Avante At Melbourne Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Melbourne, Florida.
- Location
- 1420 South Oak Street, Melbourne, Florida 32901
- CMS Provider Number
- 105671
- Inspections on file
- 30
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Avante At Melbourne Inc during CMS and state inspections, most recent first.
A resident with a PICC IV line did not receive required dressing changes as ordered, with the dressing remaining unchanged for eighteen days despite documentation in the TAR indicating otherwise. Staff interviews confirmed that LPNs documented dressing changes that were not performed, in violation of facility policy requiring weekly changes and accurate documentation.
A resident with an external fixator and ongoing right leg infection did not receive timely pre-operative Venous Doppler testing as ordered, leading to the cancellation of scheduled device removal surgery. The facility failed to verify test completion, missed follow-up appointments, and did not continue antibiotics after surgery was canceled. Key providers were not informed of these lapses, and a wound culture was not obtained, resulting in delays in both surgical intervention and infection management.
A resident with significant mobility limitations and recent orthopedic surgery missed multiple critical follow-up appointments, including a scheduled hardware removal, due to the facility's failure to arrange and cover necessary stretcher transportation. Staff communications and documentation showed confusion over financial responsibility, leading to missed care and canceled procedures, despite facility guidelines requiring timely access to outside services.
The facility failed to meet the food preferences and nutritional needs of four residents. One resident was unaware of menu options and dissatisfied with unhealthy food. Another felt hungry after meals and was served a leftover tray. A third resident on a renal diet did not receive a prescribed supplement, and a fourth received an incorrect meal order. The facility's policy to ensure meals matched residents' preferences was not followed.
The facility failed to maintain proper food temperature control, as tuna salad sandwiches were found in the temperature danger zone during a dinner tray line. The sandwiches were initially recorded at a safe temperature but later found to be inadequately chilled, with the ice machine not functioning. The Dietary Services Manager acknowledged the sandwiches were not chilled long enough to reach a safe serving temperature.
The facility failed to ensure that the binding arbitration agreement explicitly granted residents or their representatives the right to rescind the agreement within 30 days of signing. This affected 18 residents, as the agreement allowed rescission within 30 days of admission, not from the signing date. The Regional President acknowledged the issue, but no residents had requested rescission.
The facility failed to maintain and organize records for QAPI and QAA activities, impacting the quality of care and life for residents. The DON initiated a PIP for PASARR, but only 25% were reviewed. The Regional Director could not locate PIP records, and the NHA, new to her role, found no clinical PIP records. Meeting minutes showed no QAA recommendations, indicating a lack of systematic documentation and monitoring.
The facility failed to maintain and organize records for Quality Assurance Performance Improvement (QAPI) activities, impacting the quality of care for residents. The DON and Regional Director of Clinical Services admitted to incomplete reviews of PASARRs and an inability to locate PIP records. The NHA confirmed the absence of clinical PIP records, highlighting a deficiency in the facility's quality assurance processes.
The facility failed to provide a homelike environment in the North and South unit dining rooms, affecting 8-20 residents per meal. Observations showed meals served on trays without tablecloths or centerpieces, creating an institutional atmosphere. A resident and staff noted the lack of homelike elements, and the Administrator acknowledged the issue as a dignity concern.
The facility failed to provide a homelike dining environment for residents in the North and South unit dining rooms. Residents were served meals on trays without tablecloths or centerpieces, creating an institutional atmosphere. A resident and the Registered Dietetic Technician expressed that decorations could improve the dining experience. The Administrator acknowledged that serving meals on trays could be a dignity issue.
The facility failed to provide emergency equipment for a resident with a tracheostomy, did not monitor a resident's blood glucose levels as ordered, and inadequately monitored the nutritional status of several residents, leading to significant weight loss without timely intervention.
Two residents were found self-administering medications without proper assessments or physician orders. One resident, cognitively intact, had various herbal supplements and vitamins at his bedside, while another, with moderate cognitive impairment, kept Tylenol for arthritis pain. The facility did not conduct required evaluations to ensure safe self-administration, as confirmed by the DON.
A resident with severe cognitive impairment and multiple health issues was found with her call light out of reach on the floor, despite being dependent on staff for all ADLs. Staff interviews confirmed the expectation to keep call lights accessible, but the device was left on the floor, compromising the resident's ability to request assistance.
A facility failed to conduct a new PASSAR Level I screen for a resident who developed new mental health diagnoses, including schizophreniform disorder and major depressive disorder, after admission. The initial screening was completed months prior, and the DON and Regional Director of Clinical Services were unaware of the need for a new assessment.
A resident with diabetes did not receive proper blood glucose monitoring as ordered by a physician. An LPN failed to document hourly re-checks after being unable to administer insulin due to its unavailability. The next recorded measurement was taken four hours later by another LPN, highlighting a deficiency in following physician's orders and facility standards.
