Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Haven Rehab And Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain complete skilled documentation and change-in-condition records for multiple residents. Two residents on therapy did not have required skilled daily assessments documented on several days, despite expectations that such notes be completed for all residents receiving therapy, and one of these residents had MAR entries indicating assessments that were not supported by actual assessment records. During an allergic reaction episode requiring epinephrine and EMS transfer, a resident’s primary physician was not documented as notified, and no change-in-condition or transfer assessment was recorded, contrary to facility policy. Another resident with an indwelling urinary catheter reported that the catheter had come out during the night; staff later confirmed the dislodgement and delayed reinsertion, yet there was no documentation of the event, physician notification, or related assessment in the medical record, despite active catheter orders and documentation requirements.
The facility failed to maintain an effective QAPI process to ensure required daily skilled assessments for residents receiving skilled services. A resident with multiple serious diagnoses, including paroxysmal atrial fibrillation, hypertensive heart disease, generalized muscle weakness, adult failure to thrive, and post-circulatory surgery aftercare, was receiving ordered PT and OT five times weekly but had no corresponding order for daily skilled notes and lacked skilled documentation on multiple days. An LPN/unit manager acknowledged that residents on therapy are expected to have daily skilled notes and that this resident did not. Although audits of skilled documentation were conducted, they covered less than half of the residents on skilled services and repeatedly focused on the same individuals, while this resident’s documentation was never audited, reflecting a deficiency in the facility’s QAPI monitoring of daily skilled charting.
A resident and the resident’s representative voiced concerns during an IDT care plan meeting and through negative kiosk feedback about nursing care, cleanliness, and customer service, but the facility did not properly log or process these concerns as a grievance. The SSD, who oversees grievances, could not identify the specific concerns raised during the care plan meeting, and the November grievance log contained no entry for those issues. A grievance later produced from kiosk feedback lacked detail about the complaint, did not document an investigation, and showed only that a room change would be offered, with resolution communicated to the resident but not the representative. Interviews with an LPN/unit manager indicated the representative had concerns about food allergies but no clear documentation of other issues, and review of the facility’s grievance policy showed requirements for investigation and communication that were not met in this case.
A resident with neurogenic bladder and an order for an indwelling Foley catheter reported that the catheter had come out during the night, and staff delayed reinsertion for approximately nine hours, despite an active order and ongoing treatment for a UTI. Observations showed no drainage bag present in the morning and, later, a catheter and bag with no urine output, while the resident stated the catheter was not in the bladder. Nursing staff could not produce contemporaneous documentation explaining when or how the catheter dislodged, whether the provider was notified, or why a different catheter size was used, contrary to the care plan and catheter care policy. In a separate case, another resident with COPD, diabetes, and hypertensive heart disease had orders for vital signs every shift over several days, but the MAR showed identical or nearly identical vital signs documented across multiple consecutive shifts, with one entry missing most parameters, raising concern that vital signs were not accurately obtained or recorded as required by the facility’s documentation policy.
The facility failed to ensure complete documentation of ADL care for three residents with significant care needs, resulting in missing records for essential tasks such as bed mobility, toileting, bathing, dressing, and incontinence care. Despite care plans indicating the need for extensive staff assistance, the required documentation was not present on multiple dates, as confirmed by the DON.
The facility failed to perform weekly skin assessments for eight residents and wound care assessments for two residents with non-pressure wounds. This deficiency was identified through observations, interviews, and record reviews. For instance, a resident did not have documented weekly skin checks for several weeks, despite being at risk for skin impairment due to multiple health conditions. Similarly, another resident's wound care was inadequately documented, with missing weekly skin checks and incomplete wound assessments, despite having a significant leg injury.
The facility failed to provide consistent pressure ulcer care and documentation for three residents, leading to deficiencies. A resident with a stage 4 ulcer had inconsistent wound evaluations, while another with diabetes and a foot ulcer experienced discrepancies in wound care documentation. A third resident with an ankle injury lacked documented wound evaluations, with the LPN citing personal notes and external care involvement. The DON confirmed the expectation for weekly documentation, highlighting lapses in adherence to care plans.
