The Oaks-Brevard

Inspectors wroteBased on record review and staff interviews, the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications prior to initiation for 6 of 6 residents reviewed for unnecessary medications (Residents #3, #7, #6, #51, #2, and #10).

Inspectors wroteBased on observation, record reviews and resident and staff interviews, the facility failed to maintain advance directives in both locations designated by the facility for 1 of 21 residents reviewed for advance directive (Resident #23).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC, a form used by skilled nursing facilities to inform residents of the last day of Medicare Part A coverage and provides instructions on how to file an expedited appeal) and/or a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a form used by skilled nursing facilities to inform residents about potential costs and coverage limitations for services that may not be covered by Medicare) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary notification review (Residents #97 and #6).

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a new serious mental illness disorder was identified for a resident previously determined to have a Level I PASRR status (Resident #71) and failed to develop a care plan that incorporated the PASRR Level II determination recommendations for a resident with an active diagnosis of a serious mental illness (Resident #6) for 2 of 3 residents reviewed for PASRR.

Inspectors wroteBased on staff interviews, the facility failed to have a qualified professionals to direct the facility's activity program. This practice had the potential to affect all of the residents at the facility.

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 12 of 14 months reviewed (October 2023, November 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, October 2024, and November 2024).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to ensure evening and weekend group activities were planned for the facility to meet the needs of residents who expressed that it was important to them to attend group activities for 4 of 4 residents reviewed for activities (Resident #4, #44, #51, and #56).

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to implement their grievance policies and procedures when Resident #81 reported her dentures were missing for 1 of 3 residents reviewed for grievances.

Inspectors wroteBased on record review, and staff interviews, the facility failed to implement their abuse policy and procedure in the areas of reporting to administration, completing a thorough investigation and failing to notify adult protective services, when Resident #85 reported that three staff members had held his arms down in bed and would not let him go to the bathroom and yelled at him not to ring the call light. This deficient practice occurred for 1 of 3 residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews with staff, responsible party, the Consultant pharmacist, and the Medical Director (MD), the facility failed to have effective systems in place for the identification, storage and returning of a controlled medication (opioid) when a resident discharged home and failed to maintain the unused controlled medication for return to the pharmacy for 1 of 2 residents reviewed for pharmacy services (Resident #176).

Inspectors wroteBased on observations, record review, and staff and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendations for storing narcotics in a locked and permanently affixed compartment for 1 of 2 medication rooms reviewed for medication storage (West Hall Medication Storage Room).

Inspectors wroteBased on record review, and Medical Director, Nurse Practitioner, Consulting Pharmacist, resident and staff interviews, the facility failed to prevent a significant medication error when they failed to enter an admission order for an as needed (PRN) migraine nasal spray, that was to be continued from the hospital discharge summary when Resident #81 admitted to the facility. As a result, Resident #81 did not have the PRN migraine nasal spray during her entire stay at the facility. This affected 1 of 3 residents reviewed for medication errors. (Resident #81)

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to store narcotics in a locked permanently affixed compartment for 1 of 2 medication rooms reviewed for medication storage (West Hall Medication Storage Room).

Inspectors wroteBased on observations and staff interviews the facility failed to maintain doors in good repair (rooms 408, 405, 502, 506, 507, 609, 610, both doors of the main dining room, and both doors of the television room), maintain clean and sanitary floors (rooms 402, 405, 408), ensure a bathroom was free of lingering odors (bathroom in room [ROOM NUMBER]), maintain clean and sanitary hallway floors (400 hall and 600 hall), label and properly store personal care equipment in shared bathrooms (rooms 401, 402, 405, and 506), maintain clean and sanitary privacy curtains (rooms 407, 408, 501-A, and 610), maintain a bedside commode in good repair (bedside commode in the bathroom of room [ROOM NUMBER]), and maintain walls and baseboards in good repair (rooms [ROOM NUMBERS]) for 1 of 2 units (West Wing) on 3 of 3 halls (400 hall, 500 hall, 600 hall) reviewed for safe, clean, and homelike environment.

