Broward Oaks Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow the professional standards for the care and management of pressure ulcers for 1 of 2 residents reviewed for wound care (Resident #1).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow the professional standards of practice for the care and management of an indwelling urinary catheter and failed to follow their own policy for catheter care for 2 of 2 residents reviewed for urinary care (Resident #1 and Resident #3).

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify a significant weight loss in a timely manner and failed to prevent further significant weight loss for 1 of 4 residents sampled for nutrition (Resident #35).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to accurately document the Comprehensive Assessments for 4 of 30 sampled residents (Residents #13, #49, #76, and #26), related to diagnoses, vision, and oxygen use.

Inspectors wrote2. Record review for Resident #70 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on [DATE] with diagnoses that included in part the following: Cerebral Infarction, Glaucoma, Muscle Weakness (Generalized), Seizures, Other Lack of Coordination, Anxiety Disorder, Contracture Left Elbow, Contracture Left Wrist, and Contracture Left Ankle. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 7 indicating severe cognitive impairment. Review of facility incident log revealed Resident #70 had an unwitnessed fall on 04/13/25. The Fall Risk Evaluation for Resident #70 completed 09/29/24 documented a score of 12 indicating at risk. The Fall Evaluation Morse for Resident #70 completed 04/14/25 documented a score of 75 indicating a high risk for falling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for urinary catheter care and failed to follow care plan interventions for catheter care, for 1 of 3 sampled residents (Resident #26).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to follow the Physician orders regarding oxygen therapy for 8 of 8 sampled residents (Residents #25, #49, #50, #99, #20, #29, #22, and #44). The facility also failed to correctly document oxygen therapy on Minimum Data Set (MDS) assessment for 3 of 8 sampled residents (Residents #49, #50, and #99).

Inspectors wroteBased on observations, interviews and record review the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving and dispensing and administering of all medications as well as drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled to include removing discontinued medications timely for 4 of 9 residents reviewed for controlled medications (Residents #56, #13, #68, and #308).

Inspectors wroteBased on observations, interviews and record review, the facility failed to monitor behaviors and side effects accurately for Residents on Psychotropic medications (Residents #29, #48, #63, and #10), and failed to monitor side effects for a resident on anticoagulant (Resident #29) for 5 of 5 residents sampled for Unnecessary Medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication error related to expired insulin, for one of 5 sampled residents (Resident #68).

Inspectors wroteBased on observations, interviews and record review the facility failed to secure medications at the bedside for 2 of 30 sampled residents (Residents #19 and #68).

Inspectors wroteBased on observations, review and record review, the facility failed to provide food in a form designed to meet individual needs for the Pureed diet observed during 1 of 2 visits to the main kitchen. This has the potential to affect the 20 out of 98 residents on a Pureed diet.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of 2 visits to the main kitchen.

Inspectors wrote2. Record review for Resident #93 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Muscle Weakness (Generalized), Dysphagia, Expressive Language Disorder, and Adult Failure to Thrive. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status was not attempted due to the resident is rarely/never understood. On 05/05/25 at 10:10 AM observation of Resident #93 receiving tube feeding. There was no Enhanced Barrier Precaution (EBP) sign posted in room or on door. During an interview conducted on 05/05/25 at 10:34 AM with Staff A, Registered Nurse (RN), who stated he has worked at the facility for just over 1 year. When asked about Enhanced Barrier Precautions (EBP) he said he does not have any residents on EBP on his assignment today. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure residents Do Not Resuscitate (DNR) directives were signed by the resident's Power of Attorney (POA) agent for 1 of 27 sampled residents reviewed for Advances Directives, Resident #67.

Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to develop care plans for 2 of 3 sampled residents reviewed for Peripherally Inserted Central Catheter (PICC) lines, Resident #89 and Resident #557; and failed to develop care plans for residents with a Left Ventricular Assist Device (LVAD) for 1 of 1 sampled resident reviewed for a LVAD, Resident #87.

