Health inspection·August 21, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policy review, the facility failed to protect the residents' right to be free from neglect for four residents (#1, #4, #2, and #3) of seven sampled residents related to: 1. two staff members (G and H) failed to implement the care planned transfer intervention for one resident (#1) resulting in the resident being transferred incorrectly and Resident #1 obtained a humeral neck fracture, 2. One staff member (Staff L) failed to gain consent for a strait catheterization for one resident (#4), 3. the facility failed to prevent neglect by the lack of documentation of an assessment for a change in condition for one resident (#2), and 4. the facility failed to timely implement a new admission which resulted in one resident (#3) being transferred back to the hospital. Findings included: 1. A review of the facility's policy titled, Administrator/Employment Administration/Nursing Policies/Risk Management/Social Services/Staff Development-Abuse, Neglect, Exploitation & Misappropriation, undated, on page 7, documented the definitions of neglect and mistreatment as: Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. Mistreatment: Mistreatment means inappropriate treatment or exploitation of a resident. Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm. Person centered care: For purposes of this subpart, person center-care means to focus on the residents as the locus of control and support the resident in making their own choices and having control over their daily lives. On 08/21/2023 at 1:54 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA stated on 07/01/2023, no time given, the resident complained of Page 1 of 15 106120 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shoulder pain. An X-ray was ordered on 07/01/2023 at 5:14 p.m. The NHA said she became aware of the results of the Xray on 07/02/2023. Because it was a fracture of unknown origin at that moment, the NHA stated an investigation was conducted and the results were staff were suspended. The NHA stated, We did not feel that they did anything harmful to her, but we found they did not transfer her correctly. The correct transfer would be the Hoyer lift. The NHA stated the resident said, she could stand up. They should have gone and checked the Kardex (a desktop file system that gives a brief overview of each patient), and they did not. They were both new and new to the patient. They did not know the resident. They should have checked the Kardex. They should have followed the Kardex. The aides said there was nothing that occurred during the transfer that may have caused it. Then the DON said the resident had osteopenia; her bones are brittle. The NHA said, I do not know if you have seen her, but her head leans to one side; she has contractures; there is strain already. The NHA reported education for the nursing staff was conducted. Before assisting in a resident transfer, it is mandatory you confirm the proper transfer technique required for the resident. Such as stand pivot, sit to stand, or Hoyer by reviewing the resident's Kardex in the (electronic clinical record) to ensure the resident's safety. The NHA stated the two aides were written up. The NHA stated we felt in the end, although we did have something happen, but we did not cause it. After talking to the doctor, we did not feel our staff caused the injury and with osteopenia there is the likelihood of something happening even when she is turned in bed. A review of Resident #1's admission Record documented an admission date of 04/01/2021. Her diagnoses information included: contractures of muscle, multiple sites; lack of coordination; muscle weakness (generalized); vascular dementia, unspecified severity; syncope and collapse and unspecified osteoarthritis. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section G - Functional Status documented for Transfers, the resident was total dependence with two + persons physical assist. Section C - Cognitive Patterns, dated 04/10/2023, documented a Brief Interview for Mentals Status score of 14, which meant the resident was cognitively intact. A review of Resident #1's Care Plan with a Focus Area of Activities of Daily Living (ADL) documented the resident had an ADL self-care performance deficit, initiated 04/02/2021. The interventions for transfer included: She [Resident #1] requires Mechanical Lift (Hoyer) with (2) staff assistance for transfers, created on 06/30/2021. A review of a SBAR (Situation, Background, Assessment, Recommendation) Communication and Progress Note, dated 07/01/2023, 16:00 (4:00 p.m.), documented the nursing notes as: On morning shift, the resident was transferred by stand and pivot verse the lift. She states that when she did, she felt her shoulder pop and there has been pain since. Resident has limited mobility and states her pain is 10/10. A review of a SBAR, dated 07/01/2023 at 17:00 (5:00 p.m.), documented the nursing notes as: CNA [certified nursing assistant] transferred patient via stand and pivot vs. [versus] Hoyer. Resident now c/o [complaint of] pain 10/10. States It happened this morning during transfer from bed to wheelchair. Nurse gave Tramadol 25 MG [milligram] for pain. Alerted MD [medical doctor] who requested xray of left shoulder. A review of Resident #1's progress notes, 07/02/2023, 16:17 (4:17 p.m.) showed: Nursing Note: X-ray result shows: Acute humeral neck fracture. Results sent to MD with new orders to send to ER (emergency room) for evaluation. Resident is alert and complains of mostly shoulder pain .EMS [emergency 106120 Page 2 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0600 medical services] in facility at time to transport resident to [local hospital]. Level of Harm - Minimal harm or