Face Sheet revealed he was initially admitted to the facility on [DATE]. His diagnoses to include Parkinson's disease, insomnia, type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, major depressive disorder, and absence of right leg below the knee. Review of Resident #39's current physician orders revealed an order for Carbidopa-levodopa 25-250mg(milligrams) four times a day for Parkinson's disease, which started on 2/15/23. An order for Eliquis 5mg tablet twice a day for acquired absence of right leg below the knee, which started on 9/25/22; Jardiance 25mg one a day for type 2 diabetes mellitus with diabetic neuropathy, which started on 9/25/22; and Temazepam 15mg once a day for insomnia, which started on 9/25/22. Review of Resident #39's March 2023 Medication Administration Record (MAR) revealed: -Eliquis 5mg was not administered on 3/21/23 7:00 a.m.-11:00 a.m. Not administered: Drug/Item Unavailable, and on 3/22/23 7:00 a.m.-11:00 a.m. Not administered: Drug/Item Unavailable. -Jardiance 25mg was not administered on 3/27/2023 7:00a.m.-3:00p.m. Not administered: Other Comment: Medication not available to administer. -Temazepam 15mg was not administered on 3/14/23 HS [hours of sleep] Not administered: Drug/Item Unavailable. 3/16/23 HS Not administered: Drug/Item Unavailable. 3/17/23 HS Not administered: Drug/Item Unavailable. 3/20/23 HS Not administered: Drug/Item Unavailable. 3/22/23 HS Not administered: Drug/Item Unavailable. 3/23/23 HS Not administered: Drug/Item Unavailable. 106103 Page 8 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0755 3/24/22 HS Not administered: Drug/Item Unavailable. Level of Harm - Minimal harm or potential for actual harm 3/25/23 HS Not administered: Drug/Item Unavailable. 3/26/23 HS Not administered: Other. Residents Affected - Few 3/27/23 HS Not administered: Drug/Item Unavailable. Review of February 2023 and March 2023 MARs revealed Carbidopa-levodopa 25-250mg was not administered on: 2/3/23 at 12:00 p.m. Not administered: Drug/Item Unavailable. 3/27/23 at 4:00 p.m., Not administered: Drug/Item Unavailable. 3/27/23 at 8:00 p.m., Not administered: Drug/Item Unavailable. 3/28/23 at 8:00 a.m., Not administered: Drug/Item Unavailable comment: Pharmacy called to restock medication. 3/28/23 at 12:00 p.m. Not administered: On Hold Comment: awaiting delivery from pharmacy. Further medical record review was conducted and there was no evidence the physician was notified of the above missed medications. An interview was conducted on 03/29/23 at 12:40 p.m. with Resident #39. He stated, It seems like they are running out of my medications all the time. Last night I still didn't get my sleeping pill and I was up and down all night. I woke up at 3:00 a.m. and 5:00 a.m. I also have not been getting my Parkinson's medications, I got them today, but previously I had not gotten them, and I had extra tremors and cramping. My muscles tightened up. An interview was conducted on 3/29/23 at 12:49 p.m. with Staff N, License Practical Nurse (LPN) and she indicated today was her first day at the facility and confirmed Resident #39 was on her assignment. She indicated she had his Parkinson's medications available and she has had all his other medications available to administer; except he ran out of his pain medication, which she was able to pull from the emergency drug kit and the pharmacy stated they would be delivering a new medication pack at 2:00 p.m. So, he would not miss any doses. She opened her secured narcotic box in her medication cart and Resident #39's Temazepam blister pack was in the narcotic box without any missing medications. She confirmed the medication was delivered on 3/28/2023 and that it indicated the date on the blister pack. (Photographic Evidence Obtained) Review of Resident #39's care plan revealed it was last reviewed/revised on 3/28/23. It revealed, Resident has diagnosis of Depression, Anxiety, Psychosis, Insomnia with antipsychotic, antianxiety, antidepressant, and hypnotic use; and is at risk for drug related: Hypotension, gait disturbance, cognitive impairment, behavioral impairment, ADL (activities of daily living) decline, Decreased appetite, abnormal involuntary movements. Goal: Resident will be free from drug related signs and symptoms. 106103 Page 9 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0755 Approaches included but are not limited to administer medications as ordered. Level of Harm - Minimal harm or potential for actual harm Review of Resident #39's anticoagulant care plan, last edited on 3/28/23, revealed: Resident is at risk for abnormal bleeding or hemorrhage because of anticoagulant usage; Residents Affected - Few Goal: Resident will remain free from signs and symptoms of abnormal bleeding over the next 30 days . Approaches included to administer anticoagulant as currently prescribed. An interview was conducted on 3/30/23 at 10:00 a.m. with the Director of Nursing (DON) she indicated it is her expectation that meds are given as ordered. She stated it is hard with agency staff and not having the continuity of care and follow-up. She also indicated new admission, pharmacy recommendations and medications are reviewed every morning at the morning meeting. [Resident #39] has a significant psych history, we review him every Thursday at our psych meeting. He will sit in his wheelchair and doze off and then wake up and say he did not get his medications. He will also refuse medications at times but the staff need to document refusals rather than document medication not available. Review of the facility's Medication Administration policy, last revised 10/2021, revealed Policy: all medications for residents are ordered by physician/ NP [nurse practitioner] and our administered by licensed nursing personnel. Medication orders must include dosage, route, frequency, duration and reason for the medication. Unless otherwise specified by the physician/MD, orders will continue until the next monthly orders and will be reviewed and reordered as indicated by the physician every 28-30 days. Responsibility of the nursing professional is to be aware of the classification, action, correct dosage and side effects of a medication before administration. Medications are ordered and used only in specific dosages, at specific intervals of administration and for the specific treatment purpose for which each medication is indicated by the identified recorded condition. Medications will be administered following the 5 Rights: right resident, right medication, right dose, right time, and right route. The pharmacy will send a 30 [sic] supply of medications on monthly renewals. One blister pack of each medication is kept in the top drawer for use, and the surplus blister packs are kept in the bottom drawer of the cart. Overflow of the blister packs may be stored in the medication room, if there is no room in the medication cart. Standards of Practice: .11. If a medication is ordered but not present: a. Check entire cart b. Notify supervisor 106103 Page 10 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0755 c. Call pharmacy to obtain medication Level of Harm - Minimal harm or potential for actual harm d. If med [medication] cannot be located, call physician for any changes of orders Residents Affected - Few e. Unavailable medications are to be documented in the 24 hours report and carried until medication has been obtained and administered. A Medication Error Report is to be completed . 