Palatka Center For Rehabilitation And Healing

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection during wound care and the administration of gastrointestinal tube feeding. Findings include: 1) During an observation of wound care on 07/15/2026 at 2:30 PM, Staff A, Licensed Practical Nurse (LPN) performed hand hygiene, and donned a gown and clean gloves. The LPN set up wound care supplies on a sheet of tin foil and placed supplies on Resident #6's bedside table, doffed the gloves, performed hand hygiene, and applied clean gloves. The LPN cleansed the resident's coccyx wound with wound cleanser, patted the area dry with gauze, did not remove the soiled gloves, did not perform hand hygiene, or don clean gloves, and packed the wound with mupirocin, Santyl, and calcium alginate, placed a silicone foam dressing over the wound, then completed hand hygiene. During an interview on 07/15/2026 at 2:45 PM, Staff A, LPN stated that she was not aware that she needed to wash her hands and change her gloves between cleaning the wound and applying the new wound dressings. During an…

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 ensure the residents' health record showed the residents either received the pneumococcal immunization for 1 of 5 residents, Resident #43 reviewed for immunization.Findings include:Review of Resident #43's vaccination records showed a pneumococcal immunization consent signed on 8/25/2025 accepting to receive the pneumococcal vaccine.Review of Resident #43's immunization report did not document Resident #43 was administered a pneumococcal vaccine.During an interview on 7/16/2026 at 1:21 PM the Director of Nursing stated, [Resident #43's name] did not receive the pneumococcal vaccination.Review of the policy and procedure titled, Pneumococcal Vaccine with a last review date of 1/20/2026 read, Policy Statement. All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation. 4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal…

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 and interview, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) dressing changes were performed in accordance with professional standards of practice for 1 of 5 residents, Resident #2, reviewed for intravenous therapy.Findings include:During an observation on 02/27/2026 at 10:22 AM of Resident #2, the resident had a PICC (peripherally inserted central catheter) line inserted into the right upper arm. The PICC line was covered with a transparent dressing dated 2/11.During an interview on 02/27/2026 at 10:25 AM, Staff A, LPN (Licensed Practical Nurse) stated, It says 2/11 [the date on the PICC line dressing]. They are supposed to be changed weekly, I believe on Saturdays.During an interview on 02/27/2026 at 10:37 AM, Staff C, LPN stated, I think the RN [Registered Nurse] supervisor changes all the PICC line dressings. She works Monday through Friday, but she's not here today.During an interview on 02/27/2026 at 10:41 AM, the Director of Nursing stated, The PICC dressings should be changed every week, it is the responsibility of the nurse…

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 ensure resident records were complete and accurately documented for wound care treatments 1 of 5 residents, Resident #1, reviewed for wound care. Findings includedReview of Resident #1's physician order dated 01/17/2026 read, WOUND CARE: Cleanse abdominal staples with NSS [normal saline solution], pat dry, apply dry dressing every day shift. End date 01/26/2026.Review of Resident #1's Treatment Administration Record, the record did not contain documentation wound care was completed as ordered by the physician for the abdominal wound on 01/18/2026, 01/19/2026, or 1/23/2026.During an interview on 02/27/2026 at 12:40 PM, Staff A, LPN (Licensed Practical Nurse) stated, I changed [Resident #1's name]'s abdominal dressing every time I took care of her, so I must have just forgotten to document that I changed it on January 18th and 23rd.During an interview on 02/27/2026 at 1:13 PM, Staff B, LPN stated, I cannot recall whether I changed [Resident #1's name]'s dressing on January 19th or not.Review of the policy and procedure…