potential for actual harm On 08/21/2023 at 12:30 p.m. an interview was conducted with Staff G, Certified Nursing Assistant (CNA). She confirmed she gave Resident #1 a shower with another aide on 07/01/2023. She did not recall the name of the other aide. She said she worked 7:00 a.m. to 3:00 p.m., and she usually will do showers in the morning. She did not recall the time the shower was given. She said she did not have access to the (electronic medical record). She stated before the transfer, she reached out to the [technology support team]. She asked the resident and Resident #1 told her she was a two-person pivot. Staff G went to two other CNAs and they both said Resident #1 was a 2-person pivot. Staff G went to the pantry and asked Staff H, CNA to help her (with the transfer.) While Staff G was waiting, she saw the nurse, Staff I, Licensed Practical Nurse (LPN) and told her she did not have access to (the electronic medical record) and asked her what kind of transfer the resident was. Staff I, LPN said, if the resident and the aides tell you she is a two-person pivot, she is a two-person pivot. Then Staff H, CNA and Staff G, CNA went to the room, adjusted the bed, sat Resident #1 upright in the bed, and transferred her into the shower chair. Staff G stated they brought her into the shower, turned on the water and Resident #1 said I have a lot of pain in my shoulder. Her head is leaning, and she signals with her eyes. She said they normally put cream on her knee and neck for pain. Staff G went to Staff I, LPN and told her Resident #1 was complaining of shoulder pain. Staff I, LPN asked where the resident was at the time, and I told her she was in the shower. The nurse (Staff I, LPN) said, well, get her back in bed and I am headed that way now. (Staff J, CNA) was standing there with me. When (Staff I, LPN) said that, I said, I did not want to transfer her back into the bed as she was complaining of pain, utilizing the two-person pivot. At this time, Staff J, CNA, said, let me look at her (electronic medical record) and stated, she was a Hoyer lift. We hoyered her back to bed. Once we had her in bed, Staff I, LPN came in and spoke with the resident. She had the cream and she asked the resident what was going on; at that point I left the room. Staff G stated she worked into the next shift and went into the resident's room because at the beginning of the shift, you had to get vitals and Resident #1 was still complaining of pain. Staff G saw Staff B, LPN/Unit Manager (Unit Manager) and let her know. Staff B, LPN/UM ordered an X-ray . It was my fault; I know I transferred her. Residents Affected - Some A review of the facility's Baseline Plan of Care policy and procedure, dated December 2017, documented the purpose: To develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. An interview conducted on 08/21/2023 at 5:36 p.m. with the DON, she stated the policy for the Baseline Care plan was the policy the facility had. This was the Care Plan policy. The Baseline Care plan converts to the comprehensive care plan after 21 days. 2. A review of the admission Record showed Resident #4 had an admission date of 7/5/23 and diagnoses to include urinary tract infection, chronic candidiasis of vulva and vagina. A review of the MDS, signed 8/14/23, showed in Section C - Cognitive Patterns a BIMS score of 15 out of 15 indicating cognitively intact. Section G - Functional Status showed Resident #4 required extensive assistance with bed mobility, and toilet use. On 08/21/2023 at approximately 2:00 p.m. during an interview the NHA confirmed Resident #4's allegation of abuse. The NHA stated the allegation was on 07/25/2023 at 1:30 p.m. The resident stated her night shift nurse, (Staff L, LPN) performed a catheter procedure to obtain a urine sample without her consent. According to Resident #4, on 07/24/2023, Staff L, LPN, informed Resident #4 she was 106120 Page 3 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some following a doctor's order to obtain a urine sample and she needed to complete the order, however, Resident #4 stated the sample was already obtained a couple days prior and shouldn't need to be done again. Resident #4 expressed the nurse obtained the sample even after being told not to. The resident was adamant about not wanting to be strait catharized due to urinary tract infection risk. The nurse should have stopped and checked. The resident is alert and oriented. What occurred was the order had been put in without a stop date so, it popped up that the nurse should complete the task. The resident was competent. We felt that if the nurse had checked, she would have found the error, and not collected the sample. The nurse was terminated. 3. A review of Resident #3's paper hospital records revealed a Hospital admission History and Physical, dated 08/05/2023, that showed: The patient presents .with a past medical history of hypertension, COPD (Chronic obstructive pulmonary disease) wears home O2 (oxygen) at night .presents emergency room after having a mechanical fall . falling backwards hit head patient did suffer a laceration to back of head that did require sutures . patient has had multiple mechanical falls over the past month . Further review of the hospital records revealed a Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form, 3008, dated 08/08/2023, listing medical conditions of Fall at home, closed head injury, and impaired mobility. Patient risk alerts: Pressure Ulcer and Falls. Treatment Devices listed Oxygen; 2 liters continuous. On 08/22/2023 at 2:00 p.m., a family member of Resident #3 was interviewed by phone. She stated Resident #3 was transported from the hospital on [DATE] at 6:30 p.m., he would have arrived at the facility no later than 7:00 p.m. and then at 8:15 