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 and interviews, the facility failed to ensure medical records were complete and accurate with
all information related to the care and services for one resident (Resident#1) out of nine sampled residents
in accordance with accepted professional standard of practices as evidenced by no follow up
documentation following an order for a wound care consult for Resident # 1. There were 210 residents
residing in the facility at time of this complaint survey
The findings included:
Record review of demographic sheet for Resident#1 revealed admission dates of 1/31/20, 7/14/23 and
9/12/20, and discharge date s of 7/26/23, 9/1/23, and 9/25/23) with diagnosis that included Pressure Ulcer
of Sacral region, Unstageable.
Record review of the five- day Medicare Minimum Data Set (MDS) dated [DATE], Section C for cognitive
status revealed a Brief Interview for Mental Status score of Three on a scale of zero to 15, indicated severe
cognitive impairment. Section GG for functional status revealed the resident is dependent for toileting and
transfer, and Section M for skin revealed Resident #1 had one or more unhealed pressure ulcers/injuries.
Record review of the Care Plan initiated on 08/04/2023; Revised on 09/25/2023 revealed problem:
Resident#1 has a pressure injury to sacral stage 4 on readmission 8/04/23. Interventions included:
Consult/make referral for screen by wound nurse as needed.
Record review of nursing note dated 6/17/23 written at 10:29 AM revealed a nurse identified Resident #1
had a re-opened area to sacral with pinkish skin, no drainage noted. MD (Medical Doctor) aware, with
house cream applied until seen by wound nurse.
Record review of physician orders revealed an order dated 6/17/24 for a wound care consult for Resident
#1.
No other documentation regarding re-opening of wound found in the resident's medical record.
Record review of nursing note dated 6/26/23 written at 2:39 PM revealed a call received from nurse at
dialysis center that Resident #1 will be sent to a nearby hospital.
Record review of nursing note dated 7/14/23 written at 8:56 AM revealed Resident #1 was re-admitted to
facility with a sacral wound.
(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:
105513
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
105513
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge House Nursing and Rehabilitation Center
13900 NE 3rd Court
North Miami, FL 33161
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 6/19/24 at 2:13 PM, Staff A Licensed Practical Nurse (LPN) stated: If a wound is identified any time
after admission a wound care consult is ordered, and the wound care nurse evaluates the resident and get
treatments orders from physician. [Resident #1 was initially admitted on [DATE] with no wounds. There was
a wound identified on 6/17/24 and a wound care consult was ordered on that date. There is no
documentation that I evaluated the resident after 6/17/24 when the nurse recorded that the wound was
reopened. I don't remember why.
On 6/19/24 at 2:45 PM. The Director of Nursing (DON) approached surveyor with Staff A, LPN and
revealed, Resident #1 was evaluated by Staff A, LPN after an order for wound care consult was received,
however there is no documentation due to no opening of the skin observed by Staff A, LPN at the time of
evaluation, despite what was written by the nurse.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105513
If continuation sheet
Page 2 of 2
