Health inspection·August 3, 2023

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to honor resident preferences for showers for 1 of 3 residents reviewed for choices, of a total sample of 34 residents, (#101). Findings: Resident #101 was admitted to the facility on [DATE]. Her diagnoses included wedge compression fracture of thoracic vertebra, weakness, difficulty walking, low back pain, and history of falls. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 7/23/23, revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13/15. Assessment of resident #101's daily preferences revealed it was somewhat important for the resident to choose between a tub bath, shower, bed bath, or sponge bath, and noted she required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the resident's clinical records revealed the resident was scheduled for showers on Monday, Wednesday, and Friday on the 7 AM-3 PM shift. Review of the POC (Point of Care) Response History from 7/18/23 through 8/01/23, revealed the resident received a shower on 7/22/23, and on 7/28/23. Resident #101 should have received six showers during this period. The resident's Baseline Care plan assessment dated [DATE] revealed her daily preferences included, receiving showers. On 8/01/23 at 1:51 PM, resident #101 stated she had not received a shower since she was admitted to the facility, and only had bed baths. Resident #101 said she had never refused a shower and had never been offered a shower. The resident's daughter who was visit at the time stated the resident had not had a shower since she was admitted to the facility. On 8/01/23 at 3:58 PM, Licensed Practical Nurse (LPN) A, stated showers were scheduled three times weekly, and if a resident refused a shower, the Certified Nursing Assistant (CNA) would inform the resident's primary nurse. LPN A verbalized the primary nurse would check on the resident and try to encourage the resident to have their shower. If the resident still refused, the refusal would be documented. The LPN stated there was no report that resident #101 refused showers. Page 1 of 6 105757 105757 08/03/2023 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/01/23 at 4:18 PM, CNA B stated showers were scheduled for each resident three days per week, and the schedule could be viewed in the shower book/binder kept at the nurses' station. She explained when CNAs provided showers, a shower sheet was completed, and placed in the shower binder. CNA stated she had worked with resident #101, and she had not refused any care. On 8/01/23 at 4:33 PM, the Assistant Director Of Nursing (ADON) C stated showers were scheduled three times weekly for each resident. She explained the facility had a generic schedule, but if the resident/family wanted something different, they would be accommodated, and their preferences followed. ADON C stated resident #101's cognition was intact. The POC response history for the resident was reviewed with the ADON. She confirmed the resident was scheduled for showers three times weekly, and documentation indicated the resident had two showers for the period 7/18/23 through 8/01/23. The ADON stated showers were not provided per the resident's preference or facility's schedule. On 8/02/23 at 2:28 PM, resident #101 stated she was happy, because she received a shower this AM. The resident said it was her first shower since admission to the facility on 7/17/23. On 8/03/23 at 9:42 AM, the Director of Nursing (DON) stated that during record review of the resident's clinical record, documentation could not be identified regarding any refusal of care by resident #101. She stated the resident's preference for showers should be honored. The policy Resident Showers reviewed/revised April 2022, read, Residents will be provided showers as per request or as per facility schedule protocols. 105757 Page 2 of 6 105757 08/03/2023 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that an accurate comprehensive, Minimum Data Set assessment was completed for 1 of 34 sampled residents who were admitted to the facility, (#36). Findings: Resident #36 was admitted to the facility on [DATE] with diagnoses that included Cardiovascular disease, unspecified, Polyneuropathy, unspecified, Diabetes Mellitus, Depression, essential hypertension, cerebral ischemia, Chronic Obstructive Pulmonary Disease, Pulmonary fibrosis, chronic kidney disease, There was no inclusion of Hypothyroidism listed under the diagnosis section on the resident's admission record. Review of the resident's Agency for Health Care Transfer Form 5000-3008 provided to the skilled facility by the transferring hospital documented the diagnosis of Hypothyroidism under the category of Medical Conditions. Review of the resident's History and Physical from the transferring hospital documented the resident with a diagnosis of Hypothyroidism. Review of the resident's medication administration record for the months of June, July, and August documented she received the medication Levothyroxine Sodium 5 micrograms by mouth one time daily (6:00 AM) for Hypothyroidism. In an interview with resident #36 on 9/2/23 at 12:40 PM, she replied she had a diagnosis of hypothyroidism and had had it for many years Review of the residents admission Comprehensive Assessment Minimum Data Set (MDS) for September 2022, and continued MDS assessments showed a section of resident diagnosis, and Hypothyroidism was not checked or included as a current diagnosis for the resident. In an interview with the MDS Coordinator E on 8/3/23 at 1:10 PM, she confirmed the MDS assessment did not document the diagnosis of Hypothyroidism for resident #36. She noted when completing the MDS, staff reviewed the hospital records, the ordered medications, and everything about the resident's condition. She explained the MDS assessment was not accurate and did not include the resident's diagnosis which was an active diagnosis as the resident received daily medication for it 105757 Page 3 of 6 105757 08/03/2023 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for 2 of 5 residents reviewed for PASRR that were later identified with Intellectual Disability (ID) or Serious Mental Illness (SMI) out of a total sample of 34 residents, (#76, #48). Findings: 1. Review of resident #76's medical record revealed the resident was admitted to the facility on [DATE] from a nursing home. The resident had diagnoses that