p.m. Resident #3 called me in distress. He said there was no oxygen, no rails on his bed, and his urine bag was on his stomach. I asked my [family member], who lived a short distance from the facility, to go over. She got to the facility and a certified nursing assistant (CNA) was in the room. My [family member] asked the CNA for oxygen and stated Resident #3's O2 (oxygen) level was 79. I called the manager (Staff B, Licensed Practical Nurse [LPN]). (Staff B, LPN) told me the nurse (Staff D, LPN) deserved a lunch break. (Staff D, LPN) did come to the room when I was on the phone, I could hear what was said. She (Staff D) said, I have not read the chart, I do not know how much oxygen he is supposed to have. When they asked another nurse to help from another hall, she would not. He is a fall risk; they knew he was coming. He was not safe without bed rails. They did bring in the oxygen, and they got his O2 level to go up. I told (Staff B, LPN) this is negligence. (Staff B, LPN) called 911, and EMS (Emergency Medical Services) took him back to the hospital. This was a total lack of care. They should be accountable. He left the facility at about 9:50 p.m. The transporters had to stop at the front desk when they enter the facility. He was admitted back to the hospital. A review of the facility's electronic record system revealed no clinical documentation for Resident #3 having been admitted or assessed upon admission for the date of 08/10/2023. On 08/21/2023 at 3:15 p.m., an interview was conducted with the facility's Marketing Director and admission Director. The Marketing Director stated Resident #3 was put on a wait list, and when the nurse does the admission paperwork, it will update in the computer. They confirmed the admission assessment was not completed by the nurse. She further stated, we were told he went back to the hospital that evening. We were told he was put in the bed by transport. They put him in the bed without rails; he called his family. Nursing said he was put in the room without oxygen. The Marketing Director said she spoke with the transport persons and said the resident did not have oxygen during the transportation. They said they put him in a bed, the bed was low, and handed the paperwork to the nursing 106120 Page 4 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff. They did not say what time they brought him in. A representative from transport reached out and stated, There had been a blow up about the patient. We were told, (Resident #3) called the family. He called the [family member], and the [family member] called family that was close by. The family member came into the facility and allegedly found the resident and was upset and wanted the resident to go back to the hospital. I think he was in the building an hour and a half and all of this happened before the nurse could start on the paperwork. On 08/21/2023 at 3:39 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). They confirmed they had knowledge of Resident #3. The DON said she thought the resident came into the facility around 7:00 p.m. and was gone by 8:15 p.m. The NHA confirmed she submitted a Federal 5-day report for the event, and she had not substantiated the allegation of neglect. The NHA stated the admission was expected, the notification was given to us at 5:30 p.m., and he arrived around 7:00 p.m. The NHA stated she became aware of the situation between 8:30 p.m. and 9:00 p.m. when the Unit Manager (Staff B, LPN) called her because the family screamed at her. At this time, the family was in the building, the [spouse] and the [family member] and the resident were still in the building. Staff B, LPN told me they were upset because he called his [spouse], he needed his oxygen, and he did not have it. Staff E, CNA, helped the resident dial his [spouse]. Staff E, CNA, said he was not in any distress. She asked the resident if he needed anything else, then she went to the nursing station to ask for the paperwork, and to tell Staff D, LPN. Staff D, LPN had gone on break for lunch at around 8:00 p.m. Lunch is 30 minutes. The staff do not clock out for break. The DON said, the nurse (Staff D, LPN) did not know she had a new admission. She was passing medication in the adjacent hall. The transport persons dropped the paperwork off at the nursing desk and the nurse did not know. If the nurse knew she had a new admission, she would have gone and evaluated the resident, and checked the orders. For the oxygen, if the resident had an order for oxygen, she would have put the resident on oxygen. The transport company did not check in with the nurse. The NHA said, the receptionist (at the front desk entrance), could have been one of a couple of people. The front desk was there 8:00 a.m. to 8:00 p.m. The DON said, when the EMS transporters come to the building, the role of the receptionist is to direct the EMS to the assigned room, nothing else. The NHA said, for a new admission, if we know someone has arrived, immediate necessities would be reviewed within 15 minutes. The NHA stated the proactive measures implemented to prevent a future occurrence of a like kind event was, We are not using the transport company anymore. On 08/21/2023 at approximately 4:10 p.m., Staff E, CNA confirmed she worked the evening Resident #3 came to the facility. I went to look in his room, he asked me to make a phone call for him. Yes, I saw the transport people. For the shift, I was working with one nurse, I had never seen her before. I went to the nurses' station. The nurse (Staff D, LPN), was sitting at the nurses' station, and I asked for the paperwork. The nurse said it would be a few minutes. I did other things, and then I checked back with Resident #3 to see if he was wet. The paperwork I was asking for was for the vitals and the