Health inspection·January 16, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident's family interview, staff interviews and record review the facility failed to ensure 1 (Resident #2) of 3 grievances reviewed had documentation of the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the complainant's concern(s), a statement as to whether the complaint was confirmed or not confirmed, and the complainant was given a summary of the pertinent findings or conclusions regarding their concern(s). The findings included: The facility's Grievance/Concern Policy dated 3/2010 and last revised 5/1/23 stated: 1. Residents, resident representative or other individual on the resident's behalf, have the right to file a grievance with the facility at any time, without fear of discrimination or reprisal. 2. A grievance may include those with respect to care and treatment which has been furnished as well as that which has not been furnished, . and other concerns regarding their stay. 3. Grievance can be filed verbally or in writing, using the Grievance/Concern Form. 4. Grievances can be submitted to the social worker, Executive Director/Residence Director, or any manager/supervisor. The facility will make prompt efforts to resolve grievances including but not limited to grievances from residents and/or family council. 5. Grievances will be routed and tracked by Grievance Officer/social services or designee. 6. The grievance will be responded to within 7 days , and the facility will notify the complainant to provide updates on resolution for the complaint. 7. The manager responsible for investigating and resolving the grievance will complete the Grievance/Concern Form, including a plan for resolution. 8. The complainant will be informed of the final outcome and resolution. All communication will be documented on the Grievance/Concern Form. 9. Individuals not satisfied with the resolution will be directed to the Executive Director or designee who will evaluate the outcome with the concerned party. 10. All forms to be reviewed by the Executive Director. 12. A file for grievances will be maintained by the Grievance Official/social services/Residence Director or designee. 13. Grievance Official will utilize a tracking system of all complaints to ensure proper follow-up. On 1/16/25 a review of Resident #2's medical record revealed the resident was admitted from the hospital on 9/19/24 for short term rehabilitation before returning home. A nursing progress note dated 10/19/24 stated Resident #2 was discharged home accompanied by her husband and daughter. Discharge instructions were given and explained, and they voiced understanding. All belongings were taken, and prescriptions were given to the resident at the time of discharge. No questions or concerns were voiced by the resident and/or family at that time. A nursing progress note written 10/22/24 by Staff A LPN (Licensed Practical Nurse), Nursing Page 1 of 2 106137 106137 01/16/2025 The Preserve 14750 Hope Center Loop Fort Myers, FL 33912

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Supervisor said he and Social Service (SS) had called Resident #2's daughter because she had called the receptionist about concerns she had about her mother's discharge from the facility on 10/19/24. The daughter sounded upset questing why she did not receive a call back about her mother being discharged with a distended bladder, an elevated [NAME] Blood Count (WBC) and stating her mother had received the wrong medications prior to her discharge on [DATE]. Staff A LPN wrote they tried to explain the discharge process to the daughter, but she became very loud and ended the conversation very abruptly. Review of Resident #2's medical record and the facility's Grievance log noted no documentation, Staff A had reported Resident #2's daughter concerns to the Director of Nursing and/or the Social Service Director (SSD) and/or conducted an investigation into the concerns reported by Resident #2's daughter. On 1/16/25 at 10:35 a.m., in an interview with the SSD, she said when a resident, family or visitor had a grievance/concern, and they informed staff of the grievance/concern they were required to address the grievance/concern at that time. If the grievance/concern could not be addressed, they were required to inform the supervisor and/or the SSD. She then would explain the facility's Grievance/Concern Policy to the complainant and have the complainant fill out a Grievance/Comment/Concern Form (GCCF). She then would give the GCCF to the appropriate department head to do the investigation and return to her with their findings. She said the grievance/concern would be responded to within 7 days. The facility would notify the complainant to provide an update of resolution for the complaint. The SSD confirmed Staff A LPN had written on 10/22/24 in Resident #2's medical record, Resident #2's daughter had concerns related to Resident #2's discharge from the facility on 10/19/23. She said Resident #2's daughter's concerns were not listed on the Grievance log and she had no documentation Resident #2's daughter concerns were investigated as required by their Grievance/Concern policy. On 1/16/24 at 10:40 a.m., in an interview the Director of Nursing (DON), said on 10/21/24 he was told during the morning meeting, Resident #2's daughter was on the phone and wanted to talk with him. He said he spoke to Resident #2's daughter, who was upset no one had called her back, about her concerns related to her mother's discharge on [DATE]. She told him about her mother being discharged with a distended bladder, an elevated WBC and that her mother had received the wrong medications prior to her discharge on [DATE]. He said he conducted an investigation into Resident #2's daughter's concerns to include interviewing the discharge nurse and a review of Resident #2's medical record and determined the allegations were unfounded. The DON said he did not document his investigation or call Resident #2's daughter with an update on the resolution for the complaint as noted in the facility's Grievance/Concern Policy. On 1/16/25 at 11:51 a.m., in an interview with Executive Director (ED), she said when a staff member received a complaint/grievance/concern which could not be addressed at that time, they were required to document the complaint and tell the SSD about the grievance/concern at that time. The SSD then would follow their Grievance/Concern Policy and at the end of the month she would review the grievance/concerns for that month to ensure they were completed as per their grievance/concern policy. The ED said she was not informed of Resident #2's daughter's concerns related to her mother's discharge form their facility on 10/19/24 as required in their grievance policy. 106137 Page 2 of 2