The facility failed to monitor and address the nutritional needs of three residents, leading to significant weight loss. A resident with dementia experienced an 8.7% weight loss without updated weights for three months. Another resident with severe cognitive impairment lost 24.4 pounds over five months due to unreported weight loss. A third resident with end-stage renal disease had no initial weight recorded, leading to a 13% weight loss. The facility's inadequate monitoring and response to nutritional needs were evident.
A facility failed to provide emergency equipment for a resident with a tracheostomy, leading to a deficiency in care. The resident, with chronic respiratory failure and other conditions, was observed without an emergency trach kit at the bedside. The LPN was unaware of the need for such a kit, and the Central Supply staff confirmed it was their responsibility to provide it. The Unit Manager and DON acknowledged the importance of having emergency supplies available, but the facility's training and orientation processes were insufficient.
A resident with diabetes did not receive timely insulin medication due to a failure in reordering the supply before it was depleted. An LPN discovered the shortage and attempted to resolve it by contacting the physician and placing an order with the pharmacy, but the insulin was not delivered in time. The facility's guidelines required timely reordering and use of emergency supplies, which were not effectively followed.
A resident with multiple diagnoses, including difficulty swallowing and high risk for complications, did not receive proper monitoring and medication administration as per physician's orders. An LPN failed to administer Lispro insulin due to its unavailability and did not document hourly blood sugar checks as instructed by the physician. The next recorded check was four hours later by another LPN, highlighting a lapse in following the facility's standards for monitoring and documentation.
A resident with a tracheostomy and respiratory failure did not receive respiratory therapy as per physician orders. The facility lacked a current physician's order for the resident's oxygen flow rate, leading to inconsistent oxygen delivery. The oversight was identified through staff interviews and medical record reviews.
Failure to Accurately Document and Perform PICC Line Dressing Changes
Penalty
Summary
The facility failed to maintain accurate documentation and perform required dressing changes for a resident with a peripherally inserted central catheter (PICC) IV line. The resident, who was admitted with multiple diagnoses including venous insufficiency, cardiac arrest, seizures, major depressive disorder, and muscle weakness, had a physician's order for the PICC line dressing to be changed every seven days using sterile technique. Upon observation, the dressing was found to be dated eighteen days prior, indicating it had not been changed since before the resident's admission. Despite this, the Treatment Administration Record (TAR) showed that nurses documented the dressing was changed on three separate occasions during that period. Interviews with staff revealed that the nurses responsible for the documentation had not actually performed the dressing changes as recorded. One LPN admitted to documenting the change without performing it, while the other could not be reached for comment. The facility's policy required weekly dressing changes and accurate documentation upon completion of the procedure, but there was no policy specifically addressing documentation accuracy. The deficiency was identified through observation, record review, and staff interviews.
Failure to Ensure Timely Pre-Operative Testing and Infection Management
Penalty
Summary
A resident with a history of right knee dislocation, type 2 diabetes, muscle weakness, and subsequent complications including right leg wound infection and nerve palsy, was admitted to the facility following acute care hospitalization. The resident had an external fixator device in place and was dependent on staff for activities of daily living and positioning. The care plan included monitoring for infection and circulation complications, but did not specify interventions for follow-up care related to the wound or removal of the fixator. Over several months, the resident required multiple antibiotics for ongoing right leg infections and developed additional pressure injuries around the fixator pin sites. The deficiency occurred when the facility failed to ensure timely completion of pre-operative testing, specifically a Venous Doppler, as ordered by the physician prior to the scheduled surgical removal of the external fixator. The Doppler was required to be completed 24 to 48 hours before surgery, but the order was entered and signed off as completed eight days prior, without verification that the test was actually performed. When the error was discovered, a STAT order was placed, but the test was not completed in time, resulting in the cancellation of the scheduled surgery. The resident missed multiple follow-up appointments with the orthopedic surgeon due to lack of transportation and coordination by the facility, and the surgery for device removal remained unscheduled at the time of the survey. Further contributing to the deficiency, the facility did not continue the resident's antibiotics after the surgery was canceled, despite ongoing infection and purulent drainage from the wound sites. The infectious disease and wound care providers were not informed of the lapse in antibiotic therapy, and a wound culture was never obtained as previously recommended. The attending physician was not notified of the surgery cancellation or the failure to complete the required pre-operative testing. These failures resulted in delays in necessary surgical intervention and ongoing management of the resident's infection.
