Health inspection·May 12, 2022

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and and record review, the facility failed to complete, encode and transmit a required Minimum Data Set (MDS) Discharge assessment for 1 of 5 residents reviewed for hospitalization, of a total sample of 42 residents (#28). Residents Affected - Few Findings: Resident #28 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, diastolic congestive heart failure, and dementia. A progress note dated 2/22/22 read, Resident's daughter is concerned about her mother's left lower leg feeling cold because she had a stent put in.As per daughter's request she wants her mother to go to the hospital. As per Dr. [name of physician], we may send resident 911. Resident left via 911. Clinical record review revealed a SNF/NF[Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form dated 2/22/22 that indicated the resident was transferred to the hospital on 2/22/22. Review of the resident's medical record revealed an MDS Entry assessment with Assessment Reference Date (ARD) of 2/09/22, and an MDS admission assessment with ARD of 2/16/22. There was no MDS Discharge assessment to reflect resident #28's discharge from the facility on 2/22/22. On 5/12/22 at 12:04 PM, the 2nd Chair MDS Coordinator stated resident #28 was discharged to the hospital on 2/22/22. She explained an MDS Discharge assessment should be completed for all residents discharged from the facility. She verbalized the assessment would be completed by the Lead MDS/Care Plan Coordinator. During review of resident #28's MDS assessments with the 2nd chair MDS Coordinator, she confirmed an Entry MDS assessment with ARD of 2/09/22, and an MDS admission assessment with ARD of 2/16/22 were completed. She acknowledged no MDS Discharge assessment for this resident could be identified and confirmed it had been missed. On 5/12/22 at 12:10 PM and 2: 28 PM, the Lead MDS/Care Plan Coordinator stated MDS Discharge assessments should be completed, encoded and transmitted within fourteen days of the resident's discharge from the facility. She acknowledged resident #28 was discharged from the facility, and although an MDS Discharge assessment should have been completed for the resident, it was not done. She described the issue as an oversight. 3.0 Version 1.17.1, effective October 2019, provided instructions for MDS staff. Chapter 2 entitled Page 1 of 4 105868 105868 05/12/2022 Metro West Nursing and Rehab Center 5900 Westgate Drive Orlando, FL 32825

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Tracking Records and Discharge Assessments indicated the MDS Discharge assessment - Return Not anticipated or Return Anticipated must be completed when the resident is discharged from the facility and the resident is not expected/[expected] to return to the facility within 30 days. Must be completed within 14 days after the discharge date . The facility's policy Resident Assessment Instrument (RAI) Process revised on 3/27/18 indicated the Resident Care Specialist was responsible for completion of comprehensive assessments for each resident from admission to discharge. 105868 Page 2 of 4 105868 05/12/2022 Metro West Nursing and Rehab Center 5900 Westgate Drive Orlando, FL 32825

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a care plan meeting invitation, and failed to ensure participation of the resident and all required members of the interdisciplinary team (IDT) in the care plan meeting for 1 of 1 resident reviewed for care plans, out of the total sample of 42 residents (#94). Findings: Resident #94 was admitted to the facility on [DATE] with diagnoses including stroke with left sided weakness and end stage renal disease with dialysis. The Minimum Data Set (MDS) admission assessment with assessment reference date of 4/09/22 revealed the resident's Brief Interview for Mental Status score was 13, which indicated he was cognitively intact. The MDS assessment showed that the resident and the family participated in the assessment. On 5/10/22 at 9:35 AM, resident #94 stated he did not remember participating in any care plan meetings since he was admitted to the facility. Review of Progress Notes from 4/08/22 to 4/13/22 revealed a care plan meeting note dated 4/12/22 at 3:15 PM that read, Care plan meeting held with IDT, spoke to neighbor who states he will return home to live with his father upon discharge. There were no progress notes entered by individual members of the IDT and no summary of discussions held in the meeting regarding the resident's plan of care. On 5/12/22 at 11:11 AM, the Lead MDS/Care Plan Coordinator explained the care planning process. She stated all residents had their comprehensive care plans completed within the first 21 days in the facility. The Lead MDS/Care Plan Coordinator explained the facility either hand-delivered care plan invitation meeting letters to residents who were alert and oriented, or mailed the letters to the families of residents who were cognitively impaired. She stated she met with resident #94 on 4/12/22 and he gave her permission to discuss his care plans with his neighbor as his father was not available. The Lead MDS/Care Plan Coordinator reviewed documentation in her office and was unable to find a copy of the care plan meeting invitation letter for resident #94. She provided a Care Plan Attendance Log form dated 4/12/22 which showed signatures for meeting attendees that included herself, the Unit Manager, Therapy Manager, Social Services and Certified Dietary Manager. She confirmed the sections for the resident and family attendance were left blank, and there was no documentation on the form to show resident #94 was informed about his plan of care or that the resident/family was invited. When asked why it was important for the resident to attend his care plan meeting, she stated it was the opportunity for the IDT to explain his care and answer his questions. She confirmed each member of the IDT was expected to be present at the meeting. On 5/12/22 at 11:31 AM, resident #94 reviewed a sample Care Plan Meeting Invitation Letter and reiterated he had never received that letter. He stated he did not attend a care plan meeting with the 5 members of the IDT listed on the attendance log provided by the Lead MDS/Care Plan Coordinator. On 5/12/22 at 12:14 PM, the Lead MDS/Care Plan Coordinator reviewed the resident's electronic medical record and his paper chart and validated there were no copies of the Care Plan Meeting Invitation Letter. She recalled resident #94 was on isolation precautions on the scheduled day of the care 105868 Page 3 of 4 105868 05/12/2022 Metro West Nursing and Rehab Center 5900 Westgate Drive Orlando, FL 32825

F 0657 Level of Harm - Minimal harm or potential for actual harm plan meeting, so she was the only member of IDT who went to the room. She stated she did not bring the pen or the paperwork to the room and resident #94 was not able to sign for his attendance. The Lead MDS/Care Plan Coordinator did not respond when asked why the care plan meeting was not held by phone, or at a later date when the resident was off isolation precautions. She could not explain why she was able to enter the resident's room, but the other members of the IDT could not do so. Residents Affected - Few Review of the facility's Policies and Procedures Care Plan Conference revised on 2/18/19 revealed staff were responsible for assisting residents to engage in the care planning process. The document indicated a copy of the care plan meeting notification letter would be retained in the medical record. The policy indicated that care plan meeting should be documented in the progress notes and should include a summary of the meeting and attendees including a licensed nurse and the nurse's aid and a member of dietary staff, social service representative and to the extent practicable, the participation of the resident and the resident's representative(s). On 5/12/22 at 2:26 PM, the Lead MDS/Care Plan Coordinator validated the facility's policy required inclusion of residents' direct care aides in the IDT and documentation if the nurses' aide was not available. She stated the facility did not include nurses' aides in care plan meetings. However, the Lead MDS/Care Plan Coordinator confirmed input from nurses' aides was important as they spent more time with residents than any other member of the IDT. 105868 Page 4 of 4