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 prevent the possible spread of infection for not implementing enhanced barrier precautions for 1 of 3 residents, Resident #2, reviewed for intravenous therapy care.Findings included:During an observation on 02/27/2026 at 10:32 AM, Staff A, LPN (Licensed Practical Nurse) was observed changing Resident #2's PICC (peripherally inserted central catheter) line dressing. The LPN was not wearing a gown.During an interview on 02/27/2026 at 10:43 AM the Director of Nursing stated, [Resident #2's name] should be on enhanced barrier precautions due to her IV (intravenous) and her wound. [Staff A's name] should have worn a gown. [Resident #2's name] doesn't have an order for enhanced barrier precautions.During an interview on 02/27/2026 at 10:48 AM, Staff A, LPN stated, I didn't think I needed to wear a gown to change a PICC line dressing.Review of Resident #2's care plan dated 02/02/2026 read, [Resident #2's name] is on IV Antibiotic Medications r/t [related to] Wound Infection. Interventions: Provide enhanced barrier…

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 a rationale when actions were not taken for pharmacy recommendations for 3 (Resident #7, #84, and #99) of 5 residents review for unnecessary medication. Findings include: 1)Review of Resident #7 Drug Regimen Review dated 7/10/2024 read, Consultant Pharmacist Recommendations. Currently receiving Oxybutynin (Ditropan) three times daily for urinary incontinence. Oxybutynin (Ditropan) can increase risk of dizziness and falls. Per clinical record, with recent falls. Periodic discontinuation recommended to determine current need and minimize resistance to the drug. Please evaluate, consider trail taper to two times daily with eventual discontinue, if appropriate . Physician Response: Disagree with no rationale included. Review of Resident #7 Drug Regimen Review dated 11/27/2024 read, Consultant Pharmacist Recommendations. Currently with active order for Hydrocodone/APAP which can increase risk of falls with recent documented falls per clinical record. Please evaluate possible casual relationship, Consider tapering dose or…

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 that residents were treated with dignity and respect and were free from physical restraint use when 1 resident had a splint on one hand and a nonskid sock covering the other hand for 1 resident (Resident #116) of 2 residents observed for positioning and mobility. Findings include: Review of the admission record documented that Resident #116 was admitted to the facility on [DATE], with medical diagnoses including hemiplegia [the complete loss of movement of one side of the body] and hemiparesis [weakness and partial loss of movement of one side of the body] following cerebral infarction affecting right dominant side [a stroke affecting the right side of the body],cognitive communication deficit[ difficulty communicating], and contracture, left hand [ a tightening of muscles and ligaments that prevents normal movement of the affected part]. During an observation on 02/17/2025 at 1:53 PM, Resident #116 was wearing a splint on her left…

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 1 (Resident #4) of 6 residents reviewed for respiratory services and 1 (Resident #143) of 5 reviewed for unnecessary medications. Findings include: 1)Resident #4 physician order dated 7/5/2024 read, Oxygen @ 3 L/Min (at 3 liters per minute) continuous inhalation via nc (nasal cannula) every shift for sob (shortness of breath). Review of Resident #4 Minimum Data Set (MDS) titled Quarterly dated 12/24/2024 read, Section O Special Treatments, Procedures and Programs: Oxygen therapy was coded No. Review of Resident #4 admission Record resident was admitted on [DATE] with diagnosis including but not limited to acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and acute posthemorrhagic anemia. During an interview on 2/19/2025 at 3:40 PM with the Regional MDS Consultant stated, [Resident #4's MDS appears to need to be corrected. I will modify Section O and correct the oxygen section.…

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 an interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #44) of 3 residents reviewed for urinary tract infections (UTI) , and for 1 resident (Resident #21) of 4 residents reviewed for mood and behaviors. Findings include: Review of Resident #21's medical record documented diagnoses that included depression. Review of Resident #21's physician progress note dated 1/31/2025 read, Chief Complaint: Depression, dementia and insomnia. Reason for Today's Encounter: Today, I saw the patient for medication management as patient has active psychiatric diagnosis, is on psych( psychiatric) meds(medications), is in the facility setting, and the last psychiatric visit was 4 or more weeks ago and as it was reported to me that patient is unstable requiring psychiatric assessment. History of Present Illness: This is a [AGE] year old patient with a past psychiatric history of depression, dementia and insomnia. Review of Resident #21's progress…