Failure to Provide Timely Post-Operative Transportation and Follow-Up
Penalty
Summary
The facility failed to provide timely assistance and post-operative follow-up transportation for a resident who required specialized stretcher transport for multiple medical appointments following a right knee dislocation and surgical intervention. The resident, who was cognitively intact and dependent on staff for all activities of daily living due to significant lower extremity limitations, missed several critical follow-up appointments, including post-surgical evaluations and a scheduled surgery to remove hardware, because the facility did not arrange or cover the necessary transportation. Documentation showed that the facility's process for arranging transportation involved handwritten forms and required approval from the Nursing Home Administrator for costly services, but there was confusion and lack of clarity regarding financial responsibility, resulting in missed appointments and canceled procedures. The resident expressed frustration that he was told by facility staff he would have to pay for transportation himself, leading him to attempt to make his own arrangements. Records confirmed that some appointments were missed or rescheduled due to transportation issues, and at least one transportation bill remained unpaid by the facility. The orthopedic provider's office and infectious disease notes corroborated that timely follow-up was not achieved, and the resident's surgery was canceled due to incomplete pre-operative testing, which was also the facility's responsibility. Interviews with staff, including the Medical Records Coordinator and Discharge Planner, revealed inconsistent practices and understanding regarding who was responsible for arranging and paying for transportation, especially for residents requiring specialized services. Facility guidelines stated that the facility was responsible for ensuring timely services, whether provided internally or through outside resources, but this was not followed in the resident's case, resulting in a failure to meet the resident's post-operative care needs.
Failure to Accommodate Resident Food Preferences and Nutritional Needs
Penalty
Summary
The facility failed to accommodate the food preferences and nutritional needs of four residents, leading to deficiencies in their care. Resident #77, who was admitted with a regular diet, expressed dissatisfaction with the unhealthy breakfast options provided and was unaware of the ability to request different menu items. The Dietetic Technician, Registered (DTR) confirmed that food preferences were not discussed unless there was an issue with intake, which was not the case for this resident. Resident #403, also on a regular diet, reported feeling hungry after meals and was not informed about the option to make food selections. The DTR acknowledged that the resident's caloric needs were not being met with the current menu offerings, and snacks were not offered to supplement his diet. Additionally, the resident was served a leftover meal tray, which was not in line with facility expectations for providing fresh, warm food. Resident #34, on a renal diet, was not meeting her nutritional needs and expressed dissatisfaction with the food. Despite her diminished appetite and inadequate intake, her preferences were not discussed, and a prescribed nutritional supplement was not ordered. Resident #59, who desired weight gain, received a meal that did not match her order, and the CNA failed to verify the meal ticket before leaving the room. The facility's policy required staff to ensure meals matched residents' preferences and dietary needs, which was not adhered to in these cases.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On Kitchen manager/designee spoke with residents numbers, 34, 59, 403, and 77 to ensure food preferences were obtained. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed on residents to ensure resident food preferences have been obtained. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with CDM to ensure resident food preferences are obtained timely. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete audit of residents food preferences, ensure compliance with federal regulation F806 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Improper Food Temperature Control in Facility
Penalty
Summary
The facility failed to serve food items in accordance with professional standards for food service safety, specifically involving the handling of tuna salad sandwiches. During a dinner tray line, it was observed that the sandwiches were stacked in a deep sheet pan placed in a steam table well that was turned off but still warm due to adjacent heated wells. The temperature of the sandwiches was recorded at 50 degrees Fahrenheit, which is within the temperature danger zone for potentially hazardous foods. The sandwiches were then removed and placed in the freezer to re-chill. A second pan of sandwiches was also found in the freezer with a temperature of 46.7 degrees Fahrenheit, indicating they were not adequately chilled to a safe serving temperature of at least 41 degrees Fahrenheit. The PM cook mentioned that the sandwiches were usually placed on a bed of ice, but the ice machine was not functioning, leaving no ice available for the tray line. The temperature log showed that the sandwiches were initially recorded at 38 degrees Fahrenheit at the start of the tray line, approximately 20 minutes before the observation. The Dietary Services Manager could not explain the temperature increase and acknowledged that the sandwiches were not chilled long enough in the freezer to reach a safe temperature. The facility's Food and Nutrition Services policy requires food to be stored, prepared, distributed, and served according to professional standards, which was not adhered to in this instance.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On sandwiches not meeting temperature were immediately removed. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed on prepared food to ensure temperatures were appropriate. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with dietary staff on how to store food. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete audit of meals daily to ensure food temperatures are appropriate, ensure compliance with federal regulation F812 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Arbitration Agreement Rescission Period Not Clearly Defined
