Aviata At Big Bend
Inspection history, citations, penalties and survey trends for this long-term care facility in Perry, Florida.
- Location
- 207 Marshall Dr, Perry, Florida 32347
- CMS Provider Number
- 105631
- Inspections on file
- 31
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 12 (3 serious)
Citation history
Health deficiencies cited at Aviata At Big Bend during CMS and state inspections, most recent first.
A resident reported that an RN entered his room on more than one occasion, yelled at him, called him a liar, and told him to keep her name out of his mouth, with one incident witnessed by a social work aide and another resident. The aide stated she believed the conduct was verbal abuse and reported it to social services, and multiple staff confirmed the allegation was reported to the DON and Administrator, who acknowledged that verbal abuse is a form of abuse. The RN admitted she was angry about the resident’s intention to call 911 and went to confront him, calling him a liar. The resident also filed a grievance that he did not receive scheduled baths on two dates, which was confirmed by review of the grievance log, and he felt this was retaliation. The facility’s abuse policy requires staff to respect residents’ rights, prevent abuse, and promptly report all allegations of abuse and neglect within specified time frames.
A resident reported that a RN entered the room yelling, which the resident perceived as verbal abuse and possible retaliation, and informed both the Administrator and the DON. The DON believed the Administrator had reported the allegation to state agencies, but the Administrator, who serves as Abuse Coordinator, did not do so because she did not believe it was abuse. Facility records later showed the allegation was not reported to the state agency until weeks after it was made, despite a written abuse policy requiring prompt reporting of all abuse allegations within specified time frames.
A resident reported feeling verbally abused and retaliated against by an RN, and this allegation was communicated by the SSD and HRD to the Administrator, who also served as the abuse coordinator. Despite witness statements documenting knowledge of the alleged verbal abuse and information that a staff witness existed and a false witness statement had been given, the Administrator did not suspend the RN or report the allegation to state agencies in accordance with the facility’s abuse policy. The allegation was not reported to state agencies until weeks later, contrary to policy requirements for prompt reporting of abuse allegations.
Multiple deficiencies occurred when two residents, both at risk for elopement and one under 1:1 supervision, escaped from a secured unit after repeated exit-seeking behaviors were not adequately addressed. Another resident was left immobile in her room with her deceased roommate for hours, causing significant psychosocial harm. Additionally, a resident with a history of self-harm and aggression suffered injuries and assaulted staff while under 1:1 supervision, with staff reporting inadequate training and support. The facility lacked policies for supervision and 1:1 care, resulting in Immediate Jeopardy for all residents.
The facility did not maintain an effective QAPI program, resulting in repeated incidents where residents with behavioral and psychiatric needs experienced aggression, self-harm, and elopement. Despite care plans and supervision requirements, residents were able to harm themselves and others, exit the facility, and in one case, steal a vehicle. The QAPI committee failed to analyze these events or implement improvement plans, and did not address substantiated cases of abuse or neglect in its reviews.
Two residents with severe cognitive impairment and elopement risk were able to exit a secured unit through a broken window, with one stealing an unsecured vehicle, while another resident with a history of aggression and psychiatric disorders engaged in self-harm and assaulted staff despite being on 1:1 supervision. The facility lacked policies and staff training for supervision and 1:1 monitoring, leading to multiple serious incidents and a finding of Immediate Jeopardy.
Several residents with cognitive impairments, behavioral issues, or communication difficulties did not receive the care plan interventions required for their safety and well-being. Two residents at risk for elopement were able to exit the facility due to lapses in supervision and monitoring, while another resident with aggressive behaviors was not consistently provided with 1:1 supervision or structured activities, resulting in injury. Additionally, a resident with aphasia did not receive a communication board or a referral to speech therapy as outlined in the care plan.
A staff member assigned to 1:1 monitoring was unable to maintain direct visual contact with a resident because the door was closed or partially open with the privacy curtain pulled. Interviews revealed there was no formal policy or consistent training for 1:1 observation, despite in-service education stating residents should be within eyesight and arm's reach at all times.
The facility failed to enforce its smoking policies, leading to safety concerns for six residents. Observations revealed residents with vapes and cigarettes in their rooms, despite policies requiring these items to be stored by staff. Interviews with staff showed confusion about the policy, with some believing residents could keep cigarettes but not ignition sources. The facility's policy, last revised in 2020, required all smoking materials to be stored by nursing staff and allowed electronic smoking materials only in designated areas.
