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N0201
D

Deficiencies in Communication and Activity Program

Kissimmee, Florida Survey Completed on 02-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain ongoing communication and collaboration regarding the care and services for a resident receiving treatment at an external center. The resident's medical record indicated a moderate cognitive impairment, and the facility did not ensure consistent communication with the external center providing services. The Clinical Manager and Clinical Nurse from the center reported that a communication binder, previously used for documenting updates, had not been seen for over six months. Additionally, there was no consistent follow-up communication from the facility's nurses after each session to update the resident's condition. The Assistant Director of Nursing acknowledged the importance of such communication for coordinating care and confirmed the absence of documentation in the resident's medical record. The facility also failed to provide an ongoing program of activities that met the needs and interests of another resident. This resident, who had mild cognitive impairment and visual limitations, required activities compatible with their physical and mental capabilities, such as large print materials. However, the activity aide provided the resident with a regular print sudoku puzzle book and a coloring book, which did not accommodate the resident's visual needs. This oversight indicates a lack of attention to the resident's specific requirements as outlined in their comprehensive care plan.

Plan Of Correction

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: The Unit Manager contacted the provider to obtain Resident #12's updated treatment records, including recent lab results, treatment schedules, and any noted concerns. Resident #12's care plan was reviewed and updated to reflect current care needs, including accurate documentation and proper communication with providers, followed by monthly audits of 3 resident's records for an additional three months. Audit results will be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions taken as needed. Compliance monitoring will continue until sustained improvement is demonstrated, as determined by QAPI oversight. (e) The date of compliance is .

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