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement explicitly granted residents or their representatives the right to rescind the agreement within 30 calendar days of signing it. This deficiency affected 18 out of 102 current residents who had signed the arbitration agreements. The facility's log indicated that these residents signed the arbitration agreement, which was not a requirement for admission. The Internal Admissions staff person confirmed that she usually read the Voluntary Binding Arbitration Agreement to the residents or their representatives within 48 hours of admission and acknowledged that the agreement could be rescinded, but she was unsure of the exact time frame. Upon review, it was found that the arbitration agreement allowed rescission within 30 days of the resident's date of admission, not from the date of signature. The Regional President of Operations acknowledged that the wording did not explicitly grant the 30-day rescission period from the date of signing, which could potentially affect residents if the signing date differed from the admission date. However, it was noted that no residents had requested to rescind the agreement, suggesting that the issue had not yet impacted any residents.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On NHA notified current, in-house residents or their RP of update to Arbitration Agreement. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. No residents were found to be directly affected by this practice. Audit completed on residents admitted on or after to ensure updated Arbitration Agreements are included in admission packets. C) What measures will be put into place, or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Administrator/designee to complete education with Admissions department to ensure updated Arbitration Agreements are distributed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Administrator/designee to complete audit of residents who admitted on or after to ensure updated Arbitration Agreements are distributed. Compliance with federal regulation F847 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Deficiency in QAPI and QAA Documentation and Monitoring
Penalty
Summary
The facility failed to maintain records, monitor, and effectively conduct Quality Assurance Performance Improvement (QAPI) and Quality Assurance and Assessment (QAA) activities, which could impact the quality of care and life for all residents. During an interview, the Director of Nursing (DON) mentioned that a Performance Improvement Plan (PIP) for Pre-Admission Screening and Resident Review (PASARR) was initiated approximately one month prior, but only about 25% of the PASARRs had been reviewed or redone. The Regional Director of Clinical Services was unable to locate any records for the PIPs, indicating a lack of organization and documentation. The Nursing Home Administrator (NHA), who had been in her position since January, conducted QAPI meetings and initiated a PIP for environmental concerns and maintenance repairs. However, she was unable to locate records for clinical PIPs and could not account for activities before her tenure. The Quality Assurance Meeting minutes from January showed no QAA Committee recommendations, and the facility's guidelines emphasized the need for maintaining documentation and demonstrating evidence of ongoing QAPI activities. The absence of records and documentation for clinical PIPs highlights a deficiency in the facility's ability to systematically identify, report, investigate, analyze, and prevent adverse events, as required by their standards.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On QAPI meeting was held to complete a system review and new identified PIP were initiated. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. No residents were found to be directly affected by this practice. A review of current PIPs was completed on to assess the need for modifications or updates. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Administrator/designee to complete PIP education with department managers to reinforce adherence to identifying trends and concerns proactively. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Administrator/designee to conduct a weekly review of PIP tracking tools to ensure ongoing compliance is met ensure compliance with federal regulation F865 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Deficiency in QAPI Documentation and Monitoring
Penalty
Summary
The facility failed to maintain records, monitor, and effectively conduct Quality Assurance Performance Improvement (QAPI) activities, which could impact the quality of care and life for all residents. During an interview, the Director of Nursing (DON) and the Regional Director of Clinical Services revealed that a Performance Improvement Plan (PIP) for Pre-Admission Screening and Resident Review (PASARR) was initiated approximately one month prior, but only about 25% of the PASARRs had been reviewed or redone. The Regional Director admitted to being unable to locate any records for the PIPs, stating that they were not on record and not organized. The Nursing Home Administrator (NHA) confirmed that QAPI meetings had been conducted, but was unable to locate any records for clinical PIPs, aside from environmental and maintenance plans. The NHA acknowledged that there were no records for clinical PIPs and emphasized the importance of QAPI in monitoring, analyzing, and correcting problems to ensure residents receive necessary care and services. A review of the Quality Assurance Meeting minutes showed no QAA Committee recommendations, and the facility's guidelines required maintaining documentation and demonstrating evidence of an ongoing QAPI program. However, the facility failed to present such documentation, indicating a widespread deficiency in their quality assurance processes.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On PASSR resubmitted for resident # 62. No other deficient practice noted. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On a full house audit was completed for PASSR's needing resubmission due to new diagnosis. No other deficient practice noted. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. The DON/designee conducted education with social services and DON on ensuring request for new submission of PASSR is completed with new diagnosis meeting criteria, with an emphasis on the components of Federal regulation F644. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. The DON/Designee will conduct an audit of residents with new diagnosis meeting criteria for resubmission of PASSR to ensure compliance with N906 weekly X 4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Lack of Homelike Environment in Dining Areas
Penalty
Summary
