Health inspection·October 24, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to encode and transmit a discharge Minimum Data Set (MDS) assessment for 1 of 2 sampled discharged residents. Resident #11. Residents Affected - Few The findings included: Review of the policy titled Transfer From Distinct Part to Non-Certified Household / Neighborhood revised 10/2024 documented in part, Procedure: . 6. The MDS Coordinator shall complete the appropriate Minimum data Set (MDS) assessment. Upon entering the facility on 10/21/24, the Administrator informed the survey team that although they had five active households (resident units), only one household (Biscayne) was certified while the other four were non-certified and licensed only. The Administrator explained they did not accept residents from outside of their community and did not accept Medicaid. The Administrator stated the decertification process happened in two stages, but was completed by 11/20/23. Review of the record revealed Resident #11 was admitted to the facility on [DATE], into the certified Biscayne household. Further review of the census record revealed the resident was moved to a licensed only household, Key West, on 07/13/24. This move indicated Resident #11 no longer lived in a certified facility, which needed to be reflected in the MDS (certification) assessment. Review of the MDS assessments lacked any MDS discharge assessment for the resident's move out of the certified household as of 07/13/24. During an interview on 10/22/24 at 2:52 PM, the MDS Coordinator was asked her MDS process for a resident who moved out of the Biscayne household. The MDS Coordinator explained she would complete (encode) and transmit a discharge MDS assessment with the resident's return not anticipated. During a side-by-side review of the record, the MDS Coordinator confirmed she failed to complete and transmit the discharge MDS assessment for Resident #11. Page 1 of 2 105593 105593 10/24/2024 Willowbrooke Court at Indian River Estates 2440 Citrus Blossom Cir Vero Beach, FL 32966

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interview, the facility failed to ensure a discharge summary, to include a recapitulation of the residents stay, for 1 of 2 sampled residents, Resident #3. The findings included: Review of the policy titled Transfer and Discharge Rights, revised 10/2024, documented, in part, Documentation of Transfer or discharge: . 4. Information provided to the receiving community/provider should include the following: . Discharge Summary. The discharge packet provided by the Administrator included a form titled, Discharge Assessment & Summary. Upon entering the facility on 10/21/24, the Administrator informed the survey team that although they had five active households (resident units), only one household (Biscayne) was certified while the other four were non-certified and licensed only. The Administrator explained they did not accept residents from outside of their community and did not accept Medicaid. The Administrator stated the decertification process happened in two stages, but was completed by 11/20/23. Review of the record revealed Resident #3 was admitted to the Biscayne household on 09/25/24, and then moved to the [NAME] Villa household on 10/17/24, a non-certified and licensed only household. Review of the Minimum Data Set (MDS) assessments revealed a discharge Minimum Data Set (MDS) assessment, with return not anticipated, was completed on 10/17/24. A progress note written by Staff B, Registered Nurse (RN), on 10/17/24 at 10:47 AM documented Resident #3 was safely moved to the [NAME] Villa unit. Further review of the record lacked a discharge assessment and summary, but revealed a Room Change Notification indicating Resident #3 was moving from the skilled services bed on Biscayne to [NAME] Villa. During an interview on 10/24/24 at 11:45 AM, when asked the process when one of the residents in the Biscayne household was discharged out to one of the other households in the facility, Staff B, RN, explained she completes a functional assessment, gives verbal report to the accepting nurse, and it is treated like a room change. When asked if she completes a discharge summary, the RN stated she does not, but stated that would make sense since the resident would be moving out of the certified household into a non-certified household, similar to when they are discharged back to their apartment. 105593 Page 2 of 2