Health inspection·December 6, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy and procedure review, the facility failed to develop and implement a comprehensive person-centered care plan that addressed the sexual relationship for two (Residents #1 and #2) out of 5 residents whose care plans were reviewed. The findings include: A review of the clinical record revealed that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Epilepsy, Parkinson's, and Chronic Kidney Disease. A review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 13 out of a possible 15 points, indicating cognitively intact. Resident #1 was documented as having adequate hearing and vision, clear speech pattern, able to make herself understood and able to express her ideas and wants. A review of the clinical record revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included respiratory failure, encephalopathy, and alcohol abuse withdrawal. A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS score of 14 out of a possible 15 points, indicating cognitively intact. Resident #2 was documented as having adequate hearing and vision, clear speech pattern, able to make himself understood and able to express his ideas and wants. On 12/6/23 at 2:48 PM, Resident #1 and #2 were interviewed in the main dining room. Both were asked to be interviewed separately but they wished to remain together during the interview. Resident #2 stated he and Resident #1 wanted to get married, and asked if they could get married at the facility today. Resident #1 replied, As long as he can get me into bed without hurting me, and then she laughed. When asked if both wanting to be in a relationship with each other. They both agreed and said they had been dating for a few months and would like a room together to make things easier on everyone but were having a hard time making that happen. Further review of the clinical records for Resident #1 and Resident #2 revealed the Interdisciplinary team comprised of the resident's physician's, Psych services, and Director of Nursing (DON) had deemed both residents capable of consenting to a sexual relationship. Page 1 of 2 105565 105565 12/06/2023 Coastal Health and Rehabilitation Center 820 N Clyde Morris Blvd Daytona Beach, FL 32117

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #1 and Resident #2's care plans revealed neither resident had a care plan that addressed a focus, goal or interventions/tasks regarding their sexual relationship. A joint interview was conducted with the administrator and DON on 12/6/23 at 11:15 AM. They were asked if Resident #1 and Resident #2 had a care plan for their sexual relationship. The administrator and DON stated they were care planned for their relationship and sexual behavior. The DON was asked to verify that the care plans for Resident #1 and Resident #2 were in place. The DON stated, It should be care planned, we talk about it just about every morning and everyone is aware. She said she would check their care plans and follow back up. On 12/6/23 at 11:30 AM, the DON confirmed that Resident #1 and Resident #2 were not care planned for being in a sexual relationship with one another. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered (revised 12/2016): revealed: Page. 1, Policy Interpretation and Implementation, item 8, The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Pg. 2, item 13, Assessment of resident are ongoing and care plans are revised as information about the residents and residents' conditions change. . 105565 Page 2 of 2