Health inspection·April 29, 2021

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure it provided restorative services for one (Resident #40) resident sampled for restorative care provided, from a total sample of 44 residents. This placed Resident #40 at risk for functional decline. Residents Affected - Few The findings include: During an interview with Resident #40 on 4/26/21 at 11:36 AM, he was observed using a wheelchair as a mobility aid. He reported that he was supposed to be on restorative programs for stand-to-sit and for walking, but it was not happening. During another interview with Resident #40 on 4/28/21 at 09:30 AM, he revealed that he spoke with the Physical Therapy Manager/Therapist who told him his services would start on 5/03/21. A record review for Resident #40 revealed he was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, coronary artery disease, heart failure, hypertension, diabetes mellitus, arthritis, osteoporosis, and morbid obesity. A review of Resident #40's Significant Change Minimum Data Set assessment, dated 3/6/21, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive response. The assessment was documented that he required extensive assistance of 2 people with bed mobility and transfers, and 1-person extensive assistance to walk in his room and in the corridors. His balance during transitions and walking was not steady, and he used a walker and a wheelchair as mobility aids. The care plan for Resident #40 was reviewed and documented that Resident #40 was a fall risk and non-compliant with waiting for assistance and using his walker for transfers and ambulation. Approaches included refer to physical therapy as needed. A review of Resident #40's physician's orders dated 4/19/21 read: Discontinue skilled PT services and continue with RNP (restorative nursing program). A review of the RNP Occupational Therapy Functional Maintenance Program for Resident #40, dated 4/16/21, revealed the goal: Sit to stand transfers x 5 repetitions at the hall rail or parallel bars with minimal assistance and cues for hand/foot placement, scoot to edge of chair. (Photographic evidence obtained) A review of the CNA [NAME] for Resident #40, asking how Resident #40 ambulated in corridors and his (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105145 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Parkside Health and Rehabilitation Center 451 S Amelia Ave Deland, FL 32720 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)