106103 Page 11 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm 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-five medications were observed, and two errors were identified for two (2) (Residents #9, 18) of five (5) residents observed. These errors constituted a medication error rate of 12 percent. Residents Affected - Few Findings included: On 03/28/2023 at 08:22 a.m., an observation of medication administration with Staff K, Licensed Practical Nurse, (LPN), was conducted with Resident #18. Staff K, (LPN) obtained Blood Glucose reading prior of 251, and was observed administering the following: -Novolog Flex-Pen U-100 Insulin -Levemir Flex-Touch Pen U-100 Insulin An immediate interview was conducted with Staff K, (LPN) who confirmed that she put a needle on Novolog Flex Pen, dialed 20 units (14 units and then 6 units sliding scale per sliding scale) and then dialed 45 units on Levemir Flex-Touch Pen U-100 Insulin without first priming each pen. Staff K, (LPN) stated I was taught to dial it up to the dose, never about priming the insulin pen. Record review of active physician orders for the Resident #18 revealed: dated 01/27/2023 Novolog Flex-Pen Unit 100 Units/Milliliters (ML) (3 ML) 14 U, plus sliding scale before meals and bedtime; and 01/26/2023 Levemir Flex-Touch Pen (ML) (3 ML) Inject 45 U subcutaneously twice a day subcutaneously both for Diagnosis of Type 2 Diabetes, Mellitus with hyperglycemia. Manufacturer instructions for Priming the Novolog Pen for users are as follows: https://www.novologpro.com/administration-options/insulin-pens.html Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to 2 units. - F. Hold your NovoLog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the needle pointing upwards, press the push button all the way in. The dose selector turns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. According to manufacturer instructions for Levemir Flex-Touch Pen: https://www.novomedlink.com/content/dam/novonordisk/novomedlink/new/diabetes/patient/product/library/documents/levem 106103 Page 12 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0759 Step 2: Attach a new needle. Level of Harm - Minimal harm or potential for actual harm Step 3: Before each injection, prime your pen by performing an air shot. Turn the dose selector to select 2 units. Holding your pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Press and hold the green push button. Make sure a drop of insulin appears at the needle tip. Residents Affected - Few Step 4: Select your dose. On 03/29/2023 at 08:25 a.m., an observation of Staff I, Registered Nurse, (RN) obtaining a Blood Glucose of 165, medication administration was conducted with Resident #9 administering Humalog Kwik-Pen Insulin (Lispro) U-100. Staff I, (RN) was observed not priming the insulin pen first and dialing the to 6 units. An immediate interview was conducted with staff I, (RN) who stated No, I don't know about priming the pen, I never heard of it, it's not like drawing up from a bottle, it is foolproof, and there is no way to suck air into it. A record review of active physician orders for the Resident #9 read as follows: Dated 01/30/2023 Humalog Kwik Pen Insulin (insulin lispro) 100 unit/ml, 6 units before meals three times a day, for Diagnosis of Type 2 Diabetes, Mellitus with hyperglycemia. According to manufacturer instruction insert for priming Humalog Kwik-Pen Insulin (Lispro) U-100, https://pi.lilly.com/us/humalog-kwikpen-um.pdf Priming your Pen: -Prime before each injection. - Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. -If you do not prime before each injection, you may get too much or too little insulin. -Step 6: - To prime your Pen, turn the Dose Knob to select 2 units. Step 7: - Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: - Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle, and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose. 106103 Page 13 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the Staff L, RN, Unit Manager (UM), on 03/28/2023 at 11:42 a.m., who was asked to describe the facility procedure for drawing up insulin from a Flex-Pen or a Kwik-Pen. Staff L, (UM) revealed insulin pens are only primed with two (2) units, when you initially use for the first time, but thereafter, you do not need to prime them prior to administering to residents. A facility provided policy titled, Procedure Medication Insulin Pens, revision date 6/2022, Page 01 of Page 02 reads under Procedure as 9. Prime pen and clear air from needle if first time use of pen. There after pen do not need to be primed. Turn the needle selector to knob at end of pen to 1 or 2 units. Hold pen with needle pointing upward. Press dose know up completely and watch for insulin drop or stream to appear. Repeat, if necessary, until insulin is seen at needle tip. The dial should be back to zero after completing the priming step. During a telephone interview conducted with the Pharmacy Consultant on 03/29/2023 at 01:45 p.m., she was informed of the observations, and confirmed that despite the facility policy reading Prime pen and clear air from needle if first time use of pen. There after pens do not need to be primed. She stated, As per the package inserts from both manufacturers Novo Nordisk and Lilly for insulin pens that were used during those observations, they do require priming before dialing up the dose and administering the insulin. An interview was conducted with the Director of Nursing (DON) on 03/29/2023 at 02:03 p.m. During the interview the DON was informed of the observations conducted of medication administration for Resident's #9 and #18; and Staff not priming prefilled insulin Flex-Pens, and Kwik Pens prior to dialing doses up for administration to them. The policy was reviewed with the DON and she stated I train my nurses from what the policy states. I will inform the corporate office of what we spoke about and that they need to change their policy to reflect what the package inserts say and to prime it each time prior to administration. 106103 Page 14 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and facility record review, the facility failed to ensure the food preparation and cooking areas were clean and sanitary related to rusted food preparation tables, walls and pipes caked with grease and food debris, a ceiling vent with chipped paint directly above the food service station and an unclean ice machine in one of one kitchen for three days (3/27/2023, 3/29/2023 and 3/30/2023) of four days observed. Findings included: On 3/27/2023 an initial kitchen tour was conducted at 9:20 a.m. and the Regional Dietary Manager (RDM) revealed she was just filling as the facility's Dietary Manager. The following was observed (Photographic Evidence Obtained): 1. The metal shelf above a food preparation station, located at the side of the stove/range and behind the steam table revealed an eaten banana with only the peel, and a personal phone/electronic communication device. 2. A two metal shelf food preparation table, positioned on the right side of the steam table was observed with the bottom two shelves soiled, with paint chipped and many rusted/oxidized areas. The shelves had various packaged food products, and kitchen equipment stored on them. 3. A small metal table behind the steam table and near the stove/range was observed with a mixer on it. The legs of the mixer and the top of the table were observed with built up food debris and oxidation. 4. A large metal side food preparation table, with the mechanical can opener was observed with heavy rusting and paint chipping on the entire side, where the can opener was positioned. 5. The left side of the stove/range was observed with several metal pipes, all white in color, leading from the stove to the side wall. The pipes were observed with what appeared to be heavy grease and food debris build up. Further observation revealed metal exposed pipes that were rusted and oxidized. 