Oak Hammock At The University Of Florida INC

Based on observation, interview, and record review, the facility failed to obtain the medication dosage prior to administration for 1 of 3 residents reviewed for pain management (Resident #86).Findings include:During an observation on 6/29/2026 at 12:16 PM, Resident #86 was sitting upright in the bed with family members at the bedside. The resident was rubbing her left leg, grimacing. During an interview on 6/29/2026 at 12:16 PM, Resident #86 stated, My leg hurts all over sometimes on the top, then the pain moves to the side. Right now, it's hurting right here [points to inner calf left leg]. I want my oxycodone on time. If they bring it late, then my pain gets really bad.Review of Resident #86's physician order dated 6/23/2026 read, Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)). Apply to painful areas to LLE [Left Lower Extremity] topically four times a day for pain. The required dosage for application was not documented.Review of Resident #86's Medication Administration Record for June 2026 for application of diclofenac sodium topical gel showed the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food items were stored according to professional standard of practice, failed to serve foods at safe temperatures, and failed to ensure staff prepared food in accordance with professional standards to prevent the possible spread of food borne illness. (Photographic evidence obtained). Findings include: During an observation on 3/10/2025 at 9:15 AM with the Culinary Services Manager in the Main Dining Room, there were two packages of a food item that were not in the original packaging in the freezer with no identifying label. In refrigerator 1 there was a bag containing a white liquid with no identifying label or date. During an interview on 3/10/2025 at 9:19 AM, the Culinary Service Manager identified the food item in the bag stored in the refrigerator as yogurt and the two packages in the freezer as food molds of purred beef. The Culinary Service Manager stated, The food items should be labeled and/or dated in the refrigerator and freezer. During an observation on 3/11/2025 at 11:50 AM, there was one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to provide Advance Beneficiary notice of non-coverage in a timely manner for 2 of 3 residents reviewed for beneficiary notification, Resident #36 and #172. Findings include: Review of Resident #36's Notice of Medicare non-coverage showed Medicare coverage of current skilled nursing services would end on 3/01/2025. Review of Resident #36's Advance Beneficiary Notice of Non-coverage (ABN) was signed by Resident #36 on 3/07/2025. Review of Resident #172's Notice of Medicare non-coverage showed Medicare coverage of current skilled nursing services would end on 12/24/2024 Review of Resident #172's Advance Beneficiary Notice of Non-coverage (ABN) was signed by Resident #36 on 12/30/2024. During an interview on 03/12/2025 at 10:15 AM with the Quality Improvement Manager stated, [Resident #36's name] Advanced Beneficiary Notice of Non-Coverage (ABN) should have been given before 3/1/2025 which was her last cover day for Part A services. [Resident #36's name] ABN was given on 3/7/2025. [Resident #172's name] ABN was given on 12/30/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accuracy of minimum data set assessments for 2 of 5 residents, Residents #9 and #46. Findings include: 1) Review of Resident #9's physician order with a start date of 8/30/2024 read, Risperidone oral tablet 0.5 mg give 1 tablet by mouth one time a day for bipolar disorder. Review of Resident #9's Minimum Data Set (MDS) titled Quarterly dated 12/8/2024 read, Section N Medication: Antipsychotic: No. Review of Resident #9's Medication Administration Record (MAR) for the month of December 2024 documented the administration of Risperidone oral tablet daily. During an interview on 3/12/2025 at 12:48 PM with the MDS Coordinator stated, [Resident #9's name] Section N has a data entry error he was on antipsychotic medication. During an interview on 3/12/2025 at 12:58 AM with the Director of Nursing (DON) stated, We follow the Resident Assessment Instrument (RAI) manual. 2) Review of Resident #46's physician order dated 2/13/2025 read, Quetiapine Fumarate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to provide dialysis services consistent with professional standards related to the assessment of the resident's condition and monitoring for 1 of 2 residents reviewed for dialysis, Resident #57. Findings include: Review of Resident #57's physician order dated 2/11/2025 read, Pre/Post Dialysis Evaluation Assessment after resident returns from dialysis. Review of Resident #57's physician order dated 3/4/2025 read, Pre/Post Dialysis Evaluation Assessment after resident returns from dialysis every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for Dialysis. Review of Resident #57's assessments did not contain documentation of pre or post dialysis assessments on the following dates 2/19/2025 no pre-dialysis assessment, on 2/21/2025 no post dialysis assessment, on 2/26/2025 no post dialysis assessment, on 2/28/2025 no pre or post dialysis assessment, and on 3/7/2025 no post dialysis assessment. During an interview on 3/31/2025 at 2:40 PM with the Director of Nursing (DON) stated, We put in the order to tell staff what…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principle for 1 of 1 resident receiving intravenous therapy, Resident #41 and 1 of 3 hallways reviewed for unattended medication. Findings include: 1) During an observation on 3/10/2025 at 9:46 AM, Resident #9 was sitting in his room. On top of his bedside table there was a clear medication cup containing a white circular pill. During an interview on 3/10/2025 at 9:46 AM with Resident #9 stated, I do not know why a nurse would leave a pill on the table. I do not have any idea at what hour it was given. This should be restricted; this is no way to give a medication. It has never happened before, but I was shocked to see it on my table. Review of Resident #9 physician orders did not show documentation of medication self-administration orders. During an observation on 3/10/2025 at 10:36 AM, Resident #42's room was