valuables (inventory). I did not do the paperwork; I did not get it. Then, I went back about thirty minutes later, and Staff F, CNA, told me Staff D, LPN went to lunch. Then, I went back to his room. His (family member) was there. She said, he needs oxygen, he needs oxygen. (The family member) used the vital system and she said she was an ARNP (Advanced Registered Nurse Practitioner), and his oxygen was at 79. I ran up and got the nurse, (Staff D, LPN) and she came back with me. The (family member) said he needs oxygen and then she started calling the other nurse names. Staff D, LPN said don't call me that. Then, Staff D, LPN went and got him some oxygen. I changed his linen on his bed. It looked like there was some blood on it. I got him a blanket. The family member said he was soaking wet, but he was not wet at all. The nurse came and 106120 Page 5 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gave him oxygen. EMS, I think the family member or [spouse] called them. They (EMS) were in the room. I heard them say his vitals were stable. On 8/21/2023 at approximately 4:30 p.m., the NHA said she had been in communication with her IT (information technology) department to review the video of the entrance for the times Resident #3 had entered and left the building. A video was presented of Resident #3 coming into the facility on a stretcher at approximately 7:00 p.m. A 2nd video was presented of EMS taking Resident #3 out of the building at approximately 9:47 p.m. Which would indicate the resident was present in the facility for approximately two hours and forty-five minutes. A review of the facility's policy titled, Admissions Policy, undated, documented: .An admission team will review all inquiries for admission. The Team will include the Administrator, Director of Nursing, Care Plan (MDS) Coordinator, Nurse Liaison, admission Coordinator, Social Service Director, and Office Manager. The admission team will follow facility policies regarding admissions. The team will review each inquiry carefully to assess services required. A decision will be made to accept or deny an admission based on the ability of the facility to provide needed services and availability of beds. Final approval to admit will be made by the Administrator. The Regional Director of Operations may be contacted for guidance and direction as needed. 4. During an interview on 08/21/2023 at 11:43 a.m. Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) stated Resident #2 was due for discharge back to hospice. The family member and a private caregiver came to pick him up. The family member stated the resident was not acting like himself and the family member went and got the nurse (Staff A, LPN). Staff A, LPN checked his blood sugar, and it was in the 40s, his vital signs were stable. Staff A gave the resident both Glucagon Intramuscular (IM) and gel. The family member was back and forth about the resident going to the hospital or not. The resident started coming around. We checked his blood sugar a second time and it was in the high 50s or low 60s. The resident was able to drink juice. He was not talking in full sentences as normal. Staff B, LPN/UM stated Resident #2 was back to normal before she left the room. She asked the family member if she wanted the facility to send him to the hospital. The family member stated she wanted to talk to the gentleman; they were going to discuss it. Staff B, LPN/UM went to the nursing desk to speak with Staff A, LPN and told him to let her know what the family decided. Staff B asked Staff A to get the papers together for a hospital transfer while the family was deciding, just in case. Staff B called the physician for the hospice service to let him know what was going on and that the resident was set for discharge and the family was deciding if he was going to the hospital or not. The physician asked if the family wanted the hospice nurse to come to the facility or meet them at home to assess the resident. The family decided to send the resident to the hospital. His vital signs and blood sugar was stable. Staff B, LPN/UM informed the family it was going to be a two-hour window before non-emergency transport would arrival. The resident was at baseline and was not an emergency transport. The family member decided to take the resident to the hospital herself and then take him home. Staff B, LPN/UM stated she did not recall the staff every telling her he had been hypoglycemic before. Staff B stated she saw the resident sitting in a wheelchair in the common area waiting for his family member. She verified there was no documentation in the medical record about this incident. No notes on his blood sugar, the Glucagon administration, none of it. She stated Staff A, LPN should have documented the incident. Staff B, LPN/UM verified that Staff A, LPN had administered Glucagon without an order. Review of the admission Record showed Resident #2 was admitted on [DATE] and discharged on 07/12/2023. Record review showed the diagnoses included but was not limited to diabetes, emphysema, difficulty walking, cognitive communication deficit, atrial fibrillation, chronic kidney disease, and 106120 Page 6 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0600 congestive heart failure. Level of Harm - Minimal harm or potential for actual harm Review of the Admission, Minimum Data Set, dated [DATE], showed he had a Brief Interview for Mental Status (BIMS) score of 09 or (moderately impaired). Section G - Functional Status showed he required extensive assistance for bed mobility and toileting and limited assistance for transfers. Residents Affected - Some Record review of the July 2023 physician orders and July 2023 Medication Administration Record showed on 07/12/2023 to send Resident #2 to the emergency