6. The ceiling area over and at the side of the steam table was observed with a long line of a yellow in color gel substance. The line was approximately two inches wide by two feet long. The gel substance was also observed with a slow drip down towards the steam table and floor. Staff in the kitchen were not able to determine what the substance was or where it came from. 7. The top surface of the dish washing machine was observed with tan and white in color crumbled debris. The debris was stuck and caked on the entire right side of the machine surface. The RDM confirmed the debris and indicated the top surface of the machine should be clean. She confirmed the surface debris appeared as if it has been there for a long period of time. 8. The ice machine's plastic ice chute was observed. The edges of the ice chute had pink and black bio growth on it. The RDM confirmed the bio growth and did not know immediately who was responsible for cleaning and maintaining the machine. She confirmed the chute should be free from bio growth and would have staff take care of it. 106103 Page 15 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a kitchen tour conducted on 3/29/2023 at 11:30 a.m., with an Interim Dietary Manager, who was filling in from another facility, the following areas were observed (Photographic Evidence Obtained): 1. The metal shelf above a food preparation station, located at the side of the stove/range and behind the steam table revealed an eaten banana with only the peel, and a personal phone/electronic communication device. 2. A two metal shelf food preparation table, positioned on the right side of the steam table was observed with the bottom two shelves soiled, with paint chipped and many rusted/oxidized areas. The shelves had various packaged food products, and kitchen equipment stored on them. 3. A small metal table behind the steam table and near the stove/range was observed with a mixer on it. The legs of the mixer and the top of the table were observed with built up food debris and oxidation. 4. A large metal side food preparation table, with the mechanical can opener was observed with heavy rusting and paint chipping on the entire side, where the can opener was positioned. 5. The left side of the stove/range was observed with several metal pipes, all white in color, leading from the stove to the side wall. The pipes were observed with what appeared to be heavy grease and food debris build up. Further observation revealed metal exposed pipes that were rusted and oxidized. 6. The ceiling area over and at the side of the steam table was observed with a long line of a yellow in color gel substance. The line was approximately two inches wide by two feet long. The gel substance was also observed with a slow drip down towards the steam table and floor. During a kitchen tour conducted on 3/30/2023 at 8:50 a.m. with an Interim Certified Dietary Manager, who was filling in from another facility, the following areas were observed (Photographic Evidence Obtained): 1. A two metal shelf food preparation table, positioned on the right side of the steam table was observed with the bottom two shelves soiled, with paint chipped and many rusted/oxidized areas. The shelves had various packaged food products, and kitchen equipment stored on them. 2. The left side of the stove/range was observed with several metal pipes, all white in color, leading from the stove to the side wall. The pipes were observed with what appeared to be heavy grease and food debris build up. Further observation revealed metal exposed pipes that were rusted and oxidized. 3. The ceiling vent above the food preparation table had paint chipping and dust and debris on the slats of the vent. 4. The ceiling area over and at the side of the steam table was observed with a long line of a yellow in color gel substance. The line was approximately two inches wide by two feet long. The gel substance was also observed with a slow drip down towards the steam table and floor. 5. The ice machine filter had a dust like appearance on the vent and on the inside of the machine a 106103 Page 16 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0812 Level of Harm - Minimal harm or potential for actual harm pink and black bio growth observed. The Interim Certified Dietary Manager confirmed the observation and requested the cook to clean the area. During this tour the Interim Certified Dietary Manager confirmed the food preparation and cooking areas needed to be cleaned and or repaired. Residents Affected - Some A review of the policy and procedure titled, Environment, revised on 9/2017, revealed: All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. The procedure section revealed; 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 2. The Dining Service Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. A review of the policy and procedure titled, Equipment, revised on 9/2017, revealed: All food service equipment will be clean, sanitary, and in proper working order. The procedure section revealed; 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after each use. 4. All non-food contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly. 106103 Page 17 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to correct previously cited deficiencies related to 1.) failing to ensure Level II Preadmission Screening and Resident Review (PASRR) was completed for three (Resident #4, Resident #5, and Resident #6) of thirteen sampled residents (F644), 2.) failing to ensure a medication error rate of less than five percent for two (Resident #7 and Resident #8) of thirteen sampled residents (F759), 3.) failing to prevent neglect related to adequate supervision to ensure safety for one (Resident #2) out of twelve identified as a high elopement risk (F600), 4.) failing to report an elopement incident for one (Resident #2) of one resident reviewed (F609), 5.) failing to thoroughly investigate an elopement incident for one (Resident #2) of one residents reviewed (F610), and 6.) failing to ensure care was provided in accordance with professional standards of practice by failing to provide wound care for one (Resident #7) of thirteen sampled residents (F684) during a revisit survey conducted 6/5/2023 to 6/8/2023. Findings included: 1.) During record review of the facility plan of correction from the annual survey ending 3/30/2023 a PASARR audit had been completed related to 10 residents with qualifying mental health diagnoses. Review of the audit titled PSSAR dated 4/28/2023 confirmed that residents 4,5,6 had the following note next to their name : Not complete ( in progress). An interview with the director of social services on 6/5/2023 at 2:00 p.m. confirmed that it was his responsibility to ensure that the required Level II PASARRs were completed as required. He stated that he did follow up on the audit dated 4/28/23 , but did not understand that the Level II assessments had to be submitted as stated in the plan of correction, just that the audit was completed by the date listed in the plan of correction as 4/30/23. He confirmed at that time that he had not submitted the Level II PASARRs and he was still gathering information to submit. He stated I have a lot of other things to do, so I did not get to it. Record review of the face sheet for Resident #4 confirmed that he was admitted to the facility on [DATE] and had a qualifying mental health diagnosis of schizoaffective disorder, bipolar type ( Admission) listed. The audit sheet confirmed that the Level II PASARR was not complete - still in progress. There was no other documentation to review that would confirm that the Level II had been submitted for completion. Record review of the face sheet for Resident #5 confirmed that he was initially admitted to the facility on [DATE] with qualifying mental health diagnoses to include bipolar disorder, schizophrenia and anxiety disorder due to known physiological condition. The audit sheet titled PSSAR confirmed that the Level II PASARR was