Two residents did not receive the recommended restorative nursing care due to inconsistent documentation and staffing shortages. One resident, with a contracted wrist, was often without his prescribed splint, and the other received therapy less frequently than ordered. The facility's documentation was inadequate, and staff were frequently pulled from restorative duties to assist elsewhere, leading to neglect of residents' care needs.
The facility failed to maintain a sanitary environment in the dining rooms, laundry area, and a resident's room. Observations revealed dirty floors in the dining area and a resident's room, with staff confirming inconsistent cleaning practices. The laundry area had significant lint and debris buildup, with non-functional dryers and uncleaned filters. The Account Manager and Administrator were unaware of the last cleaning, indicating a lack of maintenance oversight.
A resident with a history of heart failure and dysphagia received improper tube feeding due to incorrect pump settings and unlabeled feeding bags. The feeding machine was set to deliver water flushes more frequently than ordered, which was confirmed by two LPNs. The facility's DON acknowledged the expectation for proper labeling and adherence to physician orders.
The facility did not post nurse staffing information in an accessible location with the required details on one survey date. Although dry erase boards displayed some information, it was not clear or accessible. A CNA confirmed the information was incomplete, and the Staffing Coordinator later admitted the oversight.
Failure to Protect Resident From Verbal Abuse and Missed Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member and to ensure required care was provided. On 1/19/26, a registered nurse (Staff A) entered Resident #1’s room while the Social Worker Aide (SWA) was present and loudly accused the resident of lying and stated she was going to tell her mother to get off his “slot.” The SWA reported that she instructed Staff A to leave the room and believed the interaction was verbal abuse, which she reported to the Social Service Director. Resident #1 reported that Staff A had previously entered his room yelling, telling him to keep her name out of his mouth, which was corroborated by another resident who was visiting at the time. Resident #1 stated he reported the verbal abuse to the Administrator and DON and wrote a grievance regarding missed baths. Multiple staff interviews confirmed that the allegation of verbal abuse was reported up the chain of command, including to the DON and Administrator, both of whom acknowledged that verbal abuse is a form of abuse. Staff A admitted she was angry because she had been informed that Resident #1 was threatening to call 911 and that she went to his room to confront him, calling him a liar. Review of the grievance log showed Resident #1 did not receive a shower or bath on 1/19/26 and 2/2/26, consistent with his complaint that he missed baths and felt he was being retaliated against by Staff A. The facility’s abuse policy requires all employees to respect residents’ rights, treat them with dignity, and immediately report allegations of abuse, neglect, exploitation, or mistreatment to the Administrator and appropriate officials within specified time frames.
Failure to Timely Report Allegation of Verbal Abuse to State Agencies
Penalty
Summary
The facility failed to immediately identify and report an allegation of verbal abuse involving one resident. On 1/19/26, a resident stated that a RN entered his room yelling at him while a social worker aide was present. The resident reported this alleged verbal abuse and his feeling of retaliation to both the Administrator and the DON. The DON reported that he spoke with the Administrator about the allegation on the same day and believed the Administrator had reported it to the state agencies. The Administrator, who is also the facility’s Abuse Coordinator, acknowledged being informed of the allegation on 1/19/26 but stated she did not report it to the state agency because she did not feel it was abuse. The facility’s abuse policy requires that any employee who witnesses or has knowledge of an allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property must report it immediately, but no later than 2 hours if it involves abuse or serious bodily injury, or within 24 hours if it does not. Facility records showed the allegation was not reported to the state agency until 2/10/26, contrary to the policy’s reporting time frames.
Failure to Timely Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation and timely reporting of an allegation of verbal abuse involving one resident. On 1/19/26, the Social Service Director reported to the Administrator, who is also the abuse coordinator, that a resident had alleged verbal abuse by a registered nurse (Staff A) and expressed that Staff A should be suspended. The Human Resource Director, who heard this report during morning meeting, also told the Administrator that Staff A needed to be suspended and began a workplace investigation the same day. Witness statements and interviews dated 1/19/26 documented knowledge of the alleged verbal abuse. The resident later stated he had informed the Administrator and DON that he felt verbally abused by Staff A and believed he was being retaliated against. On 2/11/26, the Administrator acknowledged she had been informed of the abuse allegation on 1/19/26 but did not suspend Staff A or report the allegation to the state agency, stating she did not believe it was verbal abuse because Staff A was outside the resident’s room. On 1/21/26, the Administrator became aware that a Social Worker Aide was a witness and that Staff A had provided a false witness statement, yet Staff A still was not suspended and the allegation was not reported to state agencies at that time. Facility records show the abuse report was not filed with the state agencies until 2/10/26. This response was inconsistent with the facility’s abuse policy, which requires any employee with knowledge of an allegation of abuse to report it immediately, but no later than 2 hours if it involves abuse or serious bodily injury, or within 24 hours if it does not involve abuse and does not result in serious bodily injury, to the Administrator and appropriate state officials.
