Health inspection·April 21, 2022

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 observation, interview, and record review the facility failed to ensure residents' representatives were notified of a change in resident's condition in 1 of 2 residents reviewed for changes in condition, Resident #56 Findings: Review of the medical record indicated Resident #56 was admitted to the facility on [DATE] and had a hospitalization from 12/31/2021 through 1/7/2022. Diagnosis included anemia, hypertension, atrial fibrillation (an irregular heartbeat), heart failure (a chronic condition where the heart doesn't pump blood as well as it should), major depression, and dysphagia (difficulty swallowing foods or liquids). Review of Resident #56's vital signs document weights of 150.2 pounds on 1/12/2022, 141.4 pounds on 2/7/2022, 138 pounds on 3/22/2022, 135 pounds on 3/29/2022 a weight of 132 pounds on 4/8/2022 and a weigh of 131 pounds on 4/12/2022. Review of the nursing progress note dated 3/18/2022 read: [ Advanced Practice Registered Nurse's (APRN) name] saw [Resident #56's name] today and gave recommendations to increase Remeron to 7.5 mg by mouth twice a day secondary to poor appetite. This recommendation was approved by [APRN's name]. She had previously given orders for an increase in Ready care, lab work and ST (speech therapy) eval. [evaluation] Review of Resident #56's medical record did not provide for documentation the resident's representative/guardian was notified of the resident's weight loss of 19.8 pounds over a period of three months. On 4/20/2022 at 11:30 AM Staff H, Registered Nurse (RN) stated, I do not see any notification to her guardian in the medical record related to her weight loss. On 4/21/2022 at 12:45 AM the Director of Nursing stated, All changes in condition should have notification to the physician and the resident or resident's representative. Review of the policy and procedure titled, Change in a Resident's Condition or Status approval date 2/17/2022 read, Policy: The Center shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition/status. Policy interpretation and implementation: 2. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's representative when: b. There is a significant change in the resident's physical, mental or (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 8 Event ID: 105613 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 105613 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Live Oak Healthcare and Rehabilitation Center 1620 Helvenston St SE Live Oak, FL 32064 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)