The facility failed to maintain ongoing communication with the dialysis center for three residents requiring dialysis services. Despite having care plans in place, communication books were missing, and dialysis communication forms were often incomplete. Staff interviews revealed inconsistent follow-up with the dialysis center, and there was no documentation of communication in the residents' progress notes, leading to a deficiency in providing safe and appropriate dialysis care.
The facility failed to ensure proper hand hygiene and equipment disinfection during medication administration and blood glucose monitoring. Staff did not sanitize hands or clean equipment between residents, and PPE protocols were not followed for residents on droplet precautions. Observations and interviews revealed multiple instances of non-compliance with infection control measures.
A facility failed to accurately code the MDS at discharge for a resident who was hospitalized. The resident, with multiple diagnoses, was sent to the hospital following a change in condition. However, the MDS incorrectly marked the discharge status as 'Home/Community'. The MDS Director confirmed the error during an interview.
The facility failed to ensure accurate PASRR documentation for two residents. One resident's PASRR did not mark a diagnosis of Depressive Disorder, while another's did not mark Epilepsy under Intellectual Disability. PASRRs were reviewed post-admission by the clinical team, leading to inaccuracies.
A facility failed to update a resident's care plan after discontinuing an antipsychotic medication. Despite the medication being stopped, the care plan still included interventions related to its use. The DON acknowledged the oversight, and the facility lacked a specific care plan policy, relying on the RAI manual instead.
A resident with multiple medical conditions experienced constipation and requested a suppository, which was delayed and not documented by the facility staff. The resident's care plan included monitoring for bowel irregularity, but there was no physician order or documentation of the medication administration. The LPN admitted to administering the suppository without proper documentation, leading to a deficiency in pharmaceutical services.
Two instances of improper medication storage were observed in the facility. An LPN left a resident's inhaler unattended on a medication cart while washing hands, and another LPN left an insulin bottle on a cart while administering an injection. Both actions violated the facility's policy requiring medications to be stored in locked compartments.
A resident requested a snack after breakfast, but it was not provided due to a communication breakdown among staff. A CNA acknowledged the request but did not fulfill it, claiming to have informed the assigned CNA, who was unaware of the request. The RN and DON confirmed that any CNA could provide snacks after consulting with a nurse, as per facility policy.
The facility failed to maintain accurate and complete documentation of Skilled Nursing Documentation Notes for three residents, resulting in missing records on several dates. A resident with chronic conditions had incomplete documentation despite receiving therapy services. Another resident had missing documentation and an undocumented bruise, while a third resident experienced delays in care and had incomplete records. The facility's policy requires comprehensive documentation, which was not met.
Failure to Maintain Complete Skilled Documentation and Change-in-Condition Records
Penalty
Summary
The deficiency involves failures in skilled documentation and medical record maintenance for multiple residents receiving skilled services. For one resident receiving occupational and physical therapy five times a week, the record lacked skilled daily assessments on multiple therapy days, including 3/30, 3/31, 4/4, 4/7, 4/10, and 4/11, despite the DON and LPN/Unit Manager stating that residents on therapy were expected to have daily skilled notes. The physician orders for this resident did not include an order for a skilled daily note, and the assessments section showed gaps where no skilled documentation was completed on days when therapy was ordered. Another resident, admitted and later discharged in November, had a MAR indicating that skilled assessments were confirmed as completed daily over several days; however, the assessment records showed no skilled assessments from 11/9 through 11/13, other than an admission/readmission assessment on 11/8. During this period, the resident experienced an allergic reaction with itching and redness to both upper extremities, received an epinephrine injection, and was transferred to an acute care facility via EMS at the representative’s request. The progress notes did not show that the primary care physician was notified of the change in condition or transfer, and there was no documented change in condition or transfer assessment in the medical record, despite facility policy requiring physician notification and documentation when a resident’s condition changes or when a transfer to a hospital occurs. A third resident reported that an indwelling urinary catheter had come out during the early morning hours, and stated they were told staff were waiting for a CNA. Initial observation did not show a catheter in place, and subsequent review of progress notes revealed no documentation of the catheter dislodgement on either the night it occurred or the following day. The resident’s active orders included indwelling urinary catheter care every shift, monitoring every shift, and notification of the physician for changes in urinary status. Later observation with the LPN/Unit Manager showed urinary tubing and a drainage bag with no urine output, and staff interviews confirmed that the catheter had come out around 2:00 a.m., that the night nurse had reportedly spoken with the provider about changing catheter size, and that a new catheter was inserted about nine hours later. Staff and the DON confirmed that the medical record contained no documentation of the dislodgement, physician notification, or related assessment, contrary to the facility’s documentation policy requiring complete, accurate, and care-specific entries for changes in condition and procedures performed.
