Aviata At Coral Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in West Palm Beach, Florida.
- Location
- 2939 S Haverhill Rd, West Palm Beach, Florida 33415
- CMS Provider Number
- 105795
- Inspections on file
- 29
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Aviata At Coral Bay during CMS and state inspections, most recent first.
A resident with a history of diabetes, chronic kidney disease, and recent amputations did not receive timely follow-up care for a left foot surgical wound. Documentation of wound assessments and treatments was missing or incomplete, and scheduled wound care was not consistently performed. The surgeon was not notified of the wound's worsening condition, and the resident missed a scheduled surgical follow-up. The wound deteriorated, showing signs of infection and bone exposure, before the resident was eventually sent to the hospital.
Surveyors identified infection control deficiencies, including improper cleaning of a glucometer by an RN who did not follow facility policy, lack of a gown for laundry sorting, a broom and pan left on the laundry room floor, and a dryer drum with hard residue. The Director of Housekeeping acknowledged the issues with the laundry equipment.
Multiple deficiencies in maintenance and housekeeping were observed, including non-functioning lights, damaged and dirty surfaces, unfinished repairs, and unaddressed debris in common areas and resident rooms. The Maintenance Director acknowledged these issues during an environmental tour.
A resident with significant cognitive impairment and respiratory diagnoses was repeatedly observed with her call bell on the floor and out of reach. Despite being able to communicate and operate her bed controls, the call device was not accessible to her during multiple surveyor observations.
A resident with no cognitive impairment reported missing her clothing for nearly a month, and staff were unaware of the issue until prompted by surveyors. Investigation revealed conflicting documentation about the resident's belongings and a missing inventory sheet. The facility failed to initiate a grievance in a timely manner, and the grievance process remained incomplete several days after the concern was raised.
A resident with documented mental health diagnoses, including bipolar disorder and anxiety, was not provided a PASRR Level 2 evaluation despite Level 1 screening results indicating it was needed. Medical records and psychotherapy notes confirmed the diagnoses, but the required follow-up assessment was not completed.
A resident with intact cognition and a history of cerebral infarction and atrial fibrillation did not receive physician-ordered wound care following a dermatology procedure because the orders were not transcribed to the MAR or TAR. This omission was discovered after the resident developed a wound infection, which was identified during a follow-up visit with the dermatologist. The DON confirmed the treatment was not performed due to the orders not being properly processed in the electronic health record.
Two residents requiring oxygen therapy did not receive care in accordance with physician orders, as their oxygen concentrators were set either above or below the prescribed flow rates. LPN staff confirmed the discrepancies during interviews, and photographic evidence supported the findings.
A resident was provided with side rails at the request of a family member following a recent fall, but facility staff did not complete the required evaluation or obtain informed consent prior to installation. The DON believed a therapy evaluation was sufficient and only completed the side rail assessment after the rails were already in place, contrary to facility policy.
Two residents with specific dietary needs and preferences did not receive appropriate meals, including one vegetarian who was not identified as such in facility records and another who was repeatedly served burnt or inedible food and not provided a pork-free alternative despite religious restrictions. Both residents reported their concerns to dietary staff, but the issues were not resolved, resulting in inadequate meal service.
Two residents with significant medical needs did not consistently receive restorative therapy as recommended, due to insufficient staffing and lack of documentation. Although therapy recommendations were made, the facility did not have an active restorative program, and the sole restorative aide was unable to document or provide services to all assigned residents. This resulted in a failure to provide and record required restorative therapy services.
Two residents receiving narcotic medications experienced discrepancies between paper and electronic medication records, with errors in dates and times of administration. Nursing staff admitted to documentation mistakes, and the DON confirmed the inconsistencies between the records.
A resident with severe cognitive impairment and multiple chronic conditions did not receive a pneumococcal vaccine despite having a signed consent on file. Review of records and staff interviews confirmed there was no documentation of vaccine administration after consent was obtained.
A resident with a history of wandering and multiple medical conditions eloped from the facility after lapses in 1:1 supervision occurred due to staffing shortages and inconsistent monitoring. Despite interventions such as frequent checks and electronic monitoring, the resident exited through an alarmed door and was found outside by staff and law enforcement nearly an hour later. Staff interviews confirmed that supervision was not maintained as required by the care plan, and the facility's policy did not specifically address 1:1 supervision.
The facility failed to consistently document the administration of controlled medications for three residents, leading to discrepancies between the Medication Monitoring/Control Record and the MAR. This resulted in undocumented doses of Dilaudid, Tramadol, and Oxycodone, with some medications administered more frequently than prescribed. The Director of Nursing confirmed the documentation failures.
The facility failed to conduct thorough investigations into allegations of abuse and neglect involving two residents. One resident reported verbal abuse and neglect by a CNA, while another incident involved unanswered call lights. Investigations lacked comprehensive interviews and statements from key staff and witnesses. Additionally, a grievance regarding a privacy violation by the administrator was inadequately investigated.
A resident with multiple pain-related diagnoses did not receive timely refills of prescribed pain medications, resulting in extended periods without pain relief. The facility's records showed lapses in administering Xtampza ER and Dilaudid, with the resident missing several doses over consecutive days. Interviews revealed the resident experienced significant pain and frustration due to the lack of urgency in reordering medications.
A facility failed to prevent a resident, assessed as at risk for elopement, from exiting the premises twice in one day. Despite initial interventions, the resident left the facility early in the morning and was returned by staff, but no additional measures were taken. Later, the resident eloped again and was returned by law enforcement. The RNC noted that the administration should have been informed and 1:1 observation should have been implemented.
Failure to Provide Timely Follow-Up and Communication for Surgical Wound Care
Penalty
Summary
The facility failed to provide timely follow-up care for a resident with a left foot surgical wound. The resident, who had a history of diabetes, chronic kidney disease, and recent amputations, was admitted with orders for IV antibiotics and follow-up with a surgeon and infectious disease. There was no care plan for the surgical wound, and documentation of the wound's condition or treatment was missing from admission until several days later. Orders for wound care and wound vac application were not consistently documented as completed, and there was no explanation for missed treatments. Additionally, there was no evidence that the resident attended a scheduled surgeon appointment or that the surgeon was notified of changes in the wound's condition, despite