room for lethargy; on 07/11/2023 an order to discharge the resident home with hospice services; on 07/12/2023 Two units of Aspart insulin was administered at 6:00 a.m. for a blood sugar of 168; and no order for Glucagon injection or gel. Record review of the progress notes showed no notes documented after 07/04/2023. Care plan review of the Discharge care plan, initiated 7/4/23, showed the resident was to be discharged home with his [family member]. Resident #2 had no care plan related to diabetes. During an interview on 08/21/2023 at 2:07 p.m. Staff C, CNA stated the resident was not feeling himself, he was out of it. He wanted to stay in bed which normally he was out and about. We checked his blood sugar, and it was low. The family came in and the family member stated he was not like himself. This was not like him to be like that. Staff C contacted Staff B, LPN/UM about the low blood sugar. The resident started talking and was fine .The family wanted the resident to go to the hospital and the family member was taking him. During an interview on 08/21/2023 at 11:43 a.m. Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) stated Resident #2 was due for discharge back to hospice. The family member and a private caregiver came to pick him up. The family member stated the resident was not acting like himself and the family member went and got the nurse (Staff A, LPN). Staff A, LPN checked his blood sugar, and it was in the 40s, his vital signs were stable. Staff A gave the resident both Glucagon Intramuscular (IM) and gel. The family member was back and forth about the resident going to the hospital or not. The resident started coming around. We checked his blood sugar a second time and it was in the high 50s or low 60s. The resident was able to drink juice. He was not talking in full sentences as normal. Staff B, LPN/UM stated Resident #2 was back to normal before she left the room. She asked the family member if she wanted the facility to send him to the hospital. The family member stated she wanted to talk to the gentleman; they were going to discuss it. Staff B, LPN/UM went to the nursing desk to speak with Staff A, LPN and told him to let her know what the family decided. Staff B asked Staff A to get the papers together for a hospital transfer while the family was deciding, just in case. Staff B called the physician for the hospice service to let him know what was going on and that the resident was set for discharge and the family was deciding if he was going to the hospital or not. The physician asked if the family wanted the hospice nurse to come to the facility or meet them at home to assess the resident. The family decided to send the resident to the hospital. His vital signs and blood sugar was stable. Staff B, LPN/UM informed the family it was going to be a two-hour window before non-emergency transport would arrival. The resident was at baseline and was not an emergency transport. The family member decided to take the resident to the hospital herself and then take him home. Staff B, LPN/UM stated she did not recall the staff every telling her he had been hypoglycemic before. Staff B stated she saw the resident sitting in a wheelchair in the common area waiting for his family member. She verified there was no documentation in the medical record about this incident. No notes on his blood sugar, the Glucagon administration, none of it. She stated Staff A, LPN should have documented the incident. Staff B, LPN/UM verified that Staff A, LPN had administered Glucagon without an order. 106120 Page 7 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Emergency Kit transactions showed Staff A, LPN signed out Glucagon 1 milligram (mg) on 07/12/23 at 11:25 a.m., but to another resident with the same last name as Resident #2. During an interview on 08/21/23 at 3:00 p.m. Staff B, LPN/UM stated that Staff A, LPN pulled the Glucagon from the EDK (emergency kit) but signed it out to another resident with the same last name. She stated that one dose of Glucagon was given, and the gel is over the counter and in the medication carts. Record review of the facility's policy titled, Nursing-Change in a Residents Condition or /status, undated, showed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/ mental condition and / or status. 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical / mental condition or status. Record review of the facility's policy titled, Administering Medication, revised April 2014, showed 4. Medication are administered in accordance with prescriber orders, including any required time frame. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered. b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. 106120 Page 8 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure an Interdisciplinary Discharge Summary included all the required elements and was in the medical record, and failed to ensure a Post Discharge Plan of Care was completed for two residents (#5, #7) with anticipated discharges of three sampled residents. Findings included: 1. Record review of the facility's policy titled, Social Service-Discharge Process, undated, showed the facility will promote resident discharge from the facility based on the resident's preferences and abilities. Planned discharge will be conducted in an orderly, consistent and supportive manner. 4. A physician order will be obtained for discharge. 5. The Post-Discharge Plan of Care, form will be completed by the Social Services Director with the assistance of the Interdisciplinary Team and will be reviewed with the resident/designated representative on the day of discharge. A copy of the Post-Discharge Plan of Care will be given to the resident or designated representative. Th original Post-Discharge Plan of Care will be placed in the resident's medical record. 