Failure to Ensure Daily Skilled Assessments Through Effective QAPI Monitoring
Penalty
Summary
The facility failed to maintain an effective, comprehensive QAPI program related to ensuring daily skilled assessments for residents receiving skilled services. One resident was admitted with multiple significant diagnoses, including paroxysmal atrial fibrillation, hypertensive heart disease without heart failure, generalized muscle weakness, adult failure to thrive, and a need for surgical aftercare following circulatory system surgery. The resident had active physician orders for occupational therapy five times a week for 30 days and physical therapy five times a week for 30 days, but there was no order for a skilled daily note to be completed. Review of the resident’s assessments showed there was no skilled documentation on multiple specific dates while the resident was receiving these skilled services. During interviews, an LPN/unit manager stated that daily skilled notes are done for residents receiving therapy and confirmed that this resident was not receiving daily skilled assessments, clarifying that a progress note does not take the place of the assessment. The DON reported that the facility had identified an issue with skilled documentation and that the expectation was that anyone getting therapy should have a daily skilled assessment. Review of QAPI-related audits of skilled documentation showed that only 12 of 31 residents receiving skilled services had been audited over several dates, with some residents audited repeatedly while others, including this resident, were not audited at all. The DON confirmed that the same residents were being audited and that this resident’s clinical documentation had not been reviewed, demonstrating a failure of the QAPI process to comprehensively monitor and ensure completion of required daily skilled assessments.
Failure to Properly Log, Investigate, and Communicate Resolution of a Resident Grievance
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances without reprisal by not properly identifying, documenting, and processing concerns as grievances. An IDT care plan note for Resident #1 dated 11/12/25 showed that a meeting was held with the resident and the resident’s responsible party by phone, and that concerns were addressed with the unit manager; however, there was no corresponding grievance documented on the November 2025 grievance log for any concerns voiced during that meeting or during the month. Resident #1 had been admitted earlier in November and discharged on 11/14/25. The Social Service Director (SSD), who was responsible for handling grievances, stated that when a family complains or voices concerns during a care plan meeting, a grievance should be written, but the SSD did not know what concerns Resident #1 or the representative had raised and acknowledged that the social services assistant attended the meeting instead. The SSD produced a grievance dated 11/9/25 that had been initiated in response to negative feedback left by Resident #1’s representative on the facility’s kiosk, which showed a low visit rating and dissatisfaction with nursing care, housekeeping/cleanliness, and customer service. The written grievance, however, did not contain any specific details of the complaint, did not document what was investigated, and only indicated that a room change would be provided when available, with notification of resolution documented only to the resident and not the representative. There was no documentation that the representative had been contacted or that specific concerns had been clarified. In interview, the unit manager/LPN reported that the representative frequently called but voiced no issues, though the representative had been concerned about the resident’s food allergies, and the manager could not recall any other concerns from the care plan meeting. Review of the facility’s grievance policy showed that all grievances and complaints from residents or representatives must be reviewed, investigated, and responded to, and that the person filing the grievance must be informed of the findings, which was not supported by the documentation for this resident.
