Inspection·July 17, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review and policy review, the facility failed to report an allegation of neglect for one (Resident #1) of two residents sampled for abuse and neglect. Resident #1 was served a peanut butter brownie by facility staff and had a documented peanut allergy. The resident required medication to treat the allergy and was transferred to the hospital for further evaluation. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia. Upon admission, the resident reported she had an allergy to peanuts and peanut butter. The resident's allergy was documented and reported to the dietary department along with the resident's diet order. A review of the resident's medical record revealed a nurse's note written on 06/15/2023 at 14:12 (2:12 p.m.) documenting the resident's report that she had eaten part of a brownie before realizing there was peanut butter in it. The note explained that the resident had a documented allergy to peanuts. The note documented the resident 's complaint of feeling short of breath. A call to the resident's physician resulted in an order for a dose from the epi-pen and Benadryl 25 mg. The resident reported feeling like her throat was closing. The resident was taken to the hospital approximately one hour after the resident had eaten some of the brownie. She returned within 4 hours from the hospital. An interview was conducted with the Director of Nurses (DON) on 07/17/2023 beginning at 12:25 p.m. The DON reported that she was not in the building on 06/15/2023 when the incident occurred and when she returned on 06/18/2023, she learned of the incident. She did not think it met the criteria of a Federal report, requiring submission of a report within 24 hours due to the resident not sustaining serious bodily injury. A review of the facility's policy entitled Abuse, Neglect and Exploitation revealed guidance under section V11, Response and Reporting of Abuse, Neglect, Exploitation and Misappropriation: Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility Administrator, abuse agency hotline or file a complaint with the state survey agency and adult protective services immediately or not later than 24 hours if the events that lead to the allegation do not involved abuse and do not result in serious bodily injury. Reporting and investigation should be in accordance with state law/regulation. The facility's policy defined Neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, (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: 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 07/17/2023 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)