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 review the facility failed to administer blood pressure medication following parameters for 2 (Resident #103 and 143) out of 8 residents reviewed for medication administration and failed to follow professional standards of practice during medication administration to 1 resident, Resident #456. Findings include: 1.) Review of Resident #103 physician order dated 9/7/2023 read, Metoprolol Tartrate Oral Tablet 25 MG (milligram) (Metoprolol Tartrate) Give 12.5 mg by mouth two times a day for hypertension hold for SBP<120 (systolic blood pressure less than 120). Review of Resident #103's Medication Administration Record (MAR) for the month of January 2025 documented Metoprolol Tartrate 12.5 mg was given at 0900 [9:00 AM] on 1/16/2025 with a systolic blood pressure (SBP) of 108, 1/18/2025 with a systolic blood pressure of 118, 1/19/2025 with a SBP of 115, 1/21/2025 with a SBP of 114, 1/30/2025 with a SBP of 118 and at 2100 [ 9:00 PM] on 1/5/2025 with a SBP of 113, 1/15/2025 with a SBP of…

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 staff failed to ensure that oxygen was administered consistent with professional standards of practice for two (Resident #8 and Resident #125) of 6 residents reviewed for respiratory care . Findings include: 1.) During an observation on 2/17/2025 at 10:15 AM, Resident #8 was sleeping in their bed. She was observed with a nasal cannula in her nose attached to an oxygen concentrator running at 3 liters per minute (LPM). During an observation on 2/18/2025 at 12:51 PM, Resident #8 was observed sitting at the nurse's station in her wheelchair without her oxygen therapy of 2 LPM of continuous flow via a nasal cannula. During an observation on 2/19/2025 at 8:03 AM, Resident #8 was observed sleeping in her bed. She was observed with a nasal cannula in her nose attached to an oxygen concentrator running at 3 LPM. During an interview on 02/18/25 1:36 PM with the Director of Nursing, she stated that her expectations are that if a resident has an order for continuous oxygen that the resident should be kept on the prescribed flow of…

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 ensure residents' medications regimens were free of unnecessary antibiotic use based on adequate indications to reduce the risk of the developement of antibiotic resistant organisms for 1 (Resident #134) of 6 residents reviewed for unnecessary medications. Findings include: Review of Resident #134's admission record documented diagnoses that included ,but were not limited to chronic kidney disease, stage 4 (severe). Review of Resident #134's nursing progress notes Change in Condition form dated 1/6/2025 at 2:24 PM, read, Other change in condition: . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: .GU/Urine Status Evaluation: Painful urination .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Bactrim DS one tab(tablet) po(by mouth) bid ( two times a day) x7days. Review of Resident #134's Physician orders dated 1/6/2025 at 2:29 PM read, Sulfamethoxazole-Trimethoprim Tablet 800-160…

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 in accordance with currently accepted professional standards of practice when unsecured medications were observed in resident rooms for 1 out of 4 units reviewed for unattended medication. Finding include: 1)During an observation on 2/17/2025 at 10:17 AM Resident # 65 was lying in bed and on top of her bedside table there was a bottle of Fluticasone Propionate Lotion 0.05%. (photographic evidence obtained) During an interview on 2/17/2025 at 10:17 AM Resident #65 stated, I have the nurse apply the lotion to my back when it is itchy. Review of Resident #65 physician orders did not reveal a medication self-administration order. Review of Resident #65 care plan did not document a focus for medication self-administration. During an observation on 2/17/2025 at 10:21 AM Resident #80 was sitting in a wheelchair in her room. There was a circular white tablet in a plastic medication cup on top of the bedside table. (photographic evidence obtained) During…

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 maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection by failing to perform hand hygiene during medication administration for 4 (Residents #96 and #407) of 6 residents observed for medication administration, and failed to follow acceptable standards of care for storage of respiratory care equipment for 2 ( Resident #47 and Resident #143) of 6 residents reviewed for Respiratory care. Findings include: During an observation on 2/19/25 at 8:25 AM, Staff A, Registered Nurse (RN) was observed administering a medication intravenously to Resident #96 without performing hand hygiene before donning gloves and administering the medication or after removing her gown and gloves. Staff A, RN was observed returning to the medication cart to administer another residents medications. During an interview on 2/19/25 at 8:34 AM, Staff A, RN stated, I didn't wash my hands. During an observation on 2/19/25 at 8:37 AM, Staff C, Licensed Practical Nurse…

