Rockledge Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Rockledge Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Nov 4, 2021

  Based on interview and record review, the facility failed to ensure a resident was free from neglect. The facility failed to obtain appropriate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1). These failures contributed to resident #1 suffering critically low blood glucose levels and placed him at risk for serious injury/impairment/death. While resident #1 experienced critically low blood glucose levels, there was likelihood he could have become comatose, sustained permanent brain damage and/or died . On [DATE] at approximately 4:30 PM, facility staff found resident #1 in bed, unresponsive and in respiratory distress. […]

• Immediate jeopardy, isolatedF600Mar 23, 2022

  Based on observation, interview, and record review, the facility's nursing staff neglected to perform regular and change of shift rounds to provide adequate supervision and monitoring of resident status, activities, and well-being; and the facility failed to install, maintain, and check locks to ensure a secure environment and prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 7 residents reviewed for elopement, out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. […]

• Immediate jeopardy, isolatedF689Mar 23, 2022

  Based on observation, interview, and record review, the facility failed to maintain a secure environment in an enclosed courtyard and failed to provide adequate supervision to prevent a vulnerable, cognitively impaired resident from exiting the facility, for 1 of 7 residents reviewed for elopement, out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, been accosted by unknown persons, become lost or been hit by a car. Resident #1 was seen by facility staff on 2/24/22 at approximately 2:30 AM. […]

• Immediate jeopardy, isolatedF635Nov 4, 2021

  Based on interview and record review, the facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure contributed to resident #1 suffering critically low blood glucose levels and placed him at risk for serious injury/impairment/death. While resident #1 experienced critically low blood glucose levels, there was a likelihood he could have become comatose, sustained permanent brain damage and/or died . On [DATE] at approximately 4:30 PM, facility staff found resident #1 in bed, unresponsive and in respiratory distress. When Emergency Medical Services (EMS) personnel arrived, they discovered his blood glucose level was critically low and transported him to the hospital for treatment. […]

• No harm, potential for more than minimal, patternF561Jul 13, 2023

  Based on observation, interview and record review, the facility failed to honor the right to make choices about significant aspects of activities of daily living related to preferred method of toileting (#250), and frequency and preferred method of bathing, (#9, #28, #307, #308, #252) for 6 of 8 residents reviewed for choices of a total sample of 44 residents. Findings: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses to include depression, bipolar disorder, sleep apnea. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/14/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. […]