Broward Oaks Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Broward Oaks Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF692May 8, 2025

  Based 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). The findings included: A review of the facility's policy titled, Weight Assessment and Interventions revised in September 2008 showed the following: The nursing staff will measure Resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. […]

• No harm, potential for more than minimal, isolatedF686Oct 8, 2025

  Based 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). The findings included: According to the Center for Medicare and Medicaid Services (CMS), avoidable pressure ulcer injury means the resident developed a pressure ulcer/injury, and the staff failed to do one or more of the following : Evaluate the resident's clinical condition and risk factors. Define and implement interventions that are consistent with resident needs and goals and follow professional standards of practice. Monitor and evaluate the impact of the interventions. Revise interventions as appropriate. […]

• No harm, potential for more than minimal, isolatedF690Oct 8, 2025

  Based 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). The findings included:According to the Center for Disease Control and Prevention (CDC), in the non-acute care setting. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (p.12). Education and performance feedback regarding appropriate use, hand hygiene, and catheter care (p.15). […]

• No harm, potential for more than minimal, isolatedF641May 8, 2025

  Based 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. The Findings included: 1) Record review for Resident #13 revealed that the resident was admitted to the facility on [DATE] with a re-admission on 06/14/24 with diagnoses of Generalized Anxiety Disorder; Mood Disorder Due To Known Physiological Condition; Major Depressive Disorder; Adjustment Disorder with Anxiety and Dementia. […]

• No harm, potential for more than minimal, isolatedF689May 8, 2025

  Based on observations, interviews, and record review, the facility failed to follow their Fall policy including implementation of fall interventions for 1 of 3 residents reviewed for accidents (Resident #70), and failed to prevent and have an effective response for a resident who eloped for 1 of 1 resident reviewed for elopement (Resident #259). The findings included: Review of the facility's policy titled, Elopements and Wandering Residents, date implemented 11/28/17, included in part the following: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. […]