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 implement its antibiotic stewardship protocol when it failed to monitor the use of antibiotics to reduce the risk of development of antibiotic resistance for 1 (Resident # 134) of 3 residents reviewed for urinary tract infections. Findings include: Review of Resident #134's admission record documented diagnoses that included ,but were not limited to chronic kidney disease, stage 4 (severe). Review of Resident #134's nursing progress notes Change in Condition form dated 1/6/2025 at 2:24 PM, read, Other change in condition: . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: .GU/Urine Status Evaluation: Painful urination .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Bactrim DS one tab(tablet) po(by mouth) bid ( two times a day) x7days. Review of Resident #134's Physician orders dated 1/6/2025 at 2:29 PM read, Sulfamethoxazole-Trimethoprim Tablet 800-160 MG: Give 1 tablet by mouth…

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 review of policy and procedures, the facility failed to adhere to infection control practice standards during incontinence care for 2 out of 3 residents reviewed for incontinence care (Residents #5 and #6). Findings include: 1. Review of the admission record documented that Resident #5 was admitted to the facility on [DATE] with the following diagnoses displaced intertrochanteric facture of the left femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, with (acute) exacerbation, atherosclerotic heart disease of native coronary artery heart disease) without angina pectoris (chest pain), primary generalized osteoarthritis and essential primary hypertension. During an observation on 11/7/2024 at 10:40 AM, Resident #5 was lying in bed with the television on. There were incontinence briefs on Resident #5's dresser. During an interview on 11/7/2024 at 10:40 AM, Resident #5 stated, I am incontinent and can't get up by myself.…

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 provide a clean and homelike environment in 1 of 2 wings in the facility. Findings include: During an observation while conducting the facility tour on 8/12/2024 beginning at 10:00 AM, there were one blanket on the floor near the window and one plastic cup under the resident's bedside table in Resident #10's room, one medication cup on the floor in Resident #6's room, one plastic cup on the floor and one blue glove on the floor in the bathroom in Resident #7 and Resident #8's room, dried brown substance in the front of the toilet from the seat of the toilet down to the floor and one towel under sink on the floor in Resident #9's room. During an interview on 8/12/2024 at 10:19 AM, Staff B, Housekeeper, confirmed the items observed on the floor and stated, I work 7 AM to 3 PM. There is no 3 PM -11 PM or 11 PM- 7 AM shifts for housekeeping. During an interview on 8/12/2024 at approximately 10:25 AM, Staff C, Certified Nursing Assistant (CNA), confirmed the items observed on the floor and stated, Housekeepers work…

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, record review, and interview, the facility failed to ensure comprehensive person-centered care plans were developed and implemented for 1 of 3 residents reviewed, Residents #5. Findings include: 1. Review of Resident #5's admission record revealed the resident was most recently admitted on [DATE] with diagnoses including unspecified dislocation of left hip, non-pressure chronic ulcer of right thigh, stage 2 pressure ulcer of sacral region, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture of right and left hips and knees, and Methicillin susceptible Staphylococcus aureus infection (with onset date of 6/24/2024). Review of Resident #5's care plan with the last review date of 7/17/2024 showed it read, Focus: Falls- The resident is at risk for falls r/t [related to] impaired functional mobility, sleeps on edge of bed, incontinence, bilateral knee contractures . Interventions: 2/19/24: Fall Mats. During an observation on 8/12/2024 at 11:15…

