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. 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 2 Event ID: 105593 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 105593 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willowbrooke Court at Indian River Estates 2440 Citrus Blossom Cir Vero Beach, FL 32966 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)