not complete- still in progress. There was no other documentation to review that would confirm that the Level II had been submitted for completion. Record review of the face sheet for Resident #6 confirmed that he was initially admitted on [DATE] with qualifying diagnoses to include psychotic disturbance, mood disturbance and anxiety. The audit sheet titled PSSAR confirmed that the Level II PASARR was not complete- still in progress. There was 106103 Page 18 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 no other documentation to review that would confirm that the Level II had been submitted. Level of Harm - Minimal harm or potential for actual harm Review of the facility plan of correction from the annual survey ending 3/30/23 confirmed that the required Level II PASARRs would be completed by the plan of correction date of 4/30/23. Residents Affected - Many 2.) A review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, muscle weakness, and hypertension. A review of Resident #7's physician's orders revealed the following orders: - An order, dated 6/4/2023 for azithromycin 250 milligrams (mg) by mouth (PO) one time daily on the 7:00 AM to 3:00 PM (Day) shift. - An order, dated 3/13/2023 for calcium carbonate 500 mg PO twice daily administered between the hours of 7:00 AM to 11:00 AM and 7:00 PM to 11:00 PM. - An order, dated 3/13/2023 for cholecalciferol 25 micrograms (mcg) PO once daily at 9:00 AM. - An order, dated 6/2/2023 for Claritin 10 mg PO once daily on the Day shift. - An order, dated 3/29/2023 for Colace 100 mg PO twice daily administered between the hours of 7:00 AM to 11:00 AM and 7:00 PM to 11:00 PM. - An order, dated 3/14/2023 for Eliquis 5 mg PO twice daily administered between the hours of 7:00 AM to 11:00 AM and 7:00 PM to 11:00 PM. - An order, dated 3/29/2023 for ferrous sulfate 325 mg PO twice daily administered between the hours of 7:00 AM to 11:00 AM and 7:00 PM to 11:00 PM. - An order, dated 3/14/2023 for folic acid 1 mg PO once daily administered between the hours of 7:15 AM to 11:00 AM. - An order, dated 3/19/2023 for lidocaine 5% adhesive patch topical to the back once daily, on at 9:00 AM, off at 9:00 PM. - An order, dated 3/13/2023 for magnesium 400 mg PO once every other day on the Day shift. - An order, dated 5/12/2023 for metoprolol succinate 100 mg PO once daily at 9:00 AM. - An order, dated 6/2/2023 for multivitamin tablet, one tablet PO once daily on the Day shift. An observation of medication administration was conducted on 6/5/2023 at 10:05 AM with Staff L, Licensed Practical Nurse (LPN). Staff L, LPN prepared the following medications for administration to Resident #7: - azithromycin 250 mg. 106103 Page 19 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 - calcium carbonate 500 mg. Level of Harm - Minimal harm or potential for actual harm - cholecalciferol 25 mcg. - Claritin 10 mg. Residents Affected - Many - Colace 100 mg. - Eliquis 5 mg. - ferrous sulfate 325 mg. - folic acid 1 mg. - lidocaine 5% adhesive patch. - magnesium 400 mg. - metoprolol succinate 100 mg. - multivitamin tablet. Prior to the procedure, Staff L, LPN assessed Resident #7's blood pressure and heart rate. Resident #7's metoprolol succinate was held due to ordered medication parameters. Staff L, LPN gathered the medications and entered Resident #7's room. Staff L, LPN administered PO medications to Resident #7 without difficulty. Staff L, LPN applied a lidocaine 5% topical patch to Resident #7's back. After administering Resident #7's medications, Staff L, LPN exited the room. Staff L, LPN opened the laptop on the medication cart, reviewed the medication orders, and addressed medications were being administered late as evidence by the order in the medication administration record turning red. Staff L, LPN stated all this red and I can't get any help. Staff L, LPN was not observed asking for assistance during the observation of medication administration to Resident #7. A review of Resident #8's medical records revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and hypertensive heart disease. A review of Resident #8's physician's orders revealed the following orders: - An order, dated 4/4/2023 for aspirin 81 mg PO once daily at 9:00 AM. - An order, dated 4/4/2023 for metoprolol tartrate 50 mg PO twice daily at 7:00 AM and 7:00 PM. - A order, dated 2/23/2023 for Sinemet 25 mg-100 mg PO four times daily at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. An observation of medication administration was conducted on 6/6/2023 at 9:35 AM with Staff M, LPN. Staff M, LPN prepared the following medications for administration to Resident #8: - aspirin 81 mg. 106103 Page 20 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 - metoprolol tartrate 50 mg. Level of Harm - Minimal harm or potential for actual harm - Sinemet 25 mg-100 mg. Residents Affected - Many Staff M, LPN gathered the medications and entered Resident #8's room. Staff M, LPN administered medications by mouth to Resident #8 without difficulty and exited the room. An interview was conducted on 6/6/2023 at 2:03 PM with Staff M, LPN. Staff M, LPN stated if medications are administered late, it is documented in the resident's electronic medication administration record (eMAR) and the resident's physician should be notified. Staff M, LPN stated she told the ARNP about administering medications late to Resident #8 but she did not document the communication in the resident's chart. Staff M, LPN stated it would be fine to administer Resident #8's medications late because the resident receives the same medications every day and nothing has changed in the orders. Staff M, LPN stated she would notify the resident's physician after administering the medication late and not before administering medications. An interview was conducted on 6/6/2023 at 3:30 PM with the facility's Director of Nursing (DON). The DON stated she would expect the nursing staff to follow the six rights of medication administration, which include the right medication, right dose, right resident, right route, at the right time, and the resident has the right to refuse. The DON stated if the nurse was not following the rights of medication administration, it could result in a medication error due to not following the physician's orders. The DON stated if a medication is administered late, a reason must be documented in the residents eMAR and the resident's physician and family should be notified. The DON stated the resident's physician should be notified prior to administering a medication later in case they have to change the order. The DON stated if a nurse was passing medications late and needed help they could notify herself or any other available nurse to assist in medication administration. A review of the facility policy titled Medication Administration, with no effective date, revealed under the section titled Policy medications are ordered and used only in specific dosages, at specific intervals of administration, and for the specific treatment purpose for which each medication is indicated by the identified recorded condition. Medications will be administered following the five rights; right resident, right medication, right dose, right time, and right route. The policy also revealed under the section titled Standards of Practice the responsibility for administration of drug rests entirely with the nurse. The physician may elect to order medications at intervals different from the standard medication administration times. The order will indicate the change of the times to be administered. The policy revealed under the section titled Additional Information all medications must be administered within one hour before and one hour after the scheduled time. If medication is given outside the two hour window, the physician must be informed. 