Health inspection·February 6, 2024

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete dietary assessment within recommended timeframes for 2 of 2 residents and failed to obtain preferences and allergies pertaining to lactose intolerance for 1 resident of a total sample of 16 residents, (#20, #24). Findings: 1. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included pulmonary embolism, hypertension, and gastroesophageal reflux disease. Review of the resident's physician orders revealed an entry dated 12/14/23 which indicated the resident was on a regular diet, and Lactose intolerant. No milk. No cheese. On 2/06/24 at 11:55 AM, the Dietary Manager explained that within seventy-two (72) hours of admission, the resident was seen by the Dietary Manager, and an admission Dietary Assessment was completed. The resident's food allergies, and preferences were obtained, and populated to the resident's meal ticket. The Dietary Manager stated she did not complete an admission Assessment/Dietary Review for resident #20. She noted the resident did not get the weekly menu provided when the Dietary Review was completed. She stated she was not aware of the resident's allergies. She stated that on admission, Dietary would receive a diet order, but preferences, and allergies would not be listed. She said food allergies would be obtained by the Dietary Manager. Review of the Week-At-A-Glance Spring/Summer Menus 2023 served during the time the resident was in the facility, revealed milk and cheese were included in the items served. The resident's physician order dated 12/14/23 was reviewed with the Dietary Manager. She explained the order did not get placed on the resident's meal ticket. Review of the resident's meal tracker Activity Log Report dated 12/13/23, read Allergies Added: No allergies entered. 2. Resident #24, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included diabetes type II, metabolic encephalopathy, and chronic pancreatitis Review of the resident's clinical records revealed an admission Assessment/Dietary Review was not obtained until 2/04/24, 96 hours after admission. On 2/06/24 at 12:10 PM, the Dietary Manger confirmed the resident was admitted on [DATE] and was not assessed until 2/04/24. She stated the assessment was late. Page 1 of 5 105376 105376 02/06/2024 West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904