Failure to Timely Reinsert Indwelling Catheter and Accurately Document Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and the resident’s care plan for a resident with an indwelling urinary catheter. One resident with a diagnosis of neurogenic bladder had an active order for an 18 fr indwelling urinary catheter with a 10 mL balloon and was receiving Levaquin for a UTI. The resident reported that the urinary catheter came out around 2:00–3:00 a.m., and staff told the resident they were waiting for an aide. During a morning observation, there was no urinary drainage bag present. By early afternoon, the resident was observed in a wheelchair with catheter tubing visible and a drainage bag hanging from the chair, but there was no urine in the bag, and a CNA reportedly had not drained it that day. The resident stated the catheter was not in the bladder but in the uterus. In interviews, nursing staff reported receiving in shift report that the catheter had dislodged around 2:00 a.m. and that the off‑going nurse had spoken with the physician about inserting a 16 fr catheter instead of the ordered 18 fr. One LPN stated she inserted a 16 fr catheter about an hour before the afternoon observation and planned to return to check on the resident. The unit manager acknowledged that delaying catheter insertion for approximately nine hours was not appropriate, except in the context of a toileting trial, which was not indicated in the record. Review of the resident’s progress notes showed no documentation from the previous nurse describing when or how the catheter came out, whether the physician was notified, or any rationale for the delay. A late entry was later documented indicating the resident had not voided since the catheter dislodged and that 300 mL of clear yellow urine returned after reinsertion, but this information was not contemporaneously recorded at the time of the event. A second deficiency involved failure to accurately obtain and document vital signs as ordered for another resident with diagnoses including COPD, type 2 diabetes mellitus, and hypertensive heart disease. The physician’s order required vital signs every shift for five days. Review of the MAR showed that on multiple consecutive shifts, including different days, the resident’s vital signs were documented as identical or nearly identical, with one night shift entry listing only blood pressure and “NA” for temperature, pulse, respirations, and oxygen saturation. The DON reviewed these entries and acknowledged that the repeated identical vital signs over multiple shifts were “quite a coincidence,” and the facility’s documentation policy required that services provided, changes in condition, and treatments be documented in a complete and accurate manner. The pattern of identical vital signs suggested that vital signs may not have been properly obtained and documented as ordered.
Failure to Document ADL Care and Services in Resident Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation of Activities of Daily Living (ADLs) for three sampled residents. For one resident with diagnoses including Parkinson’s, dementia, anemia, and hypotension, review of the medical record revealed missing documentation for multiple ADL tasks such as bed mobility, toileting, bathing, dressing, and incontinence care on several dates. The care plan indicated the resident required assistance with all ADLs, but the records did not reflect that care was provided or documented as required. The Director of Nursing (DON) confirmed that documentation was missing for the specified dates and acknowledged that she expected to see records of tasks performed. Another resident, with a history of diabetes, Alzheimer’s disease, hypertension, and dementia, was also found to have incomplete documentation regarding incontinence care and toileting. The care plan specified that the resident was dependent on staff for these tasks, yet the ADL records showed only one or two instances of incontinence care documented on several days, and no documentation at all on one date. The DON verified the absence of documentation for incontinence care and stated that staff were expected to document these services. A third resident, with multiple chronic conditions including diabetes with foot ulcer, hyperthyroidism, and peripheral vascular disease, had missing ADL documentation for bed mobility, toileting, transfers, and other care activities during both day and evening shifts on several dates. The care plan indicated the resident required extensive assistance for these activities. The DON confirmed that documentation was not completed for the identified dates. Facility policies reviewed required that all care and services provided be documented in the resident’s medical record, including details such as date, time, and the name and title of the individual providing care.
