Inspection·October 26, 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 interviews and record review, the facility failed to develop and implement a care plan related to discharge for one resident (Resident number 113) out of one resident reviewed for discharge. Resident number 113 discharge plans were to be discharged back to the community. The findings included: Record review of the facility's Comprehensive Care Plan Policy and Procedure (revised 10/18/2022) documented the following: Policy-It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1) The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care; 2) The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment and 3) The comprehensive care plan will describe, at a minimum, the following: d) The resident's goals for admission, desired outcomes and preferences for future discharge. Closed record review of the Demographic Face Sheet for Resident number 113 documented the resident was admitted to the facility on [DATE] with diagnoses to include rhabdomyolysis, heart failure, peripheral vascular disease, atrial fibrillation, hypertensive heart disease, dementia and major depressive disorder. The resident was discharged back to the community on 8/24/2023. Review of the Minimum Data Set (MDS) 5-Day Assessment for Resident number 113 dated 8/14/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 04 out of 15 indicating severe cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and the family expected the resident to be discharged to the community. Review of the care plans for Resident number 113 revealed there was no care plan written for discharge. Review of the Social Services Progress Notes for Resident number 113 documented the following: Dated 8/09/23: Resident's daughter stated that the goal is for him to return home but it also depends on how he does in rehab and Dated 8/21/23: Resident's daughter was advised that her father was issued NOMNC (Notice of Medicare Non-Coverage) from [ ] insurance company with a discharge date for (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 5 Event ID: 105715 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 105715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hampton Court Nursing and Rehabilitation Center 16100 NW 2nd Avenue North Miami Beach, FL 33169 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)