The facility failed to provide a homelike environment for residents dining in the North and South unit dining rooms. Observations revealed that residents were served meals on trays without tablecloths or centerpieces, creating an institutional atmosphere rather than a homelike setting. This affected approximately 8-20 residents per meal, out of the 98 residents at the facility. The dining tables were undecorated, and in some instances, held newspapers and word puzzles from earlier activities, further detracting from a homelike environment. Interviews with residents and staff highlighted the lack of homelike elements in the dining areas. A resident expressed that the dining area felt like a cafeteria and suggested that tablecloths or decorations could improve the atmosphere. The Registered Dietetic Technician also noted that more decoration, such as centerpieces, would be appreciated by everyone. The Administrator acknowledged that serving meals on trays could be considered a dignity issue, as it contributed to a more institutional feel rather than a homelike environment.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On table clothes and centerpieces were provided on the tables for North and South wing. b. On dishes, flatware, cups and food items were removed from the serving tray. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On the Director of Nursing/designee completed an audit to ensure North and South dining room tables have table clothes and centerpieces on the tables. b. On the Director of Nursing/ designee completed an audit to ensure all dishes, flatware, cups, and food are removed from the tray unless the resident declines to have items removed per their plan of care. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee completed education with staff to ensure North and South unit tables have table clothes and center pieces. b. By the Director of Nursing/ designee completed education with staff to remove dishes, flatware, cups, and food removed from the tray unless the resident prefers to have items on the tray per the plan of care. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure North and South wings tables have table clothes and center pieces compliance with federal regulation F584 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Director of Nursing/designee to complete random audit to ensure to remove dishes, flatware, cups, and food removed from the tray unless the resident prefers to have items on the tray per the plan of care compliance with federal regulation F584 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. c. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Lack of Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents dining in the North and South unit dining rooms. Observations revealed that residents were served meals on trays without tablecloths or centerpieces, creating an institutional atmosphere rather than a homelike one. This affected all residents who chose to eat in these dining areas, with varying numbers of residents per meal. The dining tables were undecorated, and items such as newspapers and word puzzles were left on the tables, further detracting from a homelike setting. Interviews with residents and staff highlighted the dissatisfaction with the dining environment. A resident expressed that the dining area felt like a cafeteria and suggested that tablecloths or decorations could improve the atmosphere. The Registered Dietetic Technician also noted that everyone would likely enjoy more decoration in the dining room. The facility's Administrator acknowledged that serving meals on trays could be considered a dignity issue, as it contributed to a more institutional feel rather than a homelike environment.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On table clothes and centerpieces were provided on the tables for North and South wing. b. On dishes, flatware, cups and food items were removed from the serving tray. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On the Director of Nursing/designee completed an audit to ensure North and South dining room tables have table clothes and centerpieces on the tables. b. On the Director of Nursing/designee completed an audit to ensure all dishes, flatware, cups, and food are removed from the tray unless the resident declines to have items removed per their plan of care. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee completed education with staff to ensure North and South unit tables have table clothes and center pieces. b. By the Director of Nursing/designee completed education with staff to remove dishes, flatware, cups, and food removed from the tray unless the resident prefers to have items on the tray per the plan of care. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure North and South wings tables have table clothes and center pieces compliance with N110 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Director of Nursing/designee to complete random audit to ensure to remove dishes, flatware, cups, and food removed from the tray unless the resident prefers to have items on the tray per the plan of care compliance with federal regulation F584 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. C. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Deficiencies in Emergency Preparedness, Monitoring, and Nutritional Care
Penalty
Summary
The facility failed to provide adequate emergency equipment and training for a resident with a tracheostomy. The resident was observed without an emergency kit at the bedside, which is crucial in case of accidental extubation. The LPN assigned to the resident was unaware of the need for such a kit and did not know the protocol for emergencies. The Unit Manager and Central Supply staff confirmed the absence of the emergency kit, and the facility's policy did not include specific orders for emergency supplies for the resident. Another deficiency involved the failure to monitor a resident's blood glucose levels as per physician's orders. The resident, who was on insulin and other medications, did not have their blood glucose re-checked after a physician's order to hold a meal and re-check levels. The Unit Manager confirmed that the re-checks were not documented, and the DON emphasized the importance of monitoring to prevent complications. The facility also failed to properly monitor the nutritional status of several residents. One resident experienced significant weight loss without timely re-evaluation or intervention. The dietary staff did not complete necessary assessments or follow up on nutritional risks. Another resident's initial weight was not obtained upon admission, leading to inaccurate assessments of weight loss. The facility's policies on weight monitoring and nutritional assessments were not followed, resulting in a lack of timely interventions for residents at nutritional risk.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On an extra tube (emergency kit) was placed at bedside for resident number 22. b. On an assessment was completed on resident number 93 no signs or symptoms of hyper or were noted. c. On staff member received education on entering physician orders in the medical record when received orders for abnormal lab results. d. On RD completed review to assess nutritional status of resident numbers, 15, 52, and 34. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit to ensure extra tube kept at bedside (Emergency kit). b. On Director of Nursing/designee completed an audit to ensure resident with order changes related to abnormal results ensure all orders are followed. c. On Audit completed to ensure nutritional status of resident with have been assessed. d. On Audit completed to ensure nutritional status of residents has been assessed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/ designee completed education with licensed Nurses on ensuring we have extra tube is kept at bedside (Emergency Kit). b. By the Director of Nursing/designee completed education with licensed nurses when orders are received related to abnormal results a physician order is placed in the resident medical record. c. By Director of Nursing/designee to complete education with RD and nurse management team to ensure nutritional status is reviewed and assessed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit extra tube is stored at bedside (emergency kit) ensure compliance with N201 Right to Adequate and Appropriate Heel care weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Director of Nursing/designee to complete random audit to ensure resident with order changes related to abnormal results ensure all orders are followed compliance with N201 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. c. Director of Nursing/designee to complete random audit to ensure nutritional status of residents has been assessed to ensure compliance with N201 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. d. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Failure to Conduct Medication Self-Administration Assessments
Penalty
Summary
The facility failed to conduct medication self-administration assessments for two residents, leading to a deficiency in ensuring the safety of self-administered medications. Resident #49, who was cognitively intact with a BIMS score of 15, was found with various herbal supplements and vitamins at his bedside, which he was taking without a physician's order or a completed self-administration evaluation. The resident had stopped taking Gabapentin, a prescribed medication, in favor of the herbal blend, yet there was no documentation or approval for this change in his medication regimen. Similarly, Resident #305, with a BIMS score indicating moderate cognitive impairment, was observed with Tylenol at his bedside, which he used for arthritis pain. Like Resident #49, there was no physician's order or self-administration evaluation for the Tylenol. The Director of Nursing confirmed that neither resident had been evaluated for medication self-administration, which is required by the facility's policy to prevent overdose and ensure safe medication practices.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusions set forth in the Statement of Deficiencies rendered by the reviewing agency. The Plan of Correction is prepared and executed solely because it is required by the provisions of federal and state law. Avante at Melbourne maintains the alleged deficiencies do not individually jeopardize the health and/or safety of its residents nor are they if such character as to limit the provider's capacity to render adequate resident care. Furthermore, Avante at Melbourne asserts that it is in substantial compliance with regulations governing the operation of long-term care facilities, and this Plan of Correction in its entirety constitutes the provider's credible allegation of compliance. A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On DON completed self-administration assessment for resident number 49. Reviewed with physician, physician declined self-admin order to add supplements to MAR stated the herbs may have contraindication with scheduled medication. b. Resident number 305 discharged from facility, readmitted declined self-administration assessment. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed on residents to ensure any resident who wished to self-administer medications has a self-administration screen completed along with a physician order to self-administer. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with Licensed Nurses to ensure residents who wish to self-administer medications have an assessment, lock box, MAR, and physician order. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit of residents who wish to administer medications by themselves have an assessment, lock box, MAR and physician order to do so weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a call light device was within reach for a resident, leading to a deficiency in accommodating the needs of the resident. The resident, a female with multiple diagnoses including dementia, chronic pain syndrome, and cognitive communication deficits, was observed on two separate occasions with the call light cord lying on the floor under her bed, out of reach. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and required a wheelchair for mobility. Staff interviews revealed that the resident was capable of using her hands and arms to activate the call light bulb if it was within reach. However, the call light was found on the floor, and staff confirmed that it should not have been left there, especially since the resident's room door was closed, preventing staff from hearing her if she called out. The Unit Manager stated that staff were expected to ensure call lights were within reach before leaving a resident's room, and that CNAs typically checked on bedbound residents every two hours. The facility's assessment emphasized person-centered care and prompt response to residents' requests, which was not adhered to in this instance.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On resident number 52 call light was picked up and clipped to the resident bedsheet, so the bulb was within reach of the resident's. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit to ensure resident call lights are within reach. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee completed education with staff to ensure residents call lights are within reach of the resident. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure resident call lights are within reach compliance with federal regulation F558 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Failure to Update PASSAR Screening for Resident with New Diagnoses
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASSAR) Level I screen for a resident who had new diagnoses that could require additional mental health services. The resident was admitted with diagnoses including dementia, cognitive communication disorder, generalized anxiety disorder, and insomnia. Later, additional diagnoses such as schizophreniform disorder, persistent mood disorder, and major depressive disorder were added. Despite these changes, the facility did not conduct a new PASSAR screening after the initial one completed in August 2023. The Director of Nursing and the Regional Director of Clinical Services were unaware that the new diagnoses necessitated a new PASSAR screen, indicating a lapse in the coordination of assessments with the pre-admission screening and resident review program.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On PASSR resubmitted for resident # 62. No other deficient practice noted. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. A full house audit was completed for PASSROs needing resubmission due to new diagnosis. No other deficient practice noted. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. The DON/designee conducted education with social services and DON on ensuring request for new submission of PASSR is completed with new diagnosis meeting criteria, with an emphasis on the components of Federal regulation F644. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. The DON/Designee will conduct an audit of residents with new diagnosis meeting criteria for resubmission of PASSR to ensure compliance with federal regulation F644 weekly for 4 weeks, then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Failure to Monitor Blood Glucose as Ordered