3.), 4.), and 5.) A review of Resident #2's medical record showed, Resident #2 was admitted to the facility on [DATE] to room near the main lobby and front entrance with the diagnoses of Alcohol abuse with intoxication, Alcohol dependence with withdrawal, Alcohol use, unspecified with intoxication delirium, Generalized anxiety disorder, post-traumatic stress disorder, Tremor and Alcohol abuse with withdrawal delirium. An Admissions Observation form showed In Progress with no information completed in the form (photographic evidence obtained) as of 06/06/23. A review of hospital records revealed: 106103 Page 21 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many -The History and Physical (H&P) dated 05/06/23 showed that Resident #2 remained confused at times. The H&P revealed Resident #2 showed confusion, gait problems and weakness. The diagnosis, assessment and plan within the H&P showed Resident #2 had Delirium, Tremors, and acute alcohol withdrawal syndrome. The plan showed, Resident #2 would be discharged to a skilled nursing facility for rehabilitation. -A progress note dated 05/10/23 at 6:18pm stated, Resident arrived to facility on stretcher by [Ambulance Company] around 1700. Alert with confusion, gate unsteady, skin check performed, scab noted on right ankle and right forearm, pressure dressing on left forearm, x in permanent marker noted on top of both feet, dinner meal offered and refused, will continue to monitor. A review of the facility's physical therapy note dated 05/11/23 showed Resident #2 precautions included fall risk and confusion. Physical therapy evaluated and completed a plan of treatment on 05/11/23. The plan for services were skills inventions to address Gait training focused on correct sequencing and hand foot placement during gait with assistive devices. Skilled interventions to include focused on dynamic activities while standing, gross motor coordination, transfer training to increase functional task performance. An additional physical therapy note dated 05/12/23 showed Resident #2 precautions included fall risk and confusion. Resident #2 required verbal instruction required due to compromised balance, functional activity tolerance, safety awareness, and strength to enhance muscle strength and improve muscle endurance in order to improve ability to ambulate with assistive device. Working on dynamic standing balance to sit to stand. Pt [Resident #2] unsteady with difficulty with sit to stand. Pt [Resident #2] cooperative but requires instruction and manual assist at times to maintain balance. Gait training using a single cane for 30 feet x 2 CGA [Contact Guard Assist] with assist of 1. Balance fair. The response to treatment showed Resident #2, actively participates, complaint with skilled interventions and required extra time to process new information. A progress note written by Staff B Unit Manager, Registered Nurse (RN) dated 05/12/23 at 7:45am showed, Writer was informed by agency nurse on the second floor that while she was coming back into the building from her 15-minute break she observed resident in the parking lot with her belongings and the resident stated, I am looking for my car per the agency nurse. The agency nurse informed the writer that she assisted resident back into the building and notified the nurse who was taking care of the resident. Writer notified Director of Nursing (DON), and Nurse Practitioner (NP) of the situation. Continued review of Resident #2's medical record revealed Behavioral: Resident is at risk for elopement as evidence by increased elopement observations score and or actual attempts to elope secondary to delirium was added to the care plan on 05/12/23. An elopement evaluation dated 05/12/23 at 4:35pm showed, Resident #2 was ambulatory, was a new admission who had made statements questioning the need to be in the facility, was cognitively impaired, had poor decision making skills, and/or pertinent diagnosis of anxiety, depression, had a history of wandering, made statements of wanting to leave and displayed behaviors of elopement which resulted in a score of being a Resident with high risk of Elopement. The elopement evaluation was completed after Resident #2's elopement incident, and with no other elopement evaluations completed between admission and the elopement incident present in the clinical record. There were no nursing skin assessments available in Resident #2's medical record after the elopement incident. The medical record showed only one progress note dated 05/12/23 at 7:45am written by Staff B Unit Manager, Registered Nurse (RN) who notified the Director of Nursing (DON), and Nurse Practitioner (NP). There was no documentation in the medical record that would indicate the resident's family or physician were notified. 106103 Page 22 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility's May 2023 reportable event log showed Resident #2's elopement incident was not logged or reported. During an interview on 06/05/23 at 10:30 am, Staff A Staff Development Coordinator (SDC) Registered Nurse (RN) stated he had not conducted any elopement training/in-services for staff in the facility since being employed at the facility as of 02/27/23. Review of the facility's adverse log showed on 06/05/23 no adverse incidents to report. Review of the facility's list of Residents with high elopement risk on 06/05/23 showed Resident #2's name was on the list. During an interview on 06/05/23 at 11:20 am, the Administrator stated, Resident #2 was considered a high elopement risk while in the facility, however Resident #2 was not in the facility now and was discharged home. During an interview on 06/05/23 at 12:45pm, Staff J Certified Nursing Assistant (CNA) stated he had been employed at the facility for a few years now and he had not participated in any elopement drills that he could recall. During an interview on 06/05/23 at 12:48pm, Staff F Certified Nursing Assistant (CNA) stated she had been employed at the facility for a few years now and usually the maintenance department conducts the elopement drills, but the facility had not had one in a long time. During an interview on 06/05/23 at 1:07pm, Staff B Unit Manager, Registered Nurse (RN) stated, the Agency Nurse [Staff C] approached her the morning of 05/12/23 and informed her that Resident #2 had eloped and was found outside looking for her car around 5:00am. Staff B RN stated since Resident #2 was already safely back in the facility and accounted for, she made a note in the Resident #2's chart and informed supervisors of the elopement that occurred on nightshift. Staff B RN stated the facility did not have any elopement drills while she worked in the facility. During an interview on 06/05/23 at 1:22pm, the Director of Nursing (DON) stated the facility had no elopement events since being employed at the facility as of 07/13/21. During a phone interview on 06/05/23 at 3:04 pm, Staff C Agency Nurse, Registered Nurse (RN) stated, the Administrator just called me a few minutes ago and told me the state would be calling soon and advised me to not answer the phone. Staff C RN stated the night of the elopement on 05/12/23 she was outside on her 15-minute break, and she found Resident #2 outside at the front of the building alone. Staff C RN stated Resident #2 was confused and was looking for her car. Staff C RN stated she escorted Resident #2 back into the facility and reported the elopement incident to Staff D Licensed Practical Nurse (LPN), Night Supervisor, who was sleeping at the time. Staff C RN stated Staff D LPN woke up, responded yeah ok and went back to sleep. Staff C RN stated she was not comfortable with the response of the night shift supervisor, so she also reported the elopement incident to Staff B Day shift Unit Manager, RN when she arrived