Failure to Perform Weekly Skin and Wound Assessments
Penalty
Summary
The facility failed to perform weekly skin assessments for eight residents and wound care assessments for two residents with non-pressure wounds. This deficiency was identified through observations, interviews, and record reviews. For instance, Resident #19 did not have documented weekly skin checks for several weeks, despite being at risk for skin impairment due to multiple health conditions. Similarly, Resident #90's wound care was inadequately documented, with missing weekly skin checks and incomplete wound assessments, despite having a significant leg injury. Resident #8 also experienced a lack of consistent skin assessments, with missing documentation for weekly skin checks and incomplete records of observed bruises. Resident #267 had multiple wounds, including a diabetic ulcer and a pressure ulcer, but lacked documented wound sizes and assessments since admission. The facility's wound care nurse and floor nurses were responsible for these assessments, but there were lapses in documentation and follow-up. Additional residents, such as Resident #362, #58, and #5, also had incomplete or missing skin and wound assessments. The facility's Director of Nursing and wound care nurse acknowledged these deficiencies, citing issues such as staff absences and lack of documentation. The facility's policies required comprehensive skin assessments and documentation, but these were not consistently followed, leading to the identified deficiencies.
Inconsistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure consistent treatment and services for pressure ulcers in three residents, leading to deficiencies in care. Resident #362, who was admitted with a stage 4 pressure ulcer on the coccyx, had a care plan that included weekly skin checks and wound assessments. However, the facility's records showed inconsistencies in the documentation of weekly wound evaluations, with only three evaluations recorded over a month-long period. The Director of Nursing (DON) confirmed that weekly wound assessments should be conducted by both the bedside nurse and the wound care nurse, indicating a lapse in adherence to the care plan. Resident #58, diagnosed with type 2 diabetes and a foot ulcer, also experienced deficiencies in wound care documentation. The resident's care plan required weekly skin checks, but the wound evaluations showed discrepancies in the frequency and detail of assessments. The evaluations revealed changes in the wound's size and stage, yet the documentation did not consistently reflect these changes. This inconsistency suggests a failure to accurately monitor and document the resident's condition, as required by the facility's policies. Resident #5, with a diagnosis of a superficial injury to the right ankle, had a care plan that included monitoring for skin impairments and weekly skin checks. However, the facility's records lacked weekly wound evaluations for a month, and the Licensed Practical Nurse (LPN) responsible for wound care admitted to not documenting current assessments. The LPN cited personal notes and external wound care involvement as reasons for the lack of documentation. The DON acknowledged the expectation for weekly documentation and noted that the absence of uploaded notes hindered the bedside nurses' ability to access necessary information. This failure to document and communicate wound care assessments contributed to the deficiency in care for Resident #5.
Lack of Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication between the facility and the dialysis center for three residents who required dialysis services. Resident #33, who was admitted with diagnoses including end-stage renal disease and hemiplegia, had a care plan that outlined specific interventions for dialysis care. However, the facility did not maintain a communication book, and the dialysis communication forms were often incomplete, lacking input from the dialysis nurse. Interviews with staff revealed that communication with the dialysis center was inconsistent, and there was no documentation of ongoing communication in the resident's progress notes. Resident #35, with diagnoses including end-stage renal disease and type 2 diabetes mellitus, also experienced a lack of communication between the facility and the dialysis center. The dialysis communication forms for this resident were consistently left blank by the dialysis nurse, and there was no documentation of communication in the progress notes. Staff interviews indicated that the facility did not routinely follow up with the dialysis center when communication forms were incomplete, relying instead on monthly calls to obtain treatment notes. Resident #268, diagnosed with chronic kidney disease stage four and other conditions, faced similar issues with incomplete dialysis communication forms and a lack of documented communication in progress notes. Staff interviews highlighted that communication with the dialysis center was sporadic, and there was no consistent follow-up when forms were incomplete. The facility's policy on dialysis care required correspondence from the dialysis center to be recorded in the plan of care, but this was not consistently done, leading to a deficiency in ensuring safe and appropriate dialysis care for the residents.
