Inspection·December 8, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review the facility failed to report an allegation of neglect related to an elopement for one resident (#4) out of three residents reviewed for elopement risk. Residents Affected - Few Findings included: An interview was conducted on 12/8/24 at 11:04 a.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON stated on 6/15/24 around 11:00 a.m. she was notified Resident #4 could not be found. The DON stated she had instructed staff to continue the search and notified the NHA. The NHA stated she instructed staff to notify the police. Review of the timeline prepared by the NHA at the time of the event showed: - On 6/15/24 at 11:00 a.m. notified by the facility Resident #4 was unable to be located. - A family member reported to the facility they saw Resident #4 sitting on the outside bench at the front of the facility. When staff went to the bench, Resident #4 was not there. The facility continued to search the building and surrounding areas. - At approximately 11:10 a.m. the facility contacted the police department for the missing resident. - At approximately 11:20 a.m. NHA arrived to the facility and an officer who was on site stated the police department would deploy a helicopter, drone and scent dogs. - At approximately 12:00 p.m. the police department contacted the facility and stated Resident #4 was found and unharmed. The police stated they would be taking Resident #4 to the local hospital per protocol. Review of the admission record of Resident #4 showed an admission date of 6/11/24 with diagnoses including malignant neoplasm of the lung and bones, congestive heart failure, hemiplegia and hemiparesis following cerebral infarction affecting the right side and other co-morbidities. Review of Resident #4's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008) dated 6/11/24 revealed in section C - Decision Making Capacity Patient [Resident #4] required a surrogate. Review of Resident #4's medical records showed a care plan with a focus dated 6/14/24, showing (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: 105777 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 105777 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Davenport Nursing and Rehab Center 206 W Orange St Davenport, FL 33837 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)