Ocala Oaks Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ocala Oaks Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF582May 16, 2024

  Based on record review and interview, the facility failed to ensure residents received the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) within the required time frame for 2 of 3 residents reviewed for beneficiary notification, Residents #18 and #25. Findings include: Review of Resident #18's CMS (Centers for Medicare and Medicaid Services) Form 20052- SNF Beneficiary Notification Review showed it read, Medicare Part A Skilled Services Episode Start Date: 11/27/2023. Last covered day of Part A Service: 1/4/2024. How was the Medicare Part A Service Termination/Discharge determined? The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. 1. […]

• No harm, potential for more than minimal, patternF756May 16, 2024

  Based on observation, interview, and record review, the facility failed to ensure that physician orders following the pharmacist's recommendation were implemented for 1 of 5 residents reviewed for unnecessary medications, Resident #38. Findings include: Review of Resident #38's admission record showed the resident was most recently admitted on [DATE] with diagnoses including heart failure, dementia, rheumatoid arthritis, anxiety disorder, poly osteoarthritis, chronic pain, major depressive disorder, shortness of breath, atrial flutter, rhabdomyolysis, and localized edema. Review of Resident #38's physician orders for Resident #38 showed an order that read, Cyclobenzaprine HCl [Hydrochloric acid] Tablet 5 MG [milligram]. Start Date: 10/25/2023. […]

• No harm, potential for more than minimal, patternF842May 16, 2024

  Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 of 12 residents reviewed for insulin administration, Residents #39, #46, and #62, and 1 of 3 residents reviewed for peripherally inserted central catheter (PICC) dressing changes, Resident #107. Findings include: 1. Review of Resident #39's admission record showed the resident was admitted to the facility most recently on 2/11/2023 with diagnoses including chronic respiratory failure, type 2 diabetes mellitus, heart failure and chronic obstructive pulmonary disease. […]

• No harm, potential for more than minimal, patternF761Jan 12, 2023

  Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 4 of 5 medication carts. Findings include: During an observation of Medication Cart #1 (200 West) on [DATE] at 9:07 AM with Staff A, License Practical Nurse (LPN), there were one opened Levemir Insulin Pen with no opened and expiration dates and one expired Prednisolone AC 1% eye drops with an opened date of [DATE]. During an interview on [DATE] at 9:10 AM, Staff A, LPN, stated that the medication should be labeled with opened date and expiration date and the expired mediation should be discarded. […]

• No harm, potential for more than minimal, patternF842Jan 12, 2023

  Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 3 of 5 residents with central venous catheter device, Residents #57, #88, and #101, and for 1 of 3 residents reviewed for gastric tube, Resident #64. Findings include: 1. Review of Resident #64's medical records revealed the resident was admitted on [DATE] with the diagnoses including unspecified fracture of right femur, disorganized schizophrenia, type 2 diabetes mellitus without complications, chronic pulmonary edema, muscle weakness, other abnormalities of gait and mobility, unspecified lack of coordination, psoriasis, essential hypertension, hyperlipidemia, methicillin resistant staphylococcus aureus infection, encounter for other specified surgical aftercare,… […]