Health inspection·June 22, 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 observations, interviews, and electronic record reviews, the facility failed to follow the care plan for 1 of 1 residents sampled for positioning and mobility. (Resident #40) Residents Affected - Few The findings include: On 6/19/23 at approximately 2:15 PM, an interview was conducted with Resident #40. During this interview, the resident stated The staff is supposed to put my splints on my feet every day, but they do not always do that for me. Observation of the resident's feet confirmed that no splints were currently applied to Resident #40's feet. Further observations made on 6/21/23 at approximately 12:30 PM, on 6/22/23 at 8:30 AM, and on 6/22/23 at approximately 12:30 PM noted no splints applied to Resident #40's feet. The splints were observed in the room and available for use but never applied to the resident's feet. A review of Resident # 40's electronic medical record revealed an order dated 3/15/23 stating, Restorative Nursing for Splinting Apply/don Hip abductor splint and Bilateral AFO's (ankle foot orthosis) to both ankles for fixed contractures of hip and ankle. Splint applied daily while patient in bed and while in wheelchair, to patient tolerance. Remove splints for ADL care and hygiene, as well as skin integrity checks, and laundering of splint. Further review of Resident #40's record revealed that the resident had a care plan for assistance with her ADL's (activities of daily living) initiated on 05/04/2022 with an included intervention of Splinting- apply hip abductor splint BL AFO's ankle foot orthosis for contractures. Apply daily while in bed and w/c (wheelchair) as tolerated. Remove as needed for cleaning, hygiene, and skin checks and encourage to keep splints on. This was last updated on 06/22/2023. On 6/22/23 at approximately 1:52 PM, an interview was conducted with Nurse B, a Licensed Practical Nurse (LPN), and Staff C, a Restorative Certified Nursing Assistant (RCNA), concerning the applying and documentation of Resident #40's splints daily. Nurse B stated that he fills in as the restorative nurse as needed and that the Certified Nursing Assistants (CNA) on the floor help to fill in for the restorative aide when she is not here to put the splints on the residents. Nurse B stated it is in the restorative task in Point Click Care (the electronic documentation program the facility uses) for the splints to be applied and the floor staff has the responsibility to document and apply the splints. Staff member C, RCNA stated that, when she is in the facility, she goes around and makes sure the splints for the residents are applied, and if the floor CNA has not put them on yet, she applies them. Staff Member C went on to state that she is not able to apply every resident's splints every day, so the floor staff helps out by applying them. When asked if she documented in the tasks for applying the splints, Staff Member C stated that she does not always complete her documentation daily. (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: 105563 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 105563 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centre Pointe Health and Rehab Center 2255 Centerville Road Tallahassee, FL 32308 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)