Apopka Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Apopka Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 9, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and respond timely to exit door alarms for 1 of 3 residents reviewed for elopement of a total sample of 7 residents, (#10). On 09/03/22 at approximately 6 PM, the facility failed to prevent resident #10, a physically and cognitively impaired resident, identified at high risk for elopement from exiting the facility unsupervised. The resident left her room and walked down the 300 unit hallway, pressed the emergency egress door crash bar which allowed the door to open, the alarm sounded and the resident exited the facility with her walker. […]

• Immediate jeopardy, isolatedF600Aug 25, 2022

  Based on observation, interview, and record review, the facility neglected to communicate essential information and ensure provision of necessary care and services to prevent falls and major injuries for a vulnerable resident; and the facility's nursing staff neglected to follow the plan of care related to safety devices and monitoring for 1 of 5 residents reviewed for falls of a total sample of 9 residents, (#2). Resident #2 had repeated falls and sustained severe head injuries. He suffered significant pain, had increased confusion and disorientation, and experienced a decline in his functional status. Resident #2 was a physically and cognitively impaired resident with a known history of falls. […]

• Immediate jeopardy, isolatedF689Aug 25, 2022

  Based on observation, interview, and record review, the facility failed to identify and implement appropriate interventions and provide adequate staff supervision to prevent falls for 1 of 5 residents reviewed for falls, (#2) and failed to provide supervision and respond timely to exit door alarms for 1 of 3 residents reviewed for elopement, (#3) of a total sample of 9 residents. Resident #2 was a physically and cognitively impaired resident with a known history of falls. Ten days after admission, the resident fell , hit his head, and was hospitalized with a hematoma or brain bleed. The resident returned to the facility on [DATE], and seven days later he fell and hit his head again. He was hospitalized for six days with skull fractures and another hematoma. […]

• Actual harm, isolatedF623Sep 9, 2022

  Based on record review and interview, the facility failed to provide a timely written notice of discharge to the residents or their representatives for 1 of 5 residents reviewed for discharge in a total sample of 9 residents, (#17). Resident #17 had severe cognitive impairment, applying the reasonable person concept, the reaction of a reasonable person to being transferred abruptly to another nursing home without notice caused psychosocial harm, such as distress and mood decline that the resident was unable to express. The resident was transferred to another nursing home that was further away from his spouse and family, making visitation more difficult and the resident's family wasn't notified in advance so they could explore other options. […]

• Actual harm, isolatedF622Aug 25, 2022

  Based on record review and interview, the facility failed to allow resident to remain in the facility and failed to provide rationale as to why the resident's care needs could not be met by the facility for 1 of 1 discharged resident in a total sample of 9 residents, (#3). Findings: Cross Reference F689 Review of resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], a nursing progress note indicated the resident fell in her room, hit her head and was transferred to the hospital. She returned to the facility on [DATE] with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]