Jacksonville SKLD Nur & Rehab

In the surveyor’s words

From the most serious findings on record at Jacksonville SKLD Nur & Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jul 28, 2021

  Based on observation, interview and record review, the facility failed to implement an infection control program in accordance with CDC guidelines to prevent the spread of COVID-19. The facility failed to identify residents who have had prolonged exposure to positive COVID 19 staff and residents and implementing transmission based precautions, failed to implement screening procedures in accordance with CDC guidelines, failed to wear required personal protective equipment during a facility outbreak, failed to perform hand hygiene as required, and failed to post signage on the use of specific PPE for staff in locations where transmission precautions are required. This failure resulted in an Immediate Jeopardy which began on [DATE] when V6, Activity Aide, tested positive for COVID 19. […]

• Actual harm, isolatedF689Sep 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure proper inflation of the air mattress in 3 (R2, R4, and R5) of 3 residents in the sample of 8 reviewed for safety. This failure resulted in R2 being found on the floor from an unwitnessed fall and suffering a laceration on the right side of the head and several skin tears. Findings include: 1. R2's undated face sheet documented that R2 was admitted to the facility on [DATE] with diagnoses of Parkinson's, dementia, neurocognitive disorder with Lewy Bodies, cachexia, and hypotension. R2's Minimum Data Sheet (MDS), dated [DATE], documented that R2 has severe cognitive impairment. R2 requires use of a wheelchair and is always incontinent of bowel and bladder. […]

• Actual harm, isolatedF689Aug 13, 2024

  Based on interview and record review the facility failed to provide safety and supervision for 1 of 3 (R3) residents reviewed for falls. This failure resulted in R3 falling, obtaining a laceration to the head, sutures and experiencing pain. Findings include: R3's Care Plan documents 6/28/23, documents that (R3) has a Self-Care Deficit As Evidenced by: Needs assistance with Activities of Daily Living (ADLs). It also documents Bed Mobility and Dressing require - One person physical assist required. R3's Care Plan continues (R3) is at risk for falls and injuries related to (r/t) cognition deficit and history of fall with fx. […]

• Actual harm, isolatedF695May 22, 2024

  Based on interview, observation, and record review, the facility failed to provide Oxygen to residents that required oxygen for 2 of 5 residents (R26, R56), reviewed for respiratory care in the sample of 40. This failure resulted in R26 becoming cyanotic with a low oxygen saturation of 51%. The Findings Include: 1. R26's Face Sheet, undated, documents R26 was originally admitted to the facility on [DATE] with diagnosis of Motor Neuron Disease, Asthma, Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, Atherosclerotic Heart Disease (ASHD), Sleep Apnea, Chronic Inflammatory Demyelinating Polyneuritis, Arthropathy, Primary Lateral Sclerosis, Major Depressive disorder, Anxiety disorder, Hypertension, Pneumonia, Malignant neoplasm of bronchus and lung, Pulmonary embolism, Venous… […]

• Actual harm, isolatedF689Aug 5, 2021

  Based on observation, interview and record review the facility failed to provide adequate supervision to prevent falls for 1 of 4 residents (R2) reviewed for falls in the sample of 18. This failure resulted in R2's fall sustaining a subdural hematoma and later expiring from this injury. Findings include: R2's Electronic Medical Record (EMR) dated 6/2021, documents R2 was admitted to the facility on [DATE] with diagnosis to include [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] (CVA), Effusion Right Knee, [CONDITION(S)] and Collapse. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderately impaired cognition, requires extensive assist of two persons for transfers and toileting. […]