Health 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 Page 1 of 4 105328 105328 04/20/2023 Santa Rosa Center for Rehabilitation and Healing 5386 Broad St Milton, FL 32570

F 0656 with surveyor findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105328 Page 2 of 4 105328 04/20/2023 Santa Rosa Center for Rehabilitation and Healing 5386 Broad St Milton, FL 32570

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide appropriate services, equipment, and assistance to a resident admitted with limited range of motion (ROM) for 1 of 1 persons reviewed for mobility. (Resident #29) The findings were: On 04/17/2023 at 2:51 pm, an observation was made of Resident #29 with contracture to left hand and wrist. An interview was conducted with Resident #29 which verified the contracture was present since being admitted into the facility. Resident #29 stated no therapy assessment, treatment, or splinting for this diagnosis has been performed since admission. Resident #29 stated he requested therapy services to the physician. A review of Resident #29's record reveals the resident was admitted into the facility on [DATE] with a diagnosis of Left Wrist Contracture, Left Hand Contracture, and Hemiplegia/Hemiparesis following Cerebral Infarction affecting left non-dominant side. On 04/19/2023 at 11:00 am, an interview was conducted with the Rehabiliation Director. She was asked to review all evaluations and notes from physical therapy (PT), occupational therapy (OT) and restorative therapy. She confirmed no documentation existed of recent restorative therapy. She also confirmed PT & OT assessments and evaluations did not address residents limited ROM to left hand/wrist contracture. A review of the resident's active orders reveals an order placed on 03/27/2023 for Restorative Nursing Program- LE active ROM exercise in seated of laying-marching/knee binds, straight leg raises, ankle pumps. Ambulate with hemi-walker 30 feet x2 CGA-stand on left side, 3 x per week for 6 weeks. A review of the hard chart orders reveal a physician's interim/telephone order for Restorative Eval for Services dated 03/23/2023. On 04/19/2023 at 10:30 am, a review of the residents Treatment Administration Record (TAR) for the month of April shows no documentation of restorative nursing services. On 04/20/2023 at 12:15 pm, an interview was conducted with the Director of Nursing in which the Policy for Restorative Nursing Program was reviewed. She was asked about the physician orders, lack of documentation in the TAR, and the restorative nurse's ability for assessing someone with a contracture. She confirmed that treatment should be provided for a resident with these diagnoses to prevent a decline in ROM/mobility. She was unable to find proper documentation that the order was carried out prior to being notified of this surveyor's concerns by management on 04/19/2023 and agreed with the surveyor's findings. 105328 Page 3 of 4 105328 04/20/2023 Santa Rosa Center for Rehabilitation and Healing 5386 Broad St Milton, FL 32570

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. Level of Harm - Minimal harm or potential for actual harm Based on interview and clinical record review, the facility failed ensure the residents received a physician's visit every 60 days for 1 of 25 residents reviewed. (Resident #70) Residents Affected - Few The findings include: A record review of Resident #70 on 4/19/23 noted that that resident had not received a visit from a physician since 10/26/22. In an interview with the Director of Nursing (DON) on 04/19/23 at 04:06 PM, the DON was asked if Resident #70 had received a physician's visit between November 2022 and present. The DON could not find any documented provider visits. It appeared that Resident #70 was mistakenly discharged from the computer documentation system the providers utilize. The DON validated that there had been no documented physician visits since 10/26/22. The DON stated she spoke with the lead provider at the practice, and he showed Resident #70 as discharged in his system. The DON stated there was some sort of glitch in the computer system they are trying to figure out. The DON stated that they believe that when the nurse practitioner discontinued her service with the patient when Resident #70 was enrolled in hospice, it also inadvertently deleted out of the lead provider's system. Based on their evaluation of Resident #70, the resident did not miss any medications or have any significant change in her status during this time period. On 04/20/23 10:06 AM, a policy that outlines the required frequency of visits from the provider was requested. The DON stated they did not have a policy; they just follow the regulation. 105328 Page 4 of 4