F 0806 The facility's policy Nutritional Assessment with effective date of May 25,2012, read, The Dietary Manager should complete the Dietary Review Form within 72 hour of admission or readmission to the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105376 Page 2 of 5 105376 02/06/2024 West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure complete medical records were readily accessible, and not restricted to access for 16 of 16 total sampled residents, (#1, #2, #3, #4, #5, #6, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25); and failed to ensure hard copy medical records were safeguarded for all residents. Findings: On 2/05/24 at 9:40 AM, an entrance conference was held with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The survey team requested items that included access to all residents' complete medical records. On 2/05/24 at 1:20 PM, surveyors were unable to view any sampled residents' Comprehensive Care Plans in the Electronic Health Record (EHR). On 2/05/24 at 3:58 PM, the Minimum Data Set (MDS) Coordinator said she had to obtain records from multiple sources to complete assessments and she didn't have direct access to all the EHRs. She explained the Social Services Director kept residents' behavioral health progress notes in her office. On 2/05/24 at 3:51 PM, the NHA was informed the medical records provided to surveyors were not complete and excluded pertinent physician progress notes, diagnostics, and laboratory results. She could not explain the issues, and said she had to notify the DON to assist. She acknowledged medical record access delayed and impeded the survey process. On 2/05/24 at 4:00 PM, the DON provided resident #1's hard chart that contained hospital clinical records. The record did not include physicians' progress notes or X-ray reports completed during the resident's stay at the facility. On 2/05/24 at 4:20 PM, the DON reviewed a copy of resident #1's physician's progress note dated 1/24/24, and signed on 2/05/24, and a chest X-ray report dated 1/24/24 with a handwritten undated and unsigned note that read, MD (Medical Doctor) aware resident to the ER (Emergency Room). The DON stated, I have no idea who wrote the note; it should have been signed and dated. On 2/06/24 at 11:10 AM, the C Unit Manager explained, Certified Nursing Assistant's (CNAs) used the EHR system for residents plan of care and status and it was where they also documented their daily tasks. She checked the EHR system and demonstrated where the resident records were located. She said the DON or Medical Records Licensed Practical Nurse (LPN) had to assist with any restrictions and stated, you must not have full access. On 2/06/24 at 11:33 AM, the Medical Records LPN conveyed that surveyors were restricted from accessing and viewing the CNA documentation for all residents. She explained she would jointly view the sampled residents' records through her access, and the Regional Nurse Consultant had to arrange surveyor access through their IT (Information Technology) department. On 2/06/24 at 10:03 AM, the Medical Records LPN said she was responsible for the facility's medical records process, and she was the only person with a key to access closed records. She explained 105376 Page 3 of 5 105376 02/06/2024 West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some physician progress notes were filed into the records every few months. She stated physicians A sent his progress notes in bulk every few months, and they were filed as they were received. She said when she worked as a nurse on nursing units, she had to call the lab or X-ray provider to obtain faxed reports because her access was restricted. On 2/06/24 at 12:16 PM, the DON said the Regional Nurse Consultant was working on obtaining access to EHR for surveyors as it was restricted. She explained facility staff could jointly view the sampled resident records with surveyors. She conveyed she understood the survey process had been impeded by medical record accessibility delays and stated, I don't know why you guys can't see everything. On 2/06/24 at 12:18 PM, surveyors were unable to review resident #16's physician progress notes and requested copies from the DON. At 2:44 PM, the DON said she wasn't sure where the records were and she had to find them. On 2/06/24 at 2:54 PM, the DON explained, nurses accessed resident medical records from the facility's EHR program that included care plans, physician's orders, and nurse progress notes. She said lab results and X-ray reports had to be accessed from their own independent programs, and physician's progress notes were received by email approximately 30 days from an encounter. She pointed to her laptop and explained that when nurses needed to retrieve up to date clinical status information for the doctor, they used the facility's EHR program and stated, they can check the orders. On 2/06/24 at 10:15 AM, the Medical Records LPN said 2024 medical records were kept in her office. During a joint observation, she demonstrated where 2023 records were stored in a closet inside an unlocked and publicly accessible copy/mail room located in the main lobby. She slid open an unlocked wooden door where approximately 30 cardboard boxes were observed on shelves. She explained, the boxes contained all residents' 2023 medical records. She acknowledged the records were not securely locked or properly safeguarded and stated, I must've left it unlocked from yesterday. On 2/06/24 at 11:33 AM, the Medical Records LPN explained the Maintenance Director had to fix the lock on the storage closet in the copy/mail room. At 2:55 PM, the Maintenance Director recalled earlier that day he received a request to repair the lock on the sliding doors of the storage closet in the copy/mail room. He stated he wasn't sure what was wrong with it, and he thought they couldn't find the key. On 2/06/24 at 3:44 PM, during a joint observation, the Medical Records office wooden door was observed open and unlocked. The MDS Coordinator and two other staff were seated directly outside the office at a conference room table. The Medical Records LPN demonstrated where 2024 medical records were stored in her office. She opened an unlocked, non-fireproof file cabinet where documents were contained. She stated she had locked her office door when she left, and remembered another staff had a key who must hav opened it. She said she wasn't sure if the room or file cabinets were properly safeguarded for fire loss. On 2/06/24 at 2:54 PM, the DON stated it was important to ensure safeguarding of medical records for confidentiality and HIPAA (Health Insurance Portability and Accountability Act) compliance. Review of the facility's standards and guidelines dated October 1, 2010 titled Maintenance of Medical Records page 1 read, PURPOSE: The facility safeguards medical records by establishing guidelines for the maintenance of resident records. 105376 Page 4 of 5 105376 02/06/2024 West Melbourne Health & Rehabilitation Center 2125 West New Haven Ave West Melbourne, FL 32904

F 0842 Level of Harm - Minimal harm or potential for actual harm Review of the Medical Records LPN job description provided by the facility titled Unit Coordinator read, . 6. a. Maintain confidentiality of all data, including resident, employee, and operations data and comply with HIPAA Privacy and Security. ESSENTIAL JOB FUNCTIONS . 10. Maintain and file discharge and reduced medical records in an orderly and appropriate manner. Safety and Equipment Functions . fire protection and prevention . Residents Affected - Some Review of the Facility assessment dated [DATE] read, 3.7 (facility name) uses an electronic health record using (software program name) and a hard chart where MDS, consultant visits, labs, hospital records are stored etc. Laptops are used for documentation. Inter-disciplinary assessments and documentation from (software program name) are all housed inside the EMR (Electronic Medical Record). The Center communicates via email to department heads and corporate partners, uses fax for pharmacy and receives electronic referrals through hospital-based portals. The Center has routine back up procedures and provides alternate means of documentation in the event of a power outage or internet outages. The Center use of electronic records is a work in progress and evolves with the changing needs of the Center. 105376 Page 5 of 5