Infection Control and PPE Lapses
Penalty
Summary
The facility failed to ensure proper hand hygiene and equipment disinfection during medication administration and blood glucose monitoring. Observations revealed that several staff members, including RNs and LPNs, did not perform hand sanitizing before or after medication passes, nor did they clean blood pressure cuffs and blood glucose monitors between resident uses. For instance, one RN was observed not sanitizing hands before administering medications and not cleaning the blood pressure machine after use. Similarly, an LPN was seen handling medication and equipment without hand sanitizing, and another LPN did not clean the blood pressure cuff between residents. Additionally, the facility did not adhere to proper PPE protocols for residents on droplet precautions. Staff members were observed exiting rooms with face shields and masks still donned, contrary to the signage instructions that required removal of face protection before room exit. Interviews with staff confirmed these lapses, with admissions of forgetting to remove PPE as required. The Director of Nursing acknowledged the expectation for staff to follow PPE instructions and the need for proper infection control practices. The facility's policies on medication administration, hand hygiene, and disinfecting were not followed, contributing to the deficiencies. The policies required hand hygiene before and after resident contact, medication administration, and glove changes, as well as cleaning and disinfecting equipment between uses. However, these procedures were not consistently implemented, as evidenced by the observations and staff interviews. The failure to adhere to these standards resulted in multiple instances of non-compliance with infection prevention and control measures.
Inaccurate MDS Coding at Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) at discharge for a resident, leading to a deficiency. Resident #111, who had been admitted with multiple diagnoses including malignant neoplasm of the lung, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, and generalized muscle weakness, was sent to the hospital for treatment and evaluation following a change in condition. Despite being hospitalized, the Discharge Return Anticipated /End of PPS Part A Stay MDS inaccurately marked the resident's discharge status as 'Home/Community'. During an interview, the MDS Director confirmed the error, acknowledging that the resident was indeed hospitalized at discharge, not sent home.
Inaccurate PASRR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Level I Preadmission Screening and Resident Review (PASRR) for two residents. Resident #19 was admitted with diagnoses including Anxiety Disorder and Major Depressive Disorder. However, the Level I PASRR did not mark the diagnosis of Depressive Disorder in the relevant section, and it indicated that no serious mental illness or intellectual disability was present, thus not requiring a Level II PASRR evaluation. Similarly, Resident #7 was admitted with diagnoses including Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, and Epilepsy. The PASRR for this resident marked Bipolar and Depressive Disorders but failed to mark the related condition of Epilepsy under Intellectual Disability, again indicating no need for a Level II evaluation. The deficiency was identified through record reviews and staff interviews, revealing that the PASRRs were not reviewed pre-admission. The Admissions Director stated that PASRRs are received from the hospital and uploaded into the system, with the clinical team reviewing them only after the resident is admitted. The Nursing Home Administrator confirmed that the clinical team, which includes the Director of Nursing, Assistant Director of Nursing, Unit Managers, and Social Services, reviews PASRRs during daily clinical meetings. This process led to inaccuracies in the PASRR documentation for the two residents, as the reviews were not conducted before admission.
Failure to Revise Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to revise the care plan for a resident after a medication was discontinued, which was identified during a review of records and interviews. The resident, who was admitted with diagnoses including unspecified dementia and other behavioral disturbances, had been prescribed Olanzapine for a psychotic disorder. This medication was discontinued on a specified date, but the care plan was not updated to reflect this change. The care plan still included interventions related to the administration and monitoring of antipsychotic medications, despite the discontinuation. During interviews, the Director of Nursing acknowledged that the care plan should have been revised to reflect the discontinued use of antipsychotic medication. The facility did not have a specific policy for care plans, instead following the Resident Assessment Instrument (RAI) manual. The RAI manual emphasizes the importance of updating care plans to reflect changes in residents' preferences and goals. This oversight in updating the care plan represents a deficiency in the facility's adherence to care planning protocols.
