Health inspection·January 14, 2025

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to notify and update the hospice provider regarding a fall for 1 of 1 resident reviewed for notification of change, out of a total sample of 5 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] for respite care. His diagnoses included dementia, Neurocognitive disorder, depressive disorder, and insomnia. Resident #1 was discharged home from the facility on 10/10/24. Review of resident #1's medical record revealed a late entry nursing progress note as well as a Situation Background Assessment and Recommendation (SBAR) note dated 10/08/24 at 4:15 AM. The notes showed resident #1 was found on the floor next to his bed, the facility Nurse Practitioner was notified on 10/08/24, and the document revealed the responsible party was not yet known, therefore not notified at that time. There was no documentation to show facility nurses contacted resident #1's hospice provider regarding the fall. On 1/13/25 at 12:32 PM, Registered Nurse (RN) A stated if a resident was on hospice services the facility process was to notify the physician, the representative, and the hospice service as a fall was a change in condition. On 1/14/25 at 12:28 PM, the interim Director of Nursing (DON) stated if a resident had a change in condition such as fall, then nursing was responsible for notifying the responsible party, the physician, and the contracted hospice. On 1/14/25 at 12:45 PM, the interim DON placed a telephone call to resident #1's hospice service. The Hospice Team Manager stated by phone that resident #1's wife called them on 10/10/24 at 10:21 AM, to report that her husband had a fall in the facility a few days before. The Hospice Team Manager stated the facility did not call or notify the hospice of resident #1's fall, instead it was his wife. On 1/14/25 at 12:50 PM, the interim DON validated there was no documentation in resident #1's medical record to show that resident #1's hospice service was notified of his change in condition regarding his fall on 10/08/24. The facility policy and procedure, Change in Condition revised 4/04/23, revealed a purpose to communicate changes in condition, regarding notification about changes in conditions as required. Page 1 of 2 105430 105430 01/14/2025 Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751

F 0849 Level of Harm - Minimal harm or potential for actual harm The policy Hospice Services with a revision date of 3/10/23 showed the facility will have an agreement with Hospice that includes the communication process for care of the resident including any changes in condition. Residents Affected - Few 105430 Page 2 of 2