Penalty
Summary
The facility failed to ensure that nurses followed physician's orders to monitor fingerstick blood glucose levels for a resident with diabetes mellitus, among other conditions. The resident, a male admitted from an acute care hospital, required insulin injections and had specific orders for blood glucose monitoring and insulin administration. On a particular day, an LPN was unable to locate the resident's Lispro insulin and contacted the physician, who instructed to hold the insulin and re-check the resident's blood glucose every hour until the refill arrived. However, the LPN did not document any re-checks during her shift, and the next recorded blood glucose measurement was taken four hours later by another LPN. The Unit Manager confirmed the lack of documentation for the hourly re-checks as per the physician's orders, and the Director of Nursing emphasized the importance of following doctor's orders to prevent complications. The facility's standards required nurses to evaluate and document the resident's status, which was not adhered to in this instance. This oversight in monitoring and documentation led to a deficiency in the care provided to the resident, as the facility did not ensure proper management of the resident's diabetes condition.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On an assessment was completed on resident number 93 no signs or symptoms of hyper or were noted. b. On Staff member received education on entering physician orders in the medical record when received orders for abnormal lab results. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On the Director of Nursing/designee completed an audit to ensure resident with order changes related to abnormal results ensure all orders are followed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/designee completed education with licensed nurses when orders are received related to abnormal results a physician order is placed in the resident medical record. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure resident with order changes related to abnormal results ensure all orders are followed compliance with federal regulation F684 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of three residents, leading to significant weight loss and potential health risks. Resident #52, a female with multiple diagnoses including dementia and diabetes, experienced an 8.7% weight loss over two months. Despite orders for monthly weights and nutritional supplements, no weights were recorded for three months after November 2024. The dietary staff was unaware of the resident's status due to the lack of updated weights, which hindered timely interventions. Resident #15, a female with severe cognitive impairment and multiple health conditions, also experienced significant weight loss. She lost 24.4 pounds, or 15.8% of her body weight, over five months. Although the dietician had recommended increased protein intake, the facility failed to report the resident's weight loss for three months, delaying necessary re-evaluation and interventions. The facility's policy required monthly weights, but this was not adhered to, resulting in unmonitored weight loss. Resident #34, admitted with end-stage renal disease and other conditions, did not have an initial weight recorded upon admission. The facility used a weight from a previous hospital stay, which was not best practice. This resident had a stage IV pressure ulcer, but the nutritional assessment did not reflect this, leading to inadequate nutritional support. The dietician failed to order recommended supplements, and no food preferences were obtained to improve the resident's intake. The lack of an initial weight and failure to implement dietary recommendations contributed to a 13% weight loss, highlighting the facility's inadequate monitoring and response to residents' nutritional needs.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On RD completed review to assess nutritional status of resident numbers, 15, 52, and 34. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed to ensure nutritional status of residents has been assessed. b. On Audit completed to ensure nutritional status of resident with have been assessed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with RD and nurse management team to ensure nutritional status is reviewed and assessed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure nutritional status of residents has been assessed to ensure compliance with federal regulation F692 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Failure to Provide Emergency Tracheostomy Equipment
Penalty
Summary
The facility failed to provide emergency equipment for a resident on mechanical ventilation with a tracheostomy, leading to a deficiency in respiratory care. The resident, who had chronic respiratory failure with hypoxia, anoxic brain damage, dysphagia, hypertensive heart disease, and tracheostomy status, was observed without an emergency trach kit at the bedside. The LPN assigned to the resident was unaware of the need for an emergency trach kit and did not know the protocol for emergency situations involving tracheostomy care. The Central Supply staff confirmed it was their responsibility to place the emergency trach kit at the bedside, but it was not present. The Unit Manager and the Director of Nursing acknowledged the importance of having emergency supplies readily available and verified that the facility's policy required such equipment to be at the bedside. However, the facility's training and orientation processes appeared insufficient, as the LPN was not adequately informed about emergency procedures. The facility's policy and procedure for respiratory and tracheostomy care indicated that care should be consistent with professional standards, but the lack of emergency equipment at the bedside demonstrated a failure to adhere to these standards.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. An extra tube (emergency kit) was placed at bedside for resident number 22. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. The Director of Nursing/designee completed an audit to ensure extra tube kept at bedside (Emergency kit). C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. The Director of Nursing/designee completed education with licensed Nurses on ensuring we have extra tube kept at bedside (Emergency Kit). D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. The Director of Nursing/designee to complete random audit of extra tube stored at bedside (emergency kit) to ensure compliance with federal regulation F695 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.