Failure to Document and Administer Medication for Constipation
Penalty
Summary
The facility failed to ensure the Plan of Care was followed for a resident concerning the administration and documentation of a medication for constipation. The resident, who had multiple medical conditions including a right above-knee amputation, diabetes, and dementia, was admitted to the facility with a care plan that included monitoring for bowel irregularity. However, there was no physician order for a bowel regimen or documentation of a Dulcolax suppository being administered on the specified date, despite the resident experiencing constipation and requesting relief. Interviews revealed that the resident's family had informed staff of the resident's pain due to constipation and requested a suppository. The nurse delayed the administration of the suppository, and there was no documentation of the order or administration in the resident's medical record. The Director of Nursing confirmed the absence of a bowel regimen order and stated that staff could contact the medical provider at any time for medication orders. The Advanced Practice Registered Nurse (APRN) stated that a verbal order for a suppository was given, but it was not documented by the nurse who administered it. The facility's policies on medication administration and physician orders require that medications be administered safely and as prescribed, with proper documentation of orders and administration. The Licensed Practical Nurse (LPN) involved admitted to administering the suppository without documenting the order or the results, citing a busy day as the reason for the oversight. This lack of documentation and adherence to the facility's policies led to the deficiency in providing pharmaceutical services to meet the resident's needs.
Improper Medication Storage Observed
Penalty
Summary
The facility failed to ensure proper storage of medications during two separate medication administration observations. In the first instance, a Licensed Practical Nurse (LPN) was observed administering medication to a resident and then leaving the resident's inhaler unattended on the medication cart while she went to wash her hands in the bathroom, where she could not see the medication. In the second instance, another LPN placed an insulin bottle on the computer keyboard of the medication cart and left it unattended while administering an insulin injection to a resident in their room. Both instances involved medications being left out of a locked compartment, contrary to the facility's policy that requires all drugs and biologicals to be stored in locked compartments under proper conditions. The Director of Nursing (DON) confirmed that the expectation is for medications not to be left unattended outside of a locked medication cart.
Failure to Provide Requested Snack to Resident
Penalty
Summary
The facility failed to provide a requested snack to a resident, leading to a deficiency in meeting the nutritional needs of the resident. On the morning of July 15, 2024, a resident expressed hunger after receiving two eggs for breakfast and requested a snack. Despite the request being communicated to a Certified Nursing Assistant (CNA), the snack was not provided. The CNA, who was not assigned to the resident, acknowledged the request but did not fulfill it, instead claiming to have informed the assigned CNA. Further interviews revealed a breakdown in communication among staff members. The assigned CNA stated she was not informed of the resident's request, and the Registered Nurse (RN) confirmed that any CNA could have provided the snack, regardless of assignment. The Director of Nursing (DON) reiterated that any CNA could fulfill snack requests after consulting with a nurse to ensure the appropriate snack is given. The facility's policy indicated that snacks should be available upon request, but this was not adhered to in this instance.
Incomplete Skilled Nursing Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of Skilled Nursing Documentation Notes for three residents. Resident #19, who has multiple chronic conditions including chronic respiratory failure and congestive heart failure, was observed with missing documentation on several dates in June and July 2024. Despite receiving various therapy services, the skilled documentation notes were not recorded on specific dates, indicating a lapse in maintaining accurate medical records. Resident #8, who also has multiple health issues such as chronic obstructive pulmonary disease and chronic kidney disease, was found to have incomplete documentation of skilled services. The resident's records lacked documentation on several dates in July 2024. Additionally, a bruise was noted on the resident's hand, but the location was not documented, and the weekly skin check was not performed as required. The Director of Nursing confirmed these documentation gaps during an interview. Resident #267, with a history of surgical amputation and other health conditions, also had missing skilled documentation notes for several days in July 2024. The resident's family reported delays in receiving care for constipation, and the resident had a wound on the head and an ulcer on the bottom. The facility's policy requires comprehensive documentation of services provided, but the records for these residents were incomplete, failing to meet the standards set by the facility's guidelines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Auburndale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Winter Haven | 2.3 mi | ★★★★★ | 0 | 0 |
| Spring Lake Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Winter Haven Health And Rehabilitation Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Winter Haven | 5.4 mi | ★★★★★ | 0 | 0 |
| Lake Mariam Health And Rehabilitation Center | 5.6 mi | ★★★★★ | 4 | 2 |
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