5. The Interdisciplinary Discharge Summary (Recapitulation of Resident's Stay) will be completed and filed in the medical record. Review of the admission Record showed Resident #7 had an original admission date of 05/06/2023 and was readmitted on [DATE] and discharged on 08/17/2023. Review of Resident #7's medical record revealed it lacked an Interdisciplinary Discharge Summary. Review of the Discharge care plan, initiated 5/9/23, showed the resident was to be discharged back home once she had met her goals. During an interview on 08/21/2023 at 2:45 p.m. the Assistant Director of Nursing (ADON) stated she was going to the social services department to see if the Interdisciplinary Discharge Summary was there. She stated they pass the Interdisciplinary Discharge Summary around from department to department for it to be filled out. She stated there was supposed to be an Interdisciplinary Discharge Summary completed on discharge. On 08/21/2023 at 3:34 p.m. the Director of Nursing (DON) brought the Interdisciplinary Discharge Summary in and stated it was in Activities. Review of the Interdisciplinary Discharge Summary with the DON revealed the nursing services and dietary status was not completed. She also verified the medical record lacked the Post-Discharge Plan of Care. 2. Review of the admission Record for Resident #5 showed a discharged date on 08/17/2023. Review of Resident #5's medical record showed a lack of an Interdisciplinary Discharge Summary. Review of the progress notes showed on 08/10/2023 that all discharge instructions had been reviewed and signed with patient and [spouse], who verbalized understanding, and had no additional questions at this time. Patient exited the facility via [spouse] and wheelchair. Review of the Discharge care plan, initiated on 7/12/23, showed the resident was to be discharged back home with a family member. 106120 Page 9 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0661 Level of Harm - Minimal harm or potential for actual harm On 08/21/2023 at 3:34 p.m. the DON brought the Interdisciplinary Discharge Summary in and stated it was in Activities. Review of the Interdisciplinary Discharge Summary with the DON revealed the vital signs were missing from the nursing services section and the dietary status was not completed. She also verified the medical record lacked the Post-Discharge Plan of Care. Residents Affected - Some 106120 Page 10 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure adequate supervision and assistance was implemented during a transfer for one resident (#1) of five residents sampled. Resident #1 was care planned to receive a mechanical lift transfer and on 07/01/2023 two staff members (G and H) verified the transfer status verbally from the resident and staff and failed to confirm the transfer status in the care plan. Resident #1 was assisted utilizing a stand and pivot transfer resulting in pain and subsequently an X-ray result identified an acute humeral neck fracture. Findings included: A review of Resident #1's admission Record documented an admission date of 04/01/2021. Her diagnoses information included: contractures of muscle, multiple sites; lack of coordination; muscle weakness (generalized); vascular dementia, unspecified severity; syncope and collapse and unspecified osteoarthritis. A review of Resident #1's Minimum Data Set (MDS), dated [DATE], Section G - Functional Status documented for Transfers, the resident was total dependence with two + persons physical assist. Section C - Cognitive Patterns, dated 04/10/2023, documented a Brief Interview for Mentals Status score of 14, which meant the resident was cognitively intact. A review of Resident #1's Care Plan with a Focus Area of Activities of Daily Living (ADL) documented the resident had an ADL self-care performance deficit, initiated 04/02/2021. The interventions for transfer included: She [Resident #1] requires Mechanical Lift (Hoyer) with (2) staff assistance for transfers, created on 06/30/2021. A review of a SBAR (Situation, Background, Assessment, Recommendation) Communication and Progress Note, dated 07/01/2023, 16:00 (4:00 p.m.), documented the nursing notes as: On morning shift, the resident was transferred by stand and pivot verse the lift. She states that when she did, she felt her shoulder pop and there has been pain since. Resident has limited mobility and states her pain is 10/10. A review of a SBAR, dated 07/01/2023 at 17:00 (5:00 p.m.), documented the nursing notes as: CNA [certified nursing assistant] transferred patient via stand and pivot vs. [versus] Hoyer. Resident now c/o [complaint of] pain 10/10. States It happened this morning during transfer from bed to wheelchair. Nurse gave Tramadol 25 MG [milligram] for pain. Alerted MD [medical doctor] who requested xray of left shoulder. A review of Resident #1's progress notes, 07/02/2023, 16:17 (4:17 p.m.) showed: Nursing Note: X-ray result shows: Acute humeral neck fracture. Results sent to MD with new orders to send to ER (emergency room) for evaluation. Resident is alert and complains of mostly shoulder pain .EMS [emergency medical services] in facility at time to transport resident to [local hospital]. On 08/21/2023 at 12:30 p.m. an interview was conducted with Staff G, Certified Nursing Assistant (CNA). She confirmed she gave Resident #1 a shower with another aide on 07/01/2023. She did not recall the name of the other aide. She said she worked 7:00 a.m. to 3:00 p.m., and she usually will do showers in the morning. She did not recall the time the shower was given. She said she did not have 106120 Page 11 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0689 Level of Harm - Actual harm Residents Affected - Few access to the (electronic medical record). She