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 staff used appropriate personal protective equipment while providing direct care to the residents on contact precautions to prevent the possible spread of infection and communicable diseases (Photographic evidence obtained). Findings include: Review of Resident #5's admission record revealed the resident was most recently admitted on [DATE] with diagnoses including unspecified dislocation of left hip, non-pressure chronic ulcer of right thigh, stage 2 pressure ulcer of sacral region, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture of right and left hips and knees, and Methicillin susceptible Staphylococcus aureus infection (with onset date of 6/24/2024). Review of Resident #5's physician order dated 6/27/2024 showed it read, Contact isolation related to MRSA [Methicillin-Resistant Staphylococcus Aureus], All services to be provided in patient room secondary to contact isolation…

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 review, the facility failed to ensure the residents with newly evident or possible serious mental disorder, intellectual disability or related condition were referred to the appropriate state designated authority for 3 of 4 residents reviewed for mood and behaviors, Residents #53, #95, #142. Findings include: 1. Review of Resident #142's admission record showed the resident was admitted on [DATE] and was diagnosed with brief psychotic disorder on 9/27/2022. Review of Resident #142's physician order dated 7/14/2023 reads, Valproic Acid (Depakote)Sent to lab 7/14/2023 1:41 AM ET [Eastern Time] one time only related to autistic disorder, brief psychotic disorder. Review of Resident #142's physician order dated 8/30/2023 reads, Depakote Oral Tablet Delayed Release (Divalproex Sodium) give 750 mg [milligram] by mouth two times a day for mood disorder. Review of State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 8/19/2022…

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 residents received respiratory care services consistent with professional standards of practice for 4 of 6 residents reviewed for respiratory care, Residents #123, #231, #104 and #142. Findings include: 1. During an observation on 10/30/2023 at 12:36 PM, Resident #123's oxygen (O2) tubing had no date. The respiratory plastic bag was on top of the O2 condenser located at the bedside, which was dated 9/13/2023 (photographic evidence obtained). During an observation on 10/31/2023 at 3:47 PM, Resident #123's respiratory plastic bag was dated 9/13/2023. There was no date on the oxygen tubing (photographic evidence obtained). During an interview on 10/31/2023 at 3:47 PM, Resident #123 stated, I need my oxygen on all the time. I get very winded without having it on. During an interview on 11/1/2023 at approximately 1:00 PM, the Director of Nursing stated, I don't have any words. Review of Resident #123's physician order dated 8/1/2023 reads, Oxygen @ [at] 2 L/Min [Liters/Minute] via NC [nasal cannula]…

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 2. Review of Resident #147's physician order dated 9/12/2022 reads, Liberal Renal diet, Regular Texture, Thin consistency. Review of Resident #147's physician order dated 9/12/2023 reads, Dialysis: Vitals Signs Pre Dialysis every day shift every Mon, Wed, Fri for Dialysis. Review of Resident #147's physician order dated 9/12/2023 reads, Dialysis: Vitals Signs Post Dialysis every evening shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for Dialysis. Review of Resident #147's physician order dated 9/12/2022 reads, Dialysis: AV Fistula- Monitor for Signs & Symptoms of Infection every shift. Assess site for any change in skin condition. Report any noted redness, edema, or increased skin temperature to MD every shift. Review of Resident #147's Medication Administration Record for October 2023 for vital signs post dialysis revealed no recording on 10/2/2023,10/6/2023, 10/9/2023, 10/11/2023, 10/13/2023, 10/16/2023, 10/20/2023, and 10/30/2023. Review of Resident #147's Medication Administration Record for October…

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 resident choices or preferences were followed. Findings include: Review of the menu posted on 10/30/2023 at 9:25 AM outside of the café dining room showed the breakfast menu included egg, sausage, cheese sandwich, and English muffin. During an observation on 10/30/2023 at 9:25 AM in the café dining room, the residents were served scrambled eggs, toast, and hot cereal. During an interview on 10/31/2023 at 12:03 PM, Resident #33 [Resident Council President] stated, The posted menus are not what we receive on numerous occasions and that food preferences are not honored nor are we given a select menu. The dietary manager stated the budget did not always allow them to have meats for breakfast. The facility has been out of eggs on several occasions, and we are served grits, cheese, and toast. During an interview on 10/31/2023 at 12:10 PM, Resident #17 stated, The kitchen runs out of the regular meal before all residents get served and the remaining residents get something totally different on numerous…

