Health inspection·April 25, 2025

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 observations, interviews, and record review, the facility failed to provide a comprehensive plan of care for 2 of 2 residents sampled for care plans. (Resident #21 and #24) Residents Affected - Few The findings include: Resident #21 A record review of Resident #21's electronic medical record (EMR) revealed that the resident is dependent on staff for activities for daily living. A review of the care plan developed by the facility for Resident #21 did not include an intervention to address the need for assistance in activities for daily living. On 4/23/2025 at approximately 1:00 PM, an interview was conducted with the Minimum Data Set Coordinator (MDS) and Care Plan Coordinator. The Care Plan Coordinator confirmed that there was not a care plan for Resident #21 in regards to activities of daily living. The Care Plan Coordinator further indicated that the information did trigger from the MDS and should have been included in the care plan. Resident #24 A record review was conducted on Resident #24's EMR concerning End Stage Renal Disease (ESRD) and dependence on hemodialysis services. The care plan developed by the facility for Resident #24 did not include goals and interventions to manage ESRD and hemodialysis services. The Care Plan Coordinator confirmed that there was not a care plan for Resident #24 for ESRD/Dialysis. She further indicated that it had triggered for a care plan from the MDS and should have been included in the care plan. The Care Plan Coordinator acknowledged that she missed developing a care plan for both of these residents. On 4/23/2025 at approximately 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON indicated that it is her expectation that, if the MDS triggers care areas, then the care plan should be updated to include those areas. The facility policy titled Comprehensive Care Plans stated: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives Page 1 of 2 105395 105395 04/25/2025 Westwood Nursing and Rehabilitation Center 1001 Mar-Walt Drive Fort Walton Beach, FL 32547

F 0656 and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: Residents Affected - Few 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 3. The Comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would be otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. 105395 Page 2 of 2