for work. Staff C RN stated the reason she did not document the elopement incident was because Resident #2 was not her assigned resident. During an additional phone interview on 06/07/23 at 10:47am, Staff C Agency Nurse, RN stated she was parked on the left side of the facility in the parking lot when facing the facility. Staff C RN stated when she walked back to the front door entrance there was a lady identified as Resident #2 106103 Page 23 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many standing adjacent to the front door near the exit driveway, and close to the road. Staff C RN remembered there were cars passing by on the road and stated that [name of street] is always a busy road. Staff C RN stated, She is lucky it was nighttime or there would be a lot more cars on that road. Resident #2 was closer to the road than the front door. Staff C RN stated when she approached, Resident #2 was very disoriented and confused. Staff C RN stated Resident #2 kept asking where her car was. Staff C RN stated Resident #2's gait was unsteady, but she was able to ambulate. During an interview on 6/5/2023 at 3:59 pm, Staff D Night Shift Supervisor Licensed Practical Nurse (LPN) stated, I worked with Resident #2 on 100 hall the night of 5/11/23. Staff D LPN confirmed she was the assigned nurse to Resident #2 the night of 05/11/23 to the morning of 05/12/23, the shift that Resident #2 eloped. Staff D LPN recalled Resident #2 was alert with confusion. Staff D LPN stated Resident #2 was very disoriented and did not know much of her physical surroundings. Staff D LPN stated Resident #2 was able to complete most of her Activities of Daily Living (ADLs) herself, so I didn't have much care to provide to her, continuing [Resident #2] was just very confused. Staff D LPN stated she last recalled seeing Resident #2 around 5am when she provided Resident #2's roommate some medication. During an interview on 06/05/23 at 3:44pm, Staff E Rehabilitation Director (RD) stated she remembered Resident #2 very well. Staff E RD stated Resident #2 was admitted to the facility with her cane and could ambulate anywhere, although she was not safe. Staff E RD elaborated and stated Resident #2 was not safe because Resident #2 had poor safety awareness. Staff E RD stated that Resident #2 could hold a conversation but had poor cognition and confusion of the surroundings and physical environment. Staff E RD confirmed Resident #2 had an elopement incident, remembered the incident was talked about in the morning care plan meeting, and that was why Resident #2 was moved upstairs. Staff E RD stated the therapy department evaluated Resident #2 on 05/11/23. Staff E RD stated she remembered Resident #2 was ambulatory, had poor cognition with poor safety awareness and had a lot of confusion. Staff E RD stated usually when a Resident was that confused and could ambulate, the resident would get immediately assigned to a room upstairs to alleviate the possibility of elopement. The RD stated, the morning of 05/12/23 after Resident #2 eloped, during the care plan meeting was when the team chose to add elopement to the care plan and move Resident #2 upstairs to the secure unit. During an interview on 06/05/2023 at 4:00pm with an employee who wished to remain anonymous, the employee confirmed a care plan meeting for Resident #2 occurred the morning of 05/12/23 where Resident #2's elopement incident was discussed. The employee stated the Administrator informed the care plan staff he was not defining the incident as an elopement even though the clinical staff disagreed. The employee stated the incident was never thoroughly investigated or reported. During an interview on 06/05/23 at 4:07 pm, Staff F Certified Nursing Assistant (CNA) stated she worked with Resident #2 on 100-hall the night of 05/11/23 into the morning of 05/12/23. Staff F CNA stated Resident #2 was very confused and combative from day one. During an interview on 06/06/23 at 11:00am, the Administrator stated he defined elopement as an unobserved danger to a Resident where a lot of time had passed and places a Resident in harm's way. The Administrator stated he was familiar with the 05/12/23 incident regarding Resident #2. The Administrator stated Resident #2 had followed Staff C Agency Nurse, RN outside on break. The Administrator stated the facility Maintenance Department tested all the doors and they all passed inspection so the only way Resident #2 could have gotten out of the facility had to be by drafting, which he defined as following Staff C Agency Staff RN outside on break that night. The Administrator stated he was notified the morning of the incident but could not recall who informed him. The Administrator stated 106103 Page 24 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the care plan team decided to move Resident #2 up to the second floor because she was confused and looking for her car. The Administrator stated he did not feel Resident #2 was in any danger based on the statement the Director of Nursing (DON) got from the Agency Nurse RN. The Administrator stated the witness statement showed the resident followed the Agency Nurse RN out the door and Agency Staff RN turned around and brought Resident #2 back in. The administrator stated based on the DON witness statement from Staff C Agency Nurse, RN, he determined it was not a reportable incident. The Administrator stated the administrative team went back and forth as to what time the incident occurred and concluded it must have been around 5:30 am. The Administrator stated that Resident #2 was found in the parking lot not really near the road, so I do not think she was in danger. The Director of Nursing got a statement, and we investigated the incident on 05/12/23. The Administrator stated Staff A Staff Development Coordinator (SCD), RN could provide documentation on elopement training provided to staff after Resident #2's incident. A review of a witness statement dated 05/12/23, provided by the Administrator for review, on 06/06/23 showed, Nurse [Agency Nurse Initials] RN went on 15-minute break exiting front door in lobby. Resident [Resident #2's initials] followed out through and was noticed by [Agency Nurse initials] RN and returned inside facility. [Agency Nurse initials] RN notified [Night shift Supervisor initials] Nurse Supervisor as she was returned to room. The witness statement was signed by the Director of Nursing and showed, interview with agency nurse. During a phone interview on 06/06/23 at 11:48am, Staff C Agency Nurse, Registered Nurse (RN) stated, I did not speak to the DON, and I have never made a witness statement about the incident. Staff C RN stated no one followed her out the front door and it was not until the end of the 15-minute break that she found Resident #2 wandering in the front of the facility near the road. Staff C RN stated again, I reported the incident to the night shift supervisor who was sleeping and said, yeah, ok and laid her head back down to sleep. Staff C RN stated, that was why I stayed to inform the day shift unit manager about the incident. During an interview on 06/06/23 at 12:36pm, the Director of Nursing (DON) stated yes, the initial on the bottom of the Agency Nurse witness statement dated 05/12/23 was hers, saying That is my signature. During an interview on 06/06/23 at 2:10 pm, Staff G admission Liaison stated she was the one who made the decisions on who got admitted to the facility or not. Staff G Admissions Liaison stated the facility did not accept anyone who was in active delirium tremens (DTs) [defined as severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations] and the Resident must be out of DTs to be admitted . The Admissions Liaison said the facility also did not accept elopement risk residents unless the person, who was classified