Plantation Oaks Nursing & Rehabilitation Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident remained free from chemical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility did not ensure that residents who are prescribed psychotropic drugs received a gradual dose reduction, unless clinically contraindicated, in an effort to discontinue these drugs for 1 (#7) of 5 (#2, #5, #7, #12, #23) residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management for 1 (#24) of 1 (#24) sampled resident reviewed for pain management.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that nursing staff had the appropriate competencies to care for resident needs. The facility staff failed to respond to call light assistance requests in a timely manner for 1 (#41) of 1 residents reviewed for sufficient and competent nurse staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to 1) maintain oxygen concentrator filters as ordered for 1 (#7) of 1 (#7) residents reviewed for respiratory care, and 2) utilize disinfectant solution per manufacturer's instructions for use in the facility shower room where 40 of 52 residents are showered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for a resident. The facility failed to ensure that interventions were implemented for an unsafe smoker as indicated in the plan of care for 1 (#45) of 3 (#7, #16, #45) residents reviewed for accidents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the most recent state inspection results since the last annual survey were available for resident review.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#7, #22, #46 and #55) of 8 (#1, #2, #7, #12, #22, #46, #51 and #55) resident rooms/bathrooms observed. The failed practice was evidenced by the resident rooms/bathrooms listed above being in need of cleaning along with the laundry room being in need of cleaning with cleaning supplies being stored directly on the floor of the laundry room.

Inspectors wroteBased on observations, record review and interview the facility failed to ensure the resident`s plan of care was implemented for 1 (#11) of 1 (#11) resident reviewed for urinary catheters. The failed practice was evidenced by resident #11 not having his urinary catheter bag covered in a privacy bag when outside of his room.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 (#53) of 3 (#33, #44, and #53) residents reviewed for limited range of motion.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents who require colostomy services received care consistent with the comprehensive person-centered care plan. The failed practice was evidenced by 1 (#11) of 1 (#11) resident reviewed for colostomy care by not having colostomy bags available in accordance with his plan of care.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 (#7, and #44) of 2 (#7, and #44) residents reviewed for accident hazards.

Inspectors wroteBased on record review and interviews, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services. The facility had extremely low weekend staff from April 1, 2024 through June 30, 2024.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data requirements was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 58 residents residing in the facility.

Inspectors wroteBased on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#4) of 5 (#4, #12, #21, #32, and #46) sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 (#4) of 5 (#4, #12, #21, #32, and #46) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it prepared food in accordance with professional standards by using hot water to thaw frozen meat.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's right to be free from physical abuse by staff CNA (Certified Nursing Assistant) for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. The Immediate Jeopardy situation began on 06/08/2024, around approximately 3:40 p.m., when S4CNA physically abused resident #1. S4CNA and S5CNA were providing care to resident #1 when resident #1 hollered and pointed his finger at S4CNA. S4CNA bent resident #1's finger on left hand back, bent his left foot back, and slapped resident in the chest. S6Licensed Practical Nurse (LPN) entered resident #1's room and observed resident #1 and S4CNA arguing. She then witnessed when the resident pointed his finger at S4CNA and S4CNA grabbed both of the resident's hands and held them down on the bed. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure staff reported physical abuse of a resident to administration immediately and failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to one or more law enforcement entities for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. The Immediate Jeopardy situation began on 06/08/2024, around approximately 3:40 p.m., as a result of resident #1 being physically abused on 06/08/2024 by S4Certified Nursing Assistant (CNA) and witnessed by S5CNA and S6LPN (Licensed Practical Nurse). The physical abuse of resident #1 was not reported immediately to S1Administration or S2Director of Nursing (DON) on 06/08/2024 by S4CNA, S5CNA or S6LPN. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care to assist resident safety and maintain the highest practical physical, mental and psychological well-being of each resident for 1 (#1) of 3 (#1, #2, #3) residents investigated for accidents. The facility failed practice was evidenced by two Certified Nurse Aide (CNA)'s and a Licensed Practical Nurse (LPN) failed to follow the facilities Accident/Incident policy and procedure when Resident #1 was found on the floor twice on 10/24/2023. Review of the facilities Accident/Incident Reports: Resident in-part Policy: When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An accident/incident report and the appropriate documentation will be completed by the end of the shift. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 1 ((#38) of 5 (#3, #17, #28, #38 and #43) residents reviewed for unnecessary medications. The facility failed to follow parameters for the administration of a blood pressure medication to resident #38.

Inspectors wroteBased on record review and interview, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#38) of 5 (#3, #17, #28, #38 and #43) residents reviewed for unnecessary medications. The pharmacist failed to address the facility did not follow parameters for the administration of a blood pressure medication.