empty. There was a medication cup with a white powdered substance on top…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to obtain laboratory services to meet the needs for 1 of 5 residents reviewed for medication administration, Resident #41. Findings include: Review of Resident #41's physician order dated 6/20/2024 read, Check BMP [basic metabolic panel] every other week. Review of Resident #41's laboratory results for BMP showed a BMP was drawn on 2/4/2025 and 3/6/2025. Review of Resident #41's Treatment Administration Record (TAR) for February 2025 did not contain documentation of a BMP being drawn on 2/19/2025 as ordered by the physician. During an interview on 3/13/2025 at 9:37 AM, the DON (Director of Nursing) stated, I reviewed the resident's chart, and the BMP was not drawn according to the physician order. During an interview with on 3/12/2025 at 11:09 AM, the Medical Doctor #1 stated that her expectations would be that if she ordered a lab to be drawn every other week, the facility would draw the lab as ordered. Record review of the facility's policy titled, Laboratory Services last reviewed on 12/16/2024, stated: Policy: The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to follow infection control standards for following enhanced barrier precautions to prevent the possible spread of infection for 1 of 3 residents for enteral nutrition, Resident #57. Findings include: During an observation 3/10/2024 at 10:24 AM, Staff B, License Practical Nurse (LPN), entered Resident #57's room without donning a gown. Resident #57's room door has an enhanced barrier sign posted outside of the room. Staff B performed hand hygiene and don gloves but did not don a gown. Staff B stopped Resident #57 feeding pump and disconnected Resident #57's J-tube/G-tube [jejunostomy/gastrojejunostomy tube] from feeding. Staff B proceeded to flush Resident #57's J-tube with water. Staff B without donning a gown emptied Resident #57's J/G - tube drainage bag. Resident #57 physician order dated 3/4/2025 it read, Enhanced Barrier Precautions during high-contact resident activities: (dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care or assisting with toileting, medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards and included expirations dates when applicable in 2 of 4 medication carts reviewed. Findings include: During an observation of Medication Cart 1 on 11/27/2023 at 9:15 AM with Staff A, Licensed Practical Nurse (LPN), there were one 30-milliliter medication cup with chocolate pudding and crushed pieces of medications with no label identifying the medication or any resident identifier, one opened bottle of Brimonidine/ timolol ophthalmic solution with no opened or expiration dates, and one opened Basaglar insulin pen with no opened or expiration dates. During an interview on 11/27/2023 at 9:25 AM, Staff A, LPN, stated, That cup of medications with the pudding is for a resident who refused the medications earlier and I was going to go back and check before I threw it out. I should have labeled who it was for and what medications were in it. The eye drops and insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during intravenous medication administration. Findings include: During an observation of medication administration on 11/27/2023 at 10:45 AM, Staff C, Licensed Practical Nurse (LPN), prepared medications for Resident #167 without performing hand hygiene, entered the resident's room and administered the medications. Staff C exited the room and went to the medication cart to prepare medications for another resident. During an observation of medication administration on 11/27/2023 at 11:00 AM, Staff C, LPN, prepared medications for Resident #52 without performing hand hygiene, entered the resident's room and administered the oral medications without performing hand hygiene. Staff C donned gloves and placed gloved hands inside the rim of the trash can and moved the trash can closer. Staff C then picked up the bag of antibiotics and intravenous tubing, removed the end cap of the intravenous tubing and attached the antibiotic bag to the intravenous line. Staff C held the uncapped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record view, the facility failed to develop a person-centered care plan for 1 of 3 residents reviewed for respiratory services, Resident #43. Findings include: Review of Resident #43's physician order dated 10/17/2023 reads, Apply Oxygen @ [at] 2 liters via nasal cannula for SOB [shortness of breath] or sats <90% [saturation less than 90 percent]. Review of Resident #43's Weights and Vital Summary reads, 11/21/2023 00:56 [12:56 AM] 93% (Oxygen via Nasal Cannula) . 11/17/2023 16:01 [4:01 PM] 98% (Oxygen via Nasal Cannula) . 11/06/2023 19:45 [7:45 PM] 96% (Oxygen via Nasal Cannula) . 11/04/2023 23:30 [1:30 PM] 95% (Oxygen via Nasal Cannula). Review of Resident #43's Minimum Data Set, dated [DATE] showed the resident uses oxygen while a resident. Review of Resident #43's care plan did not reveal a focus for shortness of breath or oxygen therapy. During an interview on 11/29/2023 at 2:00 PM, the Director of Nursing stated, Our practice is to develop care plans based on residents' needs.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accepted professional standards of practice were followed for intravenous medication administration via midline catheter for 1 of 3 residents with midline catheters, Resident #52. Findings include: Review of Resident #52's admission record showed the resident was admitted on [DATE] with the diagnoses including sepsis, tubo-ovarian abscess (a pocket of pus due to infection of the ovary and fallopian tube), pelvic inflammatory disease, peritoneal abscess, chronic obstructive pulmonary disease, essential primary hypertension, hyperlipidemia, iron deficiency anemia, primary osteoarthritis, and presence of artificial hip joint. Review of Resident #52's physician orders dated 11/4/2023 reads, Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM (grams), Use 3.375 gm intravenously four times a day for sepsis w/o [without] acute organ dysfunction/tubo ovarian abscess until 12/07/2023 06:59 [6:59 AM], Administer every 6 hours at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.