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 2. Review of Resident #20's admission record revealed the resident was admitted to the facility on [DATE]. Review of Resident #20's medical records revealed the resident had a fall with injury on 10/3/2023. Resident #20 returned to the facility following a temporary absence for hospitalization on 10/9/2023 with a new diagnosis of fracture of left radius. Review of Resident #20's Minimum Data Set showed the resident's next assessment reference date of 10/16/2023 that was 18 days overdue. During an interview on 11/3/2023 at approximately 7:45 AM, the Director of Nursing stated, My expectation is that upon return to the facility, the assessment should be completed within 14 days. Review of the facility policy and procedure titled Resident Assessment Instrument (RAI) last reviewed on 3/30/2023 reads, Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment…

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 the assessments accurately reflected the resident's status at the time of assessment for 2 of 2 residents reviewed for hospice services, Residents #27 and #41, and 1 of 4 residents reviewed for discharge, Resident #179. Findings include: 1. Review of Hospice Medicare Revocation Statement signed by Resident #27 showed the resident had revoked the hospice election on 11/23/2022 to seek aggressive treatment. Review of Resident #27's Minimum Data Set (MDS) dated [DATE] showed hospice care while a resident under Section O. Special Treatment, Procedures, and Programs. During an interview on 11/3/2023 at approximately 7:45 AM, the Director of Nursing stated Resident #27 should not be coded as hospice. Review of the facility policy and procedure titled Resident Assessment Instrument (RAI) last reviewed on 3/30/2023 reads, Intent: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of…

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 develop a person-centered care plan for 1 of 2 residents reviewed for hospice services, Resident #41, and 1 of 8 residents reviewed for nutrition, Resident #101. Findings include: 1. Review of Resident #41's physician order dated 9/29/2023 reads, [Hospice's name] Hospice. Review of Resident #41 progress notes dated 7/28/2023 reads, Consultation done on shift. [Hospice's name] consultation nurse stated that a nurse will be out to facility Monday and patient will be assigned a case manager at that time. Review of Resident #41's medical records revealed an RN-Initial Comprehensive Assessment for hospice completed on 7/28/2023. Review of Resident #41's care plan revealed no focus or interventions for hospice services. During an interview on 11/1/2023 at 10:37 AM, the Director of Nursing stated, Once hospice is recommended for a resident and the resident is signed up, we will include the services in the resident's care plan. [Resident #41's name] is receiving hospice services and should have been care planned. During an…

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 residents received treatment and care in accordance with professional standards for wound care for 1 of 3 residents reviewed for skin conditions, Resident #4. Findings include: During an observation on 10/30/2023 at 10:35 AM, Resident #4 was sitting in her wheelchair with a dressing dated 10/25/2023 on her right forearm (photographic evidence obtained). During an interview on 10/30/2023 at 10:35 AM, Resident #4 stated, I have a skin tear on my arm. Review of Resident #4's physician order dated 10/13/2023 reads, Cleanse right forearm skin tear with NS [Normal Saline] apply TAO [triple-antibiotic ointment] with dry dressing. Monitor for s/s [signs/symptoms] of pain, infection, and or any concerns. Notify MD [Medical Doctor] as needed, in the evening for right forearm skin tear. During an interview on 11/1/2023 at 10:48 AM, the Director of Nursing stated, Staff is supposed to follow physician orders. Dressing should have been changed daily. Review of the facility policy and procedure titled Wound Care…

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 ensure residents received restorative services as recommended by the physical therapist to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents reviewed for activities of daily living, Resident #161. Findings include: Review of Resident #161's care plan initiated on 5/20/2023 revealed Resident #161 was a high risk for falls related to gait/balance problems with a history of pelvic fracture and unaware of safety needs. Fall prevention interventions included physical therapy evaluation and treatment as ordered or as needed. Review of Resident #161's physical therapy discharge summary for the dates of service of 6/17/2023 through 8/4/2023, reads, Discharge Recommendations and Status, Range of Motion Program Established/ Trained: Patient is currently able to move feet up and down, and tier is functional and with Restorative Nursing Program, patient will be able to move feet up and down and move legs up and down by performing the following Restorative Nursing interventions: allow…

