Health inspection·December 12, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility policy review, the facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards of practice for three (Residents #329, #330, and #332) of 31 sampled residents, by failing to include medical diagnoses to the resident electronic medical record. The findings include: 1. A medical record review of Resident #329 revealed he was admitted on [DATE], with diagnoses including muscle weakness, difficulty walking, and other signs & symptoms involving skeletal system. A review of Resident #329's Agency for Healthcare Administration Form 5000-3008 revealed his medical diagnoses included atrial fibrillation, gastroesophageal reflux disease, cardio myopathy, alcohol cirrhosis, peripheral artery disease, coronary artery disease, hypertension, and asthma. A review of Resident #329's admission/Medicare minimum data set (MDS) assessment noted it was in progress showing a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. 2. A medical record review of Resident #330 revealed she was admitted on [DATE], with no diagnoses listed on the medical diagnosis page. A review of Resident #330's MDS assessment noted it was in progress with a BIMS score of 12, indicating the resident was cognitively intact. 3. A medical record review of Resident #332 revealed he was admitted on [DATE], with diagnoses including muscle weakness (generalized), difficulty in walking, not elsewhere classified, and other lack of coordination. A review of Resident #332's Agency for Healthcare Administration Form 5000-3008 revealed his medical diagnoses included severe anemia, diabetes mellitus, atrial fibrillation, chronic kidney disease, and pressure ulcer. A review of Resident #332's admission/Medicare 5-day MDS assessment noted it was in progress with no BIMS score indicated. On 12/11/24 at 10:07 AM, an interview was conducted with the MDS Coordinator/Registered Nurse (RN). She confirmed she was responsible for updating resident diagnoses in the electric medical record. She said, The DON will sometime add resident's initial and quarterly updates. When asked, how soon medical diagnoses were added to the electronic medical record. She replied, Within 24 hours of a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105374 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Oaks 901 Veteran's Memorial Parkway Orange City, FL 32763 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)