as an elopement risk, was wheelchair bound and could not physically wander or elope. Staff G admission Liaison stated someone who was confused and able to ambulate would be classified as a higher elopement risk. Staff G admission Liaison stated if that was the case, I will meet with the family to ensure they are comfortable with the Resident being on the more secure 2nd floor and if they are we will admit them to the second floor. The admission Liaison stated the facility would not admit anyone with a higher elopement risk to the first floor because of the front door and the busy street. Staff G admission Liaison stated, if a Resident was questionable for elopement, the protocol would be to admit to a room close to the nurse station and furthest away from an exit door. Staff G Admissions Liaison could not recall Resident #2 to discuss specific details. An observation on 06/06/23 at 2:30 pm showed Resident #2's first floor Room as located down the 106103 Page 25 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 100- hallway near the front entrance of the facility and lobby area. Resident #2's first floor room was the first room on the left side of the hallway when an individual entered the facility's front door and walked through the lobby. Resident #2's first floor room was the closest room to the front door exit in the 100-hallway. Photographic evidence was obtained. A review of the Maintenance Department door audits, provided by the Administrator for review, for the dates of 05/06/23 to 05/12/23 showed documentation that all doors passed. During an interview on 06/06/23 at 3:08pm, the Maintenance Director stated exit doors are always locked, and the front door was always locked and under keypad. The Maintenance Director stated the facility's exit doors were audited daily and put in the logbook. The maintenance logbook was reviewed with pass by each exit door audited that included 1st floor east exit door, 1st floor west exit door, 1st floor at Resident #2's room, 2nd floor by room [ROOM NUMBER], 2nd floor by room [ROOM NUMBER], 2nd floor by room [ROOM NUMBER], 2nd floor by room [ROOM NUMBER], Employee entrance door, front door, Kitchen door, physical therapy department door, and patio door for the dates of 04/29/23 to 05/26/23. The Maintenance Director stated facility's exit doors were routinely audited daily and not based solely on elopements or incidents that have occurred at the facility. A review of an additional second witness statement dated 06/05/23, provided by the Administrator for review, showed a statement from Staff D LPN. The witness statement was dated 06/05/23 regarding the elopement incident that occurred with Resident #2 on 05/12/23. During an interview on 06/06/23 at 3:57pm, the Administrator stated the facility did investigate the incident on 05/12/23, however the Administrator stated he could confirm he had a conversation with the Staff D Night Shift Supervisor Licensed Practical Nurse (LPN) on 05/12/23 but just did not write anything down. The Administrator stated he had Staff D LPN write out her written statement on 06/05/23. The Administrator stated he used the information from his undocumented conversation with the Staff D LPN on 05/12/23 and the witness statement from the DON with Staff C Agency Nurse, Registered Nurse (RN) to determine that the incident was not an elopement. During an interview on 06/06/23 at 5:00 pm, the Director of Nursing (DON) explained how the elopement decision was made based on Resident #2's elopement evaluation form dated 05/12/23. The DON stated using this elopement evaluation form Resident #2 would have been considered as a high elopement risk and proceed to behavioral elopement care plan. The DON stated based on Resident #2's active DTs, behaviors, behavioral medications, and history, I would still indicate her as an elopement risk on 05/11/23 prior to the elopement. The DON stated she did not know why the admissions observation evaluation form was not completed by the nurse as it was her expectation it be completed on admission. During an interview on 06/06/23 at 9:00pm, Staff D Nighttime Nursing Supervisor, Licensed Practical Nurse (LPN) stated that she did complete a witness statement for the 05/12/23 elopement incident on 06/05/23. Staff D LPN stated she talked with the DON on the phone at approximately 8:00am on 05/12/23; the DON asked her to confirm if the elopement occurred and if it was reported to her. Staff D LPN stated she informed the DON the Agency Nurse reported the incident to her, and the DON informed her that she would need a witness statement as the elopement was a reportable event. Staff D LPN stated she was approached on 06/05/23 and was asked for her witness statement in writing regarding the 05/12/23 incident so she wrote it up on 06/05/23 as requested. During an interview on 06/07/23 at 9:45am, the Administrator confirmed there were no working security cameras in the facility and no video to review of the incident on 05/12/23. 106103 Page 26 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0867 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/07/23 at 10:38 am, the Director of Nursing stated when she assessed Resident #2 on the elopement evaluation dated 05/12/23 she observed Resident #2 having tremors. The DON stated Resident #2 continued to show a lot of confusion and appeared to be having some hallucinations. The DON confirmed Resident #2 was prescribed both Lithium and Valium (sedative medications) and said those medications would have also made Resident #2 a risk for elopement. Residents Affected - Many An observation of [name of road] in front of the facility revealed a six (6) lane highway. Observation showed the road consisted of two Northbound lanes with a third outside lane designated for bus/turn lane and two Southbound lanes with a third outside lane designated for bus/turn lane. There was a median separating the 3 northbound lanes from the southbound lanes. [name of road] had a total of six (6) lanes. Photog[TRUNCATED] 106103 Page 27 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and facility record review the facility failed to ensure one of one dish washing machines was operating effectively for one day (3/27/2023) of four days observed. Residents Affected - Some Findings included: On 3/27/2023 at 9:12 a.m. the kitchen was toured with a Regional Dietary Manager (RDM), who she stated she was filling in at the center. The RDM revealed the kitchen does operate with a low temperature dish washing machine and staff were in the process of running it at this time. The RDM provided the dish machine temperature log for review and indicated she believed that an outside maintenance service for the dish machine has not been needed to come out and service the machine. She, along with Staff B, Dietary Aide and Staff A, Dietary Aide revealed there had not been any problems with the machine lately. At this time, Staff B stated she was unsure of what type of dish machine they used. She stated, I only scrape (the food off the plates), I don't run it; someone else runs it. Staff A, Dietary Aide revealed she operated the dish machine. She stated they had run the machine that morning. She again, confirmed she ran crates of dishes through already. Staff A confirmed the dish machine operated at low wash and rinse temperatures with a sanitizer solution. She was unsure what the wash and rinse temperatures should reach. She indicated the litmus paper (sanitizer test strip) should be dark purple. Staff A and the RDM started to look for the dish machine specification sticker to validate what the temperatures should be. Staff A replied, The wash cycle temperature should reach at least 120 degree Fahrenheit (F) , and the rinse cycle temperature should reach at least 120 degree F. Staff A and the