Inspection·April 20, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interviews, and record reviews, the facility failed to implement the comprehensive plan of care for 2 of 2 residents reviewed for care plans. (Residents #4 and #74) Residents Affected - Few The findings include: A review of Resident #4's plan of care related to nutritional problems revealed the intervention: Sip cup with meals, Assist with meals. A review of the record for Nutrition Screening & Data Collection for Skilled Nursing Facilities, dated 07/20/2020 and signed by the Certified Dietary Manager and the Registered Dietician, revealed documentation under Nutrition Summary recommending sip cup with lid ordered as adaptive equipment. A review of Occupational Therapy (OT) Notes revealed an encounter from 2/2/23 stating, feeding retraining on snack food for pleasure foods with monitored or moderate assistance for utensils and cup handling. Follow-up documentation on 03/07/23 revealed, that upon discharge from therapy services, Resident #4's eating improved to supervision or touching assistance. Mealtime observations of Resident #4 noted no assistive or adaptive cups being used. On 04/20/23 at 11:50 am, interviews were conducted with Staff G CNA, Staff H CNA, Staff I CNA, and Staff J LPN. They were asked about the intervention of an assistive or adaptive cup in Resident #4's plan of care. All denied that this intervention is being implemented and agreed that, based upon documentation, adaptive cups should be in use. A review of resident #74's plan of care for Risk for Complications Related to Diagnoses revealed the intervention: Monitor for and document any edema. Notify MD. On 04/19/23 at 9:40 am, an observation was made of Staff K, RN assessing Resident #74 in which 3+ pitting edema was noted to bilateral lower extremities. When Staff K RN was asked how she would proceed with care or notification to provider after assessment findings, Employee K RN stated, Nothing, I mean I'll keep watching her. When Staff K RN was asked directly if she would report the new findings and reports of edema by the resident to the doctor or provider, Staff K RN stated, No and proceeded to walk away from the conversation. On 04/19/2023 at 5:10 pm, an interview was conducted with the Director of Nursing (DON). When asked about the concerns with the intervention in Resident #74's plan of care, she reported that her expectation is the doctor should be notified and the assessment should be documented. The DON agreed (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 4 Event ID: 105328 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 105328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Rosa Center for Rehabilitation and Healing 5386 Broad St Milton, FL 32570 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)