included autism, bipolar disorder, major depressive disorder, frontal lobe (brain) syndrome, dementia, malnutrition, failure to thrive, and sarcopenia (progressive skeletal muscle disorder). The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 7/19/2023 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively intact. The assessment showed he rejected evaluation or care for health and well-being 1 to 3 days out of 7, required staff supervision to complete activities of daily living (ADL), received antidepressant medication for 7 out of 7 days, and he had active diagnoses that included dementia, malnutrition, depression, and bipolar disorder during the look back period. The Comprehensive Care Plan noted the resident was resistive to care and services, refused medications and laboratory tests, had impaired nutritional status, weight loss, episodes of mood swings, and he required staff assistance to complete ADLs. The plan of care noted staff were to monitor the resident for adverse effects of psychotropic medications prescribed for diagnoses of bipolar disorder and major depressive disorder. The Nutritional Evaluation dated 7/07/2023 noted the resident had a 5.6% weight loss over the previous 30 days with an intervention to increase nutritional supplements, and the resident had, recent behavioral changes. The PASRR was completed on 4/19/2021 by the previous nursing home provider. Section I noted there was no Mental Illness (MI) or Intellectual Disability (ID) suspected or present. The Psychiatric Progress Notes from 7/06/2022 to 6/30/2023 showed the resident's Diagnosis, Assessment, and Plan included mental illness, . F84.0: Autistic disorder . F31.31: bipolar disorder, current episode depressed, mild . 2. Resident #48 was admitted to the facility on [DATE] with diagnoses including arthritis, heart failure, neurocognitive disorder with Lewy bodies, dementia and atrial fibrillation, Review of the MDS significant change assessment with ARD of 7/11/23 revealed resident #48 had a Brief Interview for Mental Status (BIMS) score of 03 which indicated he was significantly cognitively impaired. The document indicated his active diagnoses included depression (other than bipolar), bipolar disorder and psychotic disorder (other than schizophrenia). 105757 Page 4 of 6 105757 08/03/2023 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of resident #48's electronic medical record (EMR) revealed diagnoses of psychotic disorder with delusions and bipolar disorder at time of admission and major depressive disorder with an onset date of 2/03/23. The record contained a Level I PASRR screening form dated 9/16/21 which did not indicate resident #48 had a mental illness (MI) or suspected MI. The record did not contain a Level II PASRR screening form. On 8/02/2023 at 10:13 AM, the Director of Nursing said residents' PASRRs were reviewed by the Social Services Director who was responsible for their accuracy. On 8/02/2023 at 1:23 PM, the Social Services Director stated he was responsible for completing and updating PASRR's and he was familiar with the process. He checked resident #76's medical record and acknowledged the PASRR dated 5/25/2021 did not include the resident's SMI or ID diagnoses identified on Psychiatric Progress Notes since 7/6/2022. He checked resident #48's medical record and verified the PASRR dated 9/16/21 did not include the resident's MI diagnoses. He explained there should have been another PASRR completed for each to ensure the residents did not require additional evaluations or services. 105757 Page 5 of 6 105757 08/03/2023 Westminster Towers 70 West Lucerne Circle Orlando, FL 32801

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure blood glucose monitoring was conducted as per the physician's orders for 1 of 1 resident of a total sample of 34 residents, (#358). Residents Affected - Few Findings: Resident #358, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses including acute kidney failure, Rhabdomyolysis, dementia, and diabetes type II. Record review of the resident's active physician's orders revealed an order dated 7/27/23 for blood glucose monitoring (accuchecks) two times per day. A Physician note dated 7/27/23 read, Patient's blood sugar was in the 145 and daughter wants blood sugars to be checked. The physician's plan on 7/27/23, and 7/31/23 included: monitor accuchecks. On 8/01/23 at 11:03 AM, resident #358 stated prior to his admission to the facility, he had blood sugar monitored daily. Record review of the resident's clinical records revealed no documentation of blood glucose monitoring. On 8/02/23 at 3:56 PM, the resident's physician orders were reviewed with the Assistant Director of Nursing (ADON) C. She confirmed a physician's order dated 7/27/23 for accucheck two times daily was in place, but the order did not populate to the resident's Medication Administration Record/Treatment Administration Record (MAR /TAR). The ADON confirmed that documentation could not be identified to indicate the resident's blood glucose was monitored as per physician's order. On 8/02/23 at 4:01 PM, Registered Nurse (RN) D confirmed that resident #358 was assigned to her. She said the resident did not have an order for blood glucose monitoring. A review of the resident's physician orders were conducted with RN D and showed order for accucheck dated 7/27/23. RN D acknowledged blood glucose was not monitored. On 8/02/23 at 4:12 PM, ADON C stated that when the physician's orders were received, orders must be confirmed by the nurses for the order to populate to the resident's MAR/TAR. A review of the resident's physician's order history revealed the order for accucheck was confirmed on 7/27/23. The ADON stated orders were reviewed the following day by the ADON, DON, and nursing leadership for accuracy, and the accucheck order was reviewed. She confirmed there was no documentation to indicate accuchecks were completed two times daily as per the physician's order. On 8/03/23 at 9:30 AM, the Director of Nursing (DON) stated physician orders were reviewed daily by the ADONs for completion, and to ensure orders populated to the resident's MAR/TAR. She verbalized that resident #358's order for accucheck was signed off as reviewed, and stated her expectation was that staff would follow the physician's order. The facility did not have a policy to address blood glucose monitoring. 105757 Page 6 of 6