Failure to Prevent Abuse, Neglect, and Elopement in Secured Unit
Penalty
Summary
The facility failed to prevent abuse and neglect for multiple residents, resulting in several serious incidents. Two residents, both identified as elopement risks with documented cognitive impairments and behavioral issues, were able to escape from a secured and locked unit. One of these residents was under one-to-one supervision at the time. The facility lacked a policy for resident supervision or one-to-one supervision, and staff were not provided with clear expectations or training prior to the elopements. Documentation revealed repeated incidents of exit-seeking behavior, tampering with alarms, and attempts to bypass security measures, yet interventions were insufficient to prevent the eventual elopement. The escape involved breaking a window, and one resident was later found walking on an interstate, while the other was located at a store miles away from the facility. The police were involved, and the events created a potential for serious injury or death. Another incident involved a resident who was immobile and left in her room with the body of her deceased roommate for nearly three hours. Despite her requests to be moved and her visible distress, staff did not accommodate her or check on her well-being during this period. The resident experienced significant psychosocial harm, including ongoing anxiety, sleep disturbances, and the need for therapy. Staff interviews confirmed that the facility's protocol should have been to move the surviving roommate before postmortem care, but this was not followed. The facility's own policy defined involuntary seclusion as a form of abuse, which was applicable in this situation. A further deficiency was identified in the care of a resident with a history of self-harm, aggression, and complex psychiatric diagnoses. This resident, also on one-to-one supervision, suffered injuries from self-harm and was involved in multiple aggressive incidents toward staff and other residents. Staff assigned to supervise this resident reported inadequate training, lack of communication tools, and feeling unsafe. Documentation of required diversional activities was inconsistent, and there was no clear policy or guidance for staff on how to conduct one-to-one supervision. The cumulative effect of these failures placed all residents at risk for abuse and neglect, resulting in a finding of Immediate Jeopardy at a widespread scope and severity.
Failure to Maintain Effective QAPI Program for Resident Safety and Supervision
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to ensure adequate supervision and safety for residents at risk for elopement, self-harm, and aggressive behaviors. Multiple residents with complex behavioral and psychiatric needs, including diagnoses such as schizoaffective disorder, impulse disorder, and major depressive disorder, experienced repeated incidents of aggression, self-injury, and elopement. The facility's QAPI committee did not perform or document thorough analysis or root cause investigations following these events, nor did it develop or implement improvement plans to address the ongoing risks and incidents. One resident with a history of agitation, aggression, and elopement risk was subject to multiple behavioral incidents, including physical aggression towards staff and other residents, self-harm, and repeated attempts to exit the facility. Despite a care plan that called for 1:1 supervision and specific interventions, the resident was able to overpower staff, exit the building, and sustain injuries. The facility issued a discharge notice stating it could not meet the resident's needs, but subsequently readmitted the resident without documented changes in condition or services, and without evidence of a QAPI review or improvement plan addressing the repeated behavioral incidents and safety concerns. Two other residents eloped from the facility by breaking a window, with one stealing an unsecured staff vehicle and traveling a significant distance before being apprehended. The facility's investigation and QAPI documentation lacked data analysis, root cause identification, or evidence of systematic review as outlined in the facility's own QAPI plan. Additionally, QAPI meeting minutes and records failed to reflect recognition of substantiated abuse, neglect, or misappropriation as issues requiring action or further investigation. The facility's failure to follow its QAPI processes and to address these serious incidents resulted in a finding of Immediate Jeopardy at a widespread scope and severity.