RDM were asked to run a dish machine for demonstration. Staff A confirmed the machine did not need to be primed and it was working fine. On 3/27/23 at 9:25 a.m. the first dish machine demonstration was observed and revealed: Wash temperature reached 135 degrees F.; Rinse temperature reached 140 degrees F. Staff A then grabbed the tube of litmus paper to demonstrate the sanitizer cycle. She waited for the crate of dishes to come out of the end of the machine and then placed a test strip on a bowl that had water on it. The litmus paper did not change color and remained the original white color. The color legend on the side of the sanitizer test strip bottle revealed 50 - 100 parts per million (ppm) should be a medium to dark purple in color. Staff A confirmed the litmus paper did not change color. Staff A stated the color should have been a deep purple. (Photographic Evidence Obtained) At 9:31 a.m., a second dish machine demonstration was observed and Staff A grabbed the tube of litmus paper to demonstrate the sanitization. She waited for the crate of dishes to come out of the end of the machine and then placed a test strip on the bowl that had water on it. The litmus paper did not change color and remained the original white color. Staff A confirmed the litmus paper did not change color. (Photographic Evidence Obtained) After this demonstration, the RDM revealed she would need to prime the sanitizer pump. She reached up on top of the dish machine and pressed a button several times. She revealed that pressing the button and priming the system should enable the sanitizer to come through now. At 9:40 a.m., a third dish machine demonstration was observed and Staff A waited for the crate of dishes to come out of the end of the machine and then placed a test strip on bowl that had water on it. The litmus paper did not change color and remained the original white color. Staff A confirmed 106103 Page 28 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the litmus paper did not change color (Photographic Evidence Obtained). The RDM revealed she was now not sure what the problem was and she would have to call the outside dish machine service company out to investigate the issue. The RDM revealed all dishes would still be washed through the dish machine, but staff would now take the dishes to the three compartment sink and run them through the sanitizer there. On 3/27/2023 at 2:00 p.m. the RDM indicated the outside dish machine service company came out and nothing was wrong with the machine itself. They determined the issue was the probe that runs the sanitizing solution to the machine was not inserted into the sanitizer solution far enough. She indicated this was resolved, and staff were educated. Review of the facility's policy and procedure titled, Equipment, revised on 9/2017, revealed: Policy and Procedure: All food service equipment will be clean, sanitary, and in proper working order. The procedure section revealed; 1. All equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after each use. 4. All non-food contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 106103 Page 29 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe environment for two (First Floor Hallway and Second Floor) of two units regarding unlocked storage rooms containing potentially hazardous supplies and chemicals. Findings included: 1. On 3/27/2023 at 11:18 a.m. the first-floor hallway was observed as a short hallway with occupied resident rooms (room [ROOM NUMBER] and 112) and administrative offices. Room numbers 113 and 115, at the end of the hall, were both observed to be storage rooms for maintenance items; both rooms were unlocked. The door to room [ROOM NUMBER] had a round doorknob with key access, the door to room [ROOM NUMBER] had a door handle with no locking mechanism and was fully open. The items in the rooms included: full paint thinner cans; full and opened cans of paint; multiple cans and containers of paint thinner, exterior primer, spackle, caulk; hand tools and electric/battery powered tools, light bulbs lying around and empty metal bed frames. One resident resided in each room [ROOM NUMBER] and 112, both were mobile with devices. On 3/27/2023 between 11:15 a.m. to 2:20 p.m., four observations were made on the first-floor hallway. The door to room [ROOM NUMBER] was fully open. At least 5 residents were observed wandering, walking or self-propelling in wheelchairs near rooms [ROOM NUMBERS]. One resident was observed to walk past room [ROOM NUMBER], look inside and continued walking. On 3/27/2023 at 2:22 p.m. an interview was conducted with the Maintenance Director (MD) regarding resident rooms 113/115. He stated when he is not in the center, he locks the doors. He continued to state, The doors are not locked if I am here, as I am going in and out of the rooms. The MD confirmed room [ROOM NUMBER] did have a doorknob that locked. He opened the unlocked door and confirmed the room was being utilized as storeroom where he fixed beds and does other various maintenance activities. In room [ROOM NUMBER], he stated this room is just the same and confirmed the door was open and the door handle did not have a lock. He said it should have a doorknob that locks, and stated this was just missed. The MD confirmed the hazard potential of the rooms. On 3/27/2023 at 2:45 p.m. the MD stated he locked the doors, and they will be kept locked at all times. 2. On 3/30/2023 at 9:10 a.m. an observation was conducted with the Interim Certified Dietary Manager (CDM) from another center, of the second-floor, containing 46 residents. Located in the center of the unit, a door with a keypad labeled Medical Supplies and Clean Utility was observed to be unlocked. Inside the room, near the door, was an unlocked treatment cart with a note affixed to it Do Not Lock; medical supplies such as syringes, alcohol prep pads, gauze, ointments and lancet devices were observed inside the cart. Items in the room included an unlabeled container of honey thick substance, orange in color, an unlabeled gallon sized bottle of a clear liquid, shampoo, lotion, razors, and other personal care products. During survey there were multiple observations on this floor of residents walking, wandering and self-propelling in wheelchairs past this room. Residents on the second floor have to have a code to get on the elevator to assist in providing safety due to cognitive deficits. 106103 Page 30 of 31 106103 03/30/2023 Gulfport Nursing Center 1430 Pasadena Ave S Pasadena, FL 33707

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/30/2023 at 12:15 p.m. an interview and observation was conducted with Staff E, CNA, regarding the Medical Supplies and Clean Utility room. The door was observed to be locked. Staff E, CNA said the lock usually does not work, and the door is open. He is not sure why it is locked right now. He opened the door with a code, closed the door then reopened the door, no code was needed the second time. On 3/30/2023 at 12:20 p.m. an interview was conducted with Staff H, CNA stated that the Medical Supplies and Clean Utility door was usually unlocked. She does not even know if there is a code as she has never had to utilize one. On 3/30/2023 at 12:30 p.m. an interview conducted with Staff D, RN stated the Medical Supplies and Clean Utility door should lock. The keypad lock usually does not work, and the door is usually open. Although the door does locks at times, it is unpredictable. On 3/30/2023 at 10:30 a.m. an interview conducted with the Nursing Home Administrator, (NHA). He stated that the storage rooms should be locked. Policies and procedures regarding the storage of hazardous liquids and supply storage were requested on 3/30/2023. The requested policies and procedures were not provided for review. 106103 Page 31 of 31