stated before the transfer, she reached out to the [technology support team]. She asked the resident and Resident #1 told her she was a two-person pivot. Staff G went to two other CNAs and they both said Resident #1 was a 2-person pivot. Staff G went to the pantry and asked Staff H, CNA to help her (with the transfer.) While Staff G was waiting, she saw the nurse, Staff I, Licensed Practical Nurse (LPN) and told her she did not have access to (the electronic medical record) and asked her what kind of transfer the resident was. Staff I, LPN said, if the resident and the aides tell you she is a two-person pivot, she is a two-person pivot. Then Staff H, CNA and Staff G, CNA went to the room, adjusted the bed, sat Resident #1 upright in the bed, and transferred her into the shower chair. Staff G stated they brought her into the shower, turned on the water and Resident #1 said I have a lot of pain in my shoulder. Her head is leaning, and she signals with her eyes. She said they normally put cream on her knee and neck for pain. Staff G went to Staff I, LPN and told her Resident #1 was complaining of shoulder pain. Staff I, LPN asked where the resident was at the time, and I told her she was in the shower. The nurse (Staff I, LPN) said, well, get her back in bed and I am headed that way now. (Staff J, CNA) was standing there with me. When (Staff I, LPN) said that, I said, I did not want to transfer her back into the bed as she was complaining of pain, utilizing the two-person pivot. At this time, Staff J, CNA, said, let me look at her (electronic medical record) and stated, she was a Hoyer lift. We hoyered her back to bed. Once we had her in bed, Staff I, LPN came in and spoke with the resident. She had the cream and she asked the resident what was going on; at that point I left the room. Staff G stated she worked into the next shift and went into the resident's room because at the beginning of the shift, you had to get vitals and Resident #1 was still complaining of pain. Staff G saw Staff B, LPN/Unit Manager (Unit Manager) and let her know. Staff B, LPN/UM ordered an X-ray . It was my fault; I know I transferred her. During this interview Staff G said, I think the guy from [technology support team] called me the next day (after the event) and told me the log in and password. Staff G, CNA, said her orientation was on 06/28/2023; she was off on 06/29/2023; on 06/30/2023 (Saturday), she was with someone; and on 07/01/2023 (Sunday) she was on the schedule. On 08/21/2023 at 12:15 p.m., an interview was conducted with Staff B, LPN/UM. Staff B, LPN/UM said (Staff G, CNA) was rounding; she let me know that during Resident #1's transfer for the shower, there was pain, this was about 4:30 p.m. on 07/01/2023. I went to Staff M, LPN, she was working the 3:00 p.m. - 11:00 p.m. shift, and I asked her what the prior shift nurse (Staff I, LPN), said about the pain Resident #1 was having. At that time, Staff M, LPN was unaware of the reported pain. So, I asked Staff M, LPN to assess the situation and follow up on it. Staff M, LPN went and the patient was complaining of a 10/10 pain in the left arm. The doctor was notified doctor and we got a STAT (immediate) X-ray. This was around 5:30 p.m. I believe the mobile X-ray was not done until the morning. I do not know if Staff M notified the [family member]. Staff M, LPN, should have notified her. Staff B, LPN/UM, pointed out Resident #1's face sheet indicated the [family member] was the responsible party and should have been called. Staff B, LPN/UM confirmed the medical record reflected no documentation the [family member] was notified on 07/01/2023. Staff B, LPN/UM said she was aware a nurse had called the [family member] on 07/02/2023 when the positive results of the X-ray were received. On 08/21/2023 at 1:54 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA stated on 07/01/2023, no time given, the resident complained of shoulder pain. An X-ray was ordered on 07/01/2023 at 5:14 p.m. The NHA said she became aware of the results of the Xray on 07/02/2023. Because it was a fracture of unknown origin at that moment, the NHA stated an investigation was conducted and the results were staff were suspended. The NHA stated, We did not feel that they did anything harmful to her, but 106120 Page 12 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0689 Level of Harm - Actual harm Residents Affected - Few we found they did not transfer her correctly. The correct transfer would be the Hoyer lift. The NHA stated the resident said, she could stand up. They should have gone and checked the [NAME] (a desktop file system that gives a brief overview of each patient), and they did not. They were both new and new to the patient. They did not know the resident. They should have checked the [NAME]. They should have followed the [NAME]. The aides said there was nothing that occurred during the transfer that may have caused it. Then the DON said the resident had osteopenia; her bones are brittle. The NHA said, I do not know if you have seen her, but her head leans to one side; she has contractures; there is strain already. The NHA reported education for the nursing staff was conducted. Before assisting in a resident transfer, it is mandatory you confirm the proper transfer technique required for the resident. Such as stand pivot, sit to stand, or Hoyer by reviewing the resident's [NAME] in the (electronic clinical record) to ensure the resident's safety. The NHA stated the two aides were written up. The NHA stated we felt in the end, although we did have something happen, but we did not cause it. After talking to the doctor, we did not feel our staff caused the injury and with osteopenia there is the likelihood of something happening even when she is turned in bed. A review of the