Failure to Supervise High-Risk Residents Results in Elopement and Aggression
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for residents identified as high risk for elopement and physical aggression. Two residents with severe cognitive impairment and documented elopement risk were not properly supervised, resulting in both exiting the secured, locked unit through a broken window. One of these residents was assigned to one-to-one (1:1) supervision at the time but was left unsupervised when the assigned CNA left the unit to use the restroom. The residents were able to break a window, exit the facility, and one subsequently stole an unsecured vehicle from the facility parking lot, driving it a significant distance before being apprehended. Documentation revealed repeated incidents of these residents tampering with security devices, refusing monitoring devices, and exhibiting exit-seeking behaviors, yet the facility lacked a policy for supervision or 1:1 monitoring and failed to implement effective interventions to prevent elopement. Another resident with a history of schizoaffective disorder, impulse control issues, and aggressive behaviors was also not adequately supervised despite being on 1:1 observation. This resident engaged in self-injurious behavior and physically assaulted staff on multiple occasions, including punching a nurse in the face and assaulting law enforcement. Staff interviews revealed a lack of training and clear protocols for managing aggressive or self-harming behaviors, with staff expressing uncertainty about how to intervene during such incidents. The care plan for this resident included instructions for 1:1 supervision and specific monitoring, but staff reported only general abuse and neglect training and no specific guidance for handling violent or self-harming behaviors. The facility did not have policies in place for resident supervision or 1:1 observation, and staff were not provided with clear expectations or training prior to the incidents. The lack of effective supervision, absence of policies, and failure to address known risks led to multiple serious incidents, including elopement, self-injury, and physical assaults. The cumulative effect of these failures resulted in a finding of Immediate Jeopardy, with the situation ongoing at the time of the survey exit.
Failure to Implement Care Plan Interventions for Supervision, Elopement Risk, and Communication Needs
Penalty
Summary
The facility failed to implement care plan interventions for multiple residents, resulting in significant deficiencies. For several residents identified as being at risk for elopement or exhibiting wandering behaviors, the facility did not consistently follow care plan interventions such as providing adequate supervision, maintaining electronic monitoring devices, or ensuring 1:1 supervision as ordered. In one instance, two residents with severe cognitive impairments and documented elopement risk were able to exit the facility by breaking a window, with one resident later found walking on a highway and the other located at a store. Documentation revealed that staff assigned to 1:1 supervision were not present at critical times, and the facility lacked policies or clear expectations for supervision or 1:1 monitoring prior to these incidents. Another resident with a history of aggressive and impulsive behaviors, as well as a risk for elopement, was not consistently provided with the required 1:1 supervision or engagement in structured activities as outlined in the care plan. Documentation of 1:1 activities was sporadic, and the resident was able to leave the facility, resulting in self-injury and injury to others. Staff reports and progress notes indicated that the resident's behavioral interventions were not reliably implemented, and there were multiple incidents of aggression and attempts to exit the building, some resulting in physical altercations and injuries. Additionally, a resident with communication difficulties and aphasia did not receive the care plan intervention of a communication board, nor was there evidence of referral to speech therapy as required. Despite repeated requests from the resident and his roommate, and documentation in the care plan that a communication board should be provided and evaluated for use, the intervention was not implemented. The care plan also called for a referral to speech therapy, but no such referral or therapy order was found in the resident's records.
Failure to Provide Adequate 1:1 Supervision Due to Lack of Policy and Training
Penalty
Summary
The facility failed to provide adequate supervision to prevent incidents for a resident requiring 1:1 monitoring. During multiple observations, a staff member assigned to 1:1 monitoring was unable to maintain direct visual contact with the resident due to the resident's door being closed or only slightly open with the privacy curtain pulled. Interviews with facility staff revealed that there was no formal policy in place for 1:1 observation, and staff assigned to this duty had not received formal training on the procedures. A review of staff in-service training showed that education on 1:1 monitoring had been conducted, stating that the resident should be within eyesight and arm's reach at all times, but this was not consistently implemented. There was no facility policy to guide staff on 1:1 observation practices.
Non-Compliance with Smoking Policies
Penalty
Summary
The facility failed to ensure adherence to its smoking policies, resulting in safety concerns for six residents. During a tour, Resident #42 was observed with a vape around her neck, and she was unsure if she was allowed to keep it. Her records showed inconsistencies regarding her smoking status, with some documents indicating she was a smoker and others not. Resident #37 was found with a vape on her bed, and although she believed staff should keep it, no one had confiscated it. Her care plan acknowledged her as a smoker, but there was no admission data available for review. Resident #65 was seen moving through the facility with a cigarette, indicating a lack of enforcement of the smoking policy. His records confirmed he was a smoker, with a care plan in place. Resident #36 was caught using a vape in his room and had a history of being evaluated as both a safe and unsafe smoker. His records showed inconsistencies in his smoking status. Resident #6, who required supervision and a smoking apron, was observed with cigarettes in his pocket and smoking under supervision, but his care plan did not mention the need for an apron. Resident #30 was also seen with cigarettes, and although considered a safe smoker, he was noted to be non-compliant with the smoking policy at times. Interviews with staff revealed confusion about the facility's smoking policy. Staff A and B had differing understandings of whether residents could keep smoking materials in their rooms. The DON stated that residents could keep cigarettes but not ignition sources, yet the policy indicated no smoking supplies should be kept in rooms. The facility's policy, last revised in 2020, required that all smoking materials be stored by nursing staff, and electronic smoking materials were only allowed in designated areas.
