Health inspection·November 14, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's representative was notified of a change in condition for 1 of 3 residents, Resident #1. Findings include: Review of the admission Record for Resident #1 documented the resident was admitted on [DATE] with diagnoses to include hypertension, muscle weakness, mild protein calorie malnutrition, diabetes mellitus, dementia and sepsis. Review of laboratory results dated [DATE] documented results that were not within the resident's normal limits and were high for the blood urea nitrogen (BUN), chloride, and the BUN creatinine ratio. Review of the nursing progress note for Resident #1 dated 10/11/2023 at 04:02 AM read. Nurse was called to resident room it was noted that a very small open area to sacrum skin was peeling off. Area cleaned and barrier cream applied will inform MD and family later. Review of nursing progress notes for the period of 10/03/2023 to 11/14/2023 did not contain documentation the resident's representative was notified of the elevated laboratory results or the skin breakdown for Resident #1. During an interview on 11/14/2023 at 11:07 AM Resident #1's representative stated that she was not informed of the skin breakdown identified on 10/11/2023, or the abnormal laboratory results on 10/3/2023. During an interview on 11/14/2023 at 12:20 PM Staff A, License Practical Nurse (LPN) stated, I did not inform the family of the laboratory results. During an interview on 11/14/2023 at 12:45 PM the Director of Nursing (DON) stated, The responsible party/family are to be notified of any change in skin integrity for the resident or abnormal lab results. The DON confirmed the family was not informed of the skin breakdown on 10/11/2023 or results of the elevated labs on 10/3/2023. Review of policy and procedure titled, Change in a Resident's Condition or Status read, The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, Page 1 of 2 105602 105602 11/14/2023 Hawthorne Center for Rehabilitation and Healing Of 4100 SW 33rd Ave Ocala, FL 34474

F 0580 billing/payments, resident rights, etc.). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105602 Page 2 of 2