Inspectors wroteBased on record review and interviews, the facility failure to administer antibiotic therapy in a timely manner for 1 of 1 sampled resident, Resident #505, as evidenced by not administering the antibiotic on 09/16/23 for two consecutive doses as ordered; and failed to ensure physician orders were followed for residents with a Left Ventricular Assistive Device (LVAD), as evidenced by lack of accurate monitoring, calulating and documentation of mean arterial pressure (MAP) for 1 of 1 sampled residents, Resident #87.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide nutritional interventions and assessments in a timely manner for 2 of 5 sampled residents reviewed for nutrition, Resident #15 and Resident #70.

Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to maintain Peripherally Inserted Central Catheter (PICC) lines in a sanitary manner for 3 of 3 sampled residents reviewed for PICC lines, Residents' #67, #89, and #557.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to address residents' pain in a timely manner for 1 of 1 sampled resident reviewed for Pain, Resident #70.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that dialysis services were consistent with professional standards of practice for 1 of 1 sampled resident reviewed for dialysis (Resident #62), as evidenced by inproper hand hygiene during observation of dialysis services and not providing the correct fluid restriction as per physician orders.

Inspectors wroteBased on interviews and record review, the facility failed to ensure physician visits were performed as required for 1 of 1 sampled resident reviewed for physician visits, Resident #76.

Inspectors wroteBased on interview, record and policy reviews, the facility failed to initiate care plans with interventions regarding the diagnosis of Trauma/Post Traumatic Stress Disorder (PTSD) in a timely manner for 1 of 1 sampled resident reviewed for Trauma, Resident #86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 12% percent, 3 medication errors were identified while observing a total of 25 opportunities, affecting Residents #70 and #77.

Inspectors wroteBased on record review, observations and interviews, the facility failed to remove expired over-the-counter (OTC) medications from the Central Supply cabinet; failed to remove expired over-the-counter medications from 1 of 3 medication carts observed (medication cart #2-West Wing); failed to secure medications at the beside for Resident #94; and failed to ensure that 1 of 2 treatment cart was locked when unattended (West Wing treatment cart).

Inspectors wroteBased on interviews and record reviews, the facility failed to provide an arbitration agreement that explicitly grants the resident or their representative the right to rescind the contract within 30 calendar days of signing it for 2 of 3 sampled residents reviewed for arbitration, Residents #76 and #3.

Inspectors wroteBased on interviews and record review, the facility failed to maintain communication with hospice, as it relates to the resident's coordinated plan of care and services, to ensure each entity is aware of their responsibilities for 1 of 1 resident reviewed for hospice (Resident #70); and failed to accurately identify a resident's services for 1 of 1 sampled resident reviewed for Hospice services, Resident #76.

Inspectors wroteBased on interview and record review, the facility failed to provide influenza and pneumococcal immunizations as required for 5 of 5 sampled residents, reviewed for immunizations, Residents #89, #87 #76, #94, and #557.

Inspectors wroteBased on interview and record review the facility failed to offer COVID-19 immunization as required for 4 of 5 sampled residents for immunizations, Residents #89, #87, #94 and #557.

Inspectors wroteBased on interviews and records review, the facility failed to ensure residents and staff were informed of their rights to file their complaints with the Ombudsman and where to find the Ombudsman posted information, for 1 of 1 sampled resident and staff reviewed for this conncern.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop care plans for 3 of 24 sampled residents reviewed: Resident #102 and Resident #357 related to hemodialysis and impaired vision; and Resident #33 related to revising the dialysis care plan.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assure that enteral nutrition had been followed by the practitioners' orders for 3 of 4 sampled residents, Residents #14, #66, and #20, reviewed for tube feeding.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to provide medication as scheduled on dialysis days for 1 of 2 sampled residents reviewed for dialysis (Resident # 33).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items that accommodated the preferences of 2 of 3 sampled residents during dining observations, Resident #102, and Resident #46.