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 maintain appropriate parameters of nutritional status for 1 of 8 residents reviewed for nutrition, Resident #169. Findings include: During an observation on 10/30/2023 at 12:36 PM, Resident #169 was eating independently in her room, with no supplement noted on her meal tray. During an observation on 10/31/2023 at 12:40 PM, Resident #169 was eating independently in her room, with no supplement noted on her meal tray. During an interview on 11/1/2023 at 12:35 PM, Resident #169's family member stated, I have not seen any supplements come with her lunch meals when I have been present. Review of Resident #169's physician order dated 9/14/2023 reads, Liberal Renal Diet, Regular Texture, Thin Consistency. Review of Resident #169's physician order dated 9/21/2023 reads, Weight: Daily x [times] 3 consecutive days and then weekly one time a day every Mon [Monday]. Review of Resident #169's Nutrition Assessment with an effective date of 10/11/2023 Reads, A. Data . 5. Rate of weight loss/gain as 5%. B. Nutrition . 3.…

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 medications were labeled in accordance with currently accepted professional principles in 1 of 3 medication rooms, and 1 of 4 medication carts. Findings include: During an observation of the Medication Room in the Ocean View Unit with Staff B, Licensed Practical Nurse (LPN)/ Unit Manager, on [DATE] at 9:55 AM, there was an open vial of Latanoprost ophthalmologic drops with no opened and expiration date. During an observation of the Front Hallway [NAME] Cart with Staff B, LPN/ Unit Manager on [DATE] at 10:12 AM, there were one opened Lyumjev KwikPen with no opened and expiration date, one opened insulin glargine-yfgn pen with no opened and expiration date, one Breo Elipta inhaler with no opened and expiration date and the front label reading discard (6 weeks), and one unopened insulin glargine-yfgn 10 milliliter (ml) vial with the label reading refrigerate until opened. During an interview on [DATE] at 10:12 AM, Staff B, LPN/ Unit…

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 was stored in the kitchen cooler and in the stock/storage room areas in accordance with professional standards. Findings include: During an initial tour of the kitchen with the Certified Dietary Manager (CDM) on 10/30/2023 at 9:15 AM, there were a full-size black tub with 3 large raw roasts with no type of identifying label or date on the product or the container, a sandwich labeled tuna and dated 10/25, and a clear bag with what appeared to be pineapple and peaches or mandarin orange bits without a date or label in the walk-in cooler. There were boxes of vanilla wafers, and four opened bread containers with no received or opened date in the stock room. During an interview on 10/30/2023 at 9:30 AM, the CDM verified that all food items should be labeled and dated in the cooler and stock/storage room. The CDM confirmed that all sandwiches should be correctly labeled and dated for storage and discarded on the 3rd day. The CDM could not confirm if the date on the tuna sandwich was the date it was made…

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 medical records were documented accurately for wound care treatments for 1 of 3 residents reviewed for skin conditions (Resident #4), and for 1 of 3 residents reviewed for turning and positioning and 1 of 4 residents reviewed for discharge (Resident #430). Findings include: 1. During an observation on 10/30/2023 at 10:35 AM, Resident #4 was sitting in her wheelchair with a dressing dated 10/25/2023 on her right forearm. During an interview on 10/30/2023 at 10:35 AM, Resident #4 stated, I have a skin tear on my arm. Review of Resident #4's physician order dated 10/13/2023 reads, Cleanse right forearm skin tear with NS [Normal Saline] apply TAO [triple-antibiotic ointment] with dry dressing. Monitor for s/s [signs/symptoms] of pain, infection, and or any concerns. Notify MD [Medical Doctor] as needed, in the evening for right forearm skin tear. Review of Resident #4's Treatment Administration Record for October 2023 showed staff initials for completion of wound treatment for forearm skin tear on…

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.