Failure to Provide Restorative Nursing Care
Penalty
Summary
The facility failed to ensure that two residents received the recommended restorative nursing care. Resident #31, who has a contracted left wrist and hemiplegia, was observed multiple times without his prescribed splint, which was supposed to be worn for up to 1.5 hours to prevent complications related to immobility. Despite having a care plan that included the application of a splint and range of motion exercises, documentation was inconsistent and lacked specific details about the exercises performed or the duration the splint was worn. Interviews with staff revealed that restorative services were not consistently provided, partly due to staffing shortages and the pulling of restorative staff to assist with other duties. Resident #55 was also affected by the facility's failure to provide restorative services as ordered. Although the resident was supposed to receive restorative therapy three times a week, records showed that services were only provided six times in the last 30 days. The Director of Nursing acknowledged that the restorative notes had not been completed since she took over the program, and staff confirmed that the resident was not receiving the prescribed frequency of therapy. The Director of Rehabilitation noted that the lack of consistent restorative services undermined the efforts of the therapy team. The facility's policy required detailed documentation of restorative interventions, but this was not adhered to, as evidenced by the lack of specific and measurable records. The Director of Nursing admitted that the documentation needed improvement and that a performance improvement plan was initiated. However, the deficiency persisted due to inadequate staffing and the absence of a dedicated restorative nurse, which led to the neglect of the residents' restorative care needs.
Sanitation Deficiencies in Facility's Dining, Laundry, and Resident Areas
Penalty
Summary
The facility failed to maintain a sanitary environment in several areas, including the dining rooms, laundry area, and a resident's room. During a tour of the dining and kitchen area, the floor was observed to have several spills, dry food, crumbs, and red stains. Staff interviews revealed that the floors were not consistently cleaned after each meal, contrary to the facility's expectations. In a resident's room, the floor around the beds was dirty with wet and discolored areas, and debris was present. A resident confirmed that the floor remained dirty, even for those who could not leave their beds. Further inspection of the facility revealed additional sanitation issues. In the Soiled Utility Room, a specimen was found double-bagged but unlabeled, and linens were not properly bagged. The laundry area had a significant buildup of lint and debris, with filters on washing machines not cleaned as instructed. The dryer area had a torn ceiling with lint buildup, and two out of three dryers were non-functional. The only working dryer had a buildup of red/brown matter inside the drum, and the lint area contained foreign objects. The Account Manager and Administrator were unaware of the last cleaning of these areas, indicating a lack of maintenance oversight.
Improper Administration of Tube Feeding and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that physician orders for tube feeding were followed and that tube feeding was administered properly for a resident. During multiple observations, the resident was found with an unlabeled tube feeding bag, and the tube feeding machine was set incorrectly. The machine was set to instill tube feeding at 60 mL/hr and water flush at 100 mL every 2 hours, contrary to the physician's orders which specified a water flush of 100 mL every 6 hours. This discrepancy was confirmed by two LPNs who reviewed the resident's medical record and acknowledged the incorrect settings on the tube feeding pump. The resident involved had a medical history of congestive heart failure, muscle weakness, dysphagia, and spinal stenosis with bone infection. The resident was cognitively intact and had a care plan in place for tube feeding due to swallowing problems. The facility's Director of Nursing acknowledged that the resident was the first to have continuous tube feeding in a long time and confirmed that the staff were expected to label the tube feeding bag properly and follow the physician's orders regarding the feeding and water flush rates. The facility's policy on enteral feeding required nurses to administer enteral feeding as ordered by the physician.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in an accessible location with the required details on one of the three survey dates. On 12/16/24, during an observation at approximately 12:00 PM, it was noted that no staffing information was posted as required anywhere in the facility. Although the dry erase boards in both the east and west wings displayed a date and the total number of actual hours worked by staff, the information was not presented in a clear and readable format accessible to residents and visitors. At approximately 1:00 PM on the same day, a Certified Nursing Assistant (CNA) acknowledged that the staffing information was incomplete on the dry erase board. Photographic evidence was obtained to support this observation. On 12/18/24, during an interview with the Staffing Coordinator Scheduler, she initially claimed that staffing was posted daily but later admitted that the staffing information was not posted on 12/16/24 as required.
Latest citations in Florida
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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