facility's Baseline Plan of Care policy and procedure, dated December 2017, documented the purpose as: To develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. During an interview conducted on 08/21/2023 at 5:36 p.m. the DON stated the policy for the Baseline Care plan was the policy the facility had. This was the Care Plan policy. The Baseline Care plan converts to the comprehensive care plan after 21 days. 106120 Page 13 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed ensure medical records were complete and accurate for one resident (#2) related to a change in condition which warranted emergency administration of medication and monitoring of three sampled residents. Findings included: Review of the admission Record showed Resident #2 was admitted on [DATE] and discharged on 07/12/2023. Record review showed the diagnoses included but was not limited to diabetes, emphysema, difficulty walking, cognitive communication deficit, atrial fibrillation, chronic kidney disease, and congestive heart failure. Review of the Admission, Minimum Data Set, dated [DATE], showed he had a Brief Interview for Mental Status (BIMS) score of 09 or (moderately impaired). Section G - Functional Status showed he required extensive assistance for bed mobility and toileting and limited assistance for transfers. Record review of the July 2023 physician orders and July 2023 Medication Administration Record showed on 07/12/2023 to send Resident #2 to the emergency room for lethargy; on 07/11/2023 an order to discharge the resident home with hospice services; on 07/12/2023 Two units of Aspart insulin was administered at 6:00 a.m. for a blood sugar of 168; and no order for Glucagon injection or gel. Record review of the progress notes showed no notes documented after 07/04/2023. Care plan review of the Discharge care plan, initiated 7/4/23, showed the resident was to be discharged home with his [family member]. Resident #2 had no care plan related to diabetes. During an interview on 08/21/2023 at 11:43 a.m. Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) stated Resident #2 was due for discharge back to hospice. The family member and a private caregiver came to pick him up. The family member stated the resident was not acting like himself and the family member went and got the nurse (Staff A, LPN). Staff A, LPN checked his blood sugar, and it was in the 40s, his vital signs were stable. Staff A gave the resident both Glucagon Intramuscular (IM) and gel. The family member was back and forth about the resident going to the hospital or not. The resident started coming around. We checked his blood sugar a second time and it was in the high 50s or low 60s. The resident was able to drink juice. He was not talking in full sentences as normal. Staff B, LPN/UM stated Resident #2 was back to normal before she left the room. She asked the family member if she wanted the facility to send him to the hospital. The family member stated she wanted to talk to the gentleman; they were going to discuss it. Staff B, LPN/UM went to the nursing desk to speak with Staff A, LPN and told him to let her know what the family decided. Staff B asked Staff A to get the papers together for a hospital transfer while the family was deciding, just in case. Staff B called the physician for the hospice service to let him know what was going on and that the resident was set for discharge and the family was deciding if he was going to the hospital or not. The physician asked if the family wanted the hospice nurse to come to the facility or meet them at home to assess the resident. The family decided to send the resident to the hospital. His vital signs and blood sugar was stable. Staff B, LPN/UM informed the family it was going to be a two-hour window before non-emergency transport would arrival. The resident was at baseline and was not an emergency transport. The family member decided to take the resident to the hospital herself and then take him 106120 Page 14 of 15 106120 08/21/2023 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0842 Level of Harm - Minimal harm or potential for actual harm home. Staff B, LPN/UM stated she did not recall the staff every telling her he had been hypoglycemic before. Staff B stated she saw the resident sitting in a wheelchair in the common area waiting for his family member. She verified there was no documentation in the medical record about this incident. No notes on his blood sugar, the Glucagon administration, none of it. She stated Staff A, LPN should have documented the incident. Staff B, LPN/UM verified that Staff A, LPN had administered Glucagon without an order. Residents Affected - Few Review of the Emergency Kit transactions showed Staff A, LPN signed out Glucagon 1 milligram (mg) on 07/12/23 at 11:25 a.m., but to another resident with the same last name as Resident #2. During an interview on 08/21/23 at 3:00 p.m. Staff B, LPN/UM stated that Staff A, LPN pulled the Glucagon from the EDK (emergency kit) but signed it out to another resident with the same last name. She stated that one dose of Glucagon was given, and the gel is over the counter and in the medication carts. Record review of the facility's policy titled, Nursing-Change in a Residents Condition or /status, undated, showed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/ mental condition and / or status. 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical / mental condition or status. Record review of the facility's policy titled, Administering Medication, revised April 2014, showed 4. Medication are administered in accordance with prescriber orders, including any required time frame. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered. b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug. 106120 Page 15 of 15