Inspection·April 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, interview, and record review, the facility failed to follow care plan interventions related to fall mat placement for two of four observations made during a four-day survey, for one (Resident #12) of three residents reviewed for falls. Findings included: Review of Resident #12's admission record revealed the resident was admitted to the facility on [DATE], with medical diagnoses that included but were not limited to multiple sclerosis, repeated Falls, muscle weakness, abnormalities of gait and mobility, cognitive communication disorder, insomnia, and overactive bladder. During an observation on 04/03/23 at 09:16 p.m., Resident #12 was observed in his bed with one fall mat to the right side of his bed, in-between his bed and the wall. The resident was interviewed at this time, and he stated, They just left the mat there, they said I fell out of bed, but I got out of bed. It didn't turn out too good. I didn't use the call light. I didn't have injuries, just my pride was damaged because I fell. Another fall mat was observed on the comforter in bed B which was unoccupied and not assigned to any residents. During an observation on 04/04/23 at 9:06 a.m., Resident #12 was observed in his bed with one fall mat on the floor in between the resident's bed and the wall. Another fall mat was observed leaning against the wall. (Picture evidence taken). An observation and interview were conducted on 4/4/23 at 1:45 p.m. Resident #12 was observed to be in bed eating chicken wings with his family. He was observed to have a floor mat on both sides of his bed. Staff A, CNA stated she was not the resident's CNA today but yesterday she was, and she was familiar with the resident. She confirmed the resident should have both floor mats on both sides of his bed. She stated they would move the floor mats when they used the lift to get him out of bed, but when he was in bed, he should have the floor mats on both sides of his bed for fall protection. Further observation and interview was conducted on 4/05/23 at 9:45 a.m. with Staff B, CNA (Agency). she stated she had worked with [Resident #12] many times before . It was observed that the resident was in bed, eyes closed, and had floor mats on both sides of his bed. Staff B, CNA stated, he is supposed to have both floor mats on the floor when he is in bed for falls. An interview was conducted on 04/05/23 at 10:00 a.m. with Staff C, Unit Manager. She stated, [Resident #12] is very lazy, very, very confused he thinks he is in New York sometimes. A couple weeks ago (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 2 Event ID: 105654 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 105654 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westchester Gardens Health & Rehabilitation 3301 N McMullen Booth Rd Clearwater, FL 33761 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)