Inspectors wroteBased on observations, record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to ensure residents choices were honored for bathing preferences and eating meals in the main dining room, residents received assistance with incontinence care and personal and oral hygiene as needed, and cognitively impaired residents received constant supervision on a locked memory care unit for 7 of 8 sampled residents (Residents #181, #52, #29, #47, #35, #59, #66, and #68). This tag is cross-referenced to: F 561: Based on observations, record review, interviews with residents and staff, the facility failed to honor the residents' choice to eat their meals in the main dining room (Resident #181 and Resident #52) and provide their preferred number of showers each week (Resident #181) for 2 of 2 residents reviewed for choices. F 677: [...]

Inspectors wroteBased on observations, record review, and staff, Physician and Pharmacy interviews, the facility failed to remove expired medications and secure medications stored at the bedside for 7 of 9 storage rooms, medication carts, and residents (West Wing and Memory Support Unit medication rooms and 400 Hall and Memory Support Unit medication carts, and for Resident #29, Resident #52, and Resident #71) reviewed for medication storage.

Inspectors wroteBased on observations, record review, and resident and staff interviews the facility failed to assess the ability of a resident to self-administer medications for 1 of 6 residents reviewed for medication administration (Resident #52).

Inspectors wrote2. Resident #52 was admitted to the facility 03/31/22. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired and was able to make his needs known. The care plan last updated 07/13/23 revealed Resident #52 had the potential for social isolation and low activity participation and interventions included interviewing him about preferences, past roles, customary routines, and interests and introducing him to residents with similar interests. An observation made on 08/13/23 at 12:25 PM revealed the meal tray cart had arrived on the 400 hall and included Resident #52's lunch meal to be eaten in his room. There were no residents observed in the main dining room. An interview with Resident #52 on 08/17/23 at 9:35 AM revealed he would like to eat all his meals in the dining room if possible. [...]

Inspectors wroteBased on observations and staff interviews the facility failed to maintain a resident's dignity by not providing privacy when changing her shirt for 1 of 1 resident reviewed for dignity (Resident #29). The reasonable person concept was applied to this deficiency. A reasonable person would be upset if observed having their clothing changed without a privacy curtain in place or their room door being closed.

Inspectors wroteBased on observations, record review, and resident and staff interviews the facility to accurately code Minimum Data Set (MDS) assessments in the areas of transfers (Resident #52), eating (Resident #52), and oxygen use (Residents #29 and #39) for 3 of 24 sampled residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in physical or mental status for 1 of 2 sampled residents reviewed for PASRR (Resident #13).

Inspectors wroteBased on observations and resident and staff interviews the facility failed to provide incontinence care (Resident #52 and Resident #29), a shave (Resident #47), and oral care (Resident #181) for 4 of 6 dependent residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to prevent four cognitively impaired residents from exiting the locked Memory Support Unit (MSU) unsupervised for 4 of 10 residents reviewed for accidents (Residents #35, #59, #66, and #68).

Inspectors wroteBased on record review and staff, Pharmacy Consultant, Nurse Practitioner (NP) #1, and Physician interviews the facility failed to implement a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident #25).

Inspectors wroteBased on observations, record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the annual recertification and complaint survey conducted on 01/07/22. This was for two deficiencies originally cited in the area of Infection Prevention and Control and Personal Privacy and Confidentiality. For one deficiency originally cited in the area of Free of Accidents and Hazards during the complaint survey conducted on 06/16/21 and one deficiency originally cited in the area of Infection Prevention and Control during the Covid-19 Focused Infection Control survey conducted on 12/23/20. The deficient practice were subsequently recited on the current annual recertification and complaint survey of 08/17/23. [...]

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to implement their infection control policy for hand hygiene when 1 of 2 facility staff (Nurse #2) did not remove his gloves and perform hand hygiene during wound care for 1 of 2 residents reviewed for pressure ulcers (Resident #44), failed to implement infection control for hand hygiene when 1 of 2 facility staff (Nurse Aide #3) did not remove her gloves and perform hand hygiene after providing incontinence care for 2 of 3 residents observed for incontinence care (Residents #29 and #52), and failed to implement infection control for hand hygiene when 1 of 2 facility staff (Nurse Aide #3) failed wear gloves when touching wet linen that contained a wet brief while providing incontinence care for 2 of 3 residents observed for incontinence care (Resident #29).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete discharge Minimum Data Set (MDS) assessments within 14 days of the discharge date for 2 of 3 residents reviewed for discharge (Residents #76 and #178).