Failure to Timely Reorder Insulin Medication
Penalty
Summary
The facility failed to provide timely insulin medication for a resident, leading to a deficiency in pharmaceutical services. The resident, a male with multiple health conditions including diabetes mellitus, was admitted to the facility and required regular insulin administration. On a specific day, a Licensed Practical Nurse (LPN) discovered that the resident's prescribed Lispro insulin was not available in the medication cart or the emergency kit. Despite contacting the physician and placing an order with the pharmacy, the insulin was not delivered in time, and the resident's blood glucose levels had to be monitored hourly until the medication arrived. The Unit Manager and Director of Nursing (DON) acknowledged that the insulin should have been reordered before the supply was depleted. The facility's guidelines required nurses to reorder medications electronically or through other means to ensure timely delivery. However, the insulin was not reordered in time, resulting in a lapse in the resident's care. The facility's standards also indicated that in cases of medication shortages, nurses were expected to use the emergency supply or arrange for an emergency delivery, which was not effectively executed in this instance.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On DON ordered from the pharmacy STAT for resident number 93. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed on residents who require to ensure is available. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with Licensed Nurses to ensure residents who receive have on. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete audit of residents who received to ensure is available and or for ordered use ensure compliance with federal regulation F755 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk Management meeting until such time substantial compliance has been determined.
Failure to Follow Physician's Orders for Insulin Administration
Penalty
Summary
Facility nurses failed to follow physician's orders for a resident who was admitted with multiple diagnoses, including difficulty swallowing and high risk for complications. The resident required specific monitoring and medication administration, including Lispro insulin. During a medication administration observation, an LPN was unable to locate the resident's Lispro in the medication cart and the emergency medication kit did not contain it. The LPN contacted the physician and obtained orders to hold the Lispro and re-check the resident's blood sugar every hour until the refill arrived from the pharmacy. However, the LPN did not document any re-checks in the medical record, and the next recorded blood sugar check was four hours later by another LPN. The Unit Manager confirmed the lack of documentation and acknowledged the failure to follow the physician's orders. The Director of Nursing emphasized the importance of monitoring residents to prevent complications and re-hospitalization. The facility's standards required nurses to evaluate and document the resident's status, which was not adhered to in this case.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusions set forth in the Statement of Deficiencies rendered by the reviewing agency. The Plan of Correction is prepared and executed solely because it is required by the provisions of federal and state law. Avante at Melbourne maintains the alleged deficiencies do not individually jeopardize the health and/or safety of its residents nor are they of such character as to limit the provider's capacity to render adequate resident care. Furthermore, Avante at Melbourne asserts that it is in substantial compliance with regulations governing the operation of long-term care facilities, and this Plan of Correction in its entirety constitutes the provider's credible allegation of compliance. A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On an assessment was completed on resident number 93 no signs or symptoms of hyper or were noted. b. On staff member received education on entering physician orders in the medical record when received orders for abnormal lab results. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit to ensure resident with order changes related to abnormal results ensure all orders are followed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/designee completed education with licensed nurses when orders are received related to abnormal results a physician order is placed in the resident medical record. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure resident with order changes related to abnormal results ensure all orders are followed compliance with N054 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.
Failure to Provide Respiratory Care Per Physician Orders
Penalty
Summary
The facility failed to provide respiratory therapy as per physician orders for a resident with acute and chronic respiratory failure, epilepsy, anoxic brain damage, dysphagia, and a tracheostomy. The resident was observed with an oxygen concentrator set at 0 liters per minute (LPM) initially, and later at 4 LPM, despite the absence of a current physician's order for the oxygen flow rate. The resident's medical record lacked a physician's order for the oxygen flow rate, and the last documented order was from before a hospitalization in April 2024, which specified 2 LPM. The South Unit Manager confirmed that the facility did not have a current physician's order for the resident's oxygen flow rate and that the nurses should verify physician orders for flow rate every shift. The oversight resulted in the resident receiving varying oxygen flow rates without a current physician's directive, highlighting a lapse in ensuring that respiratory care was provided according to physician orders. This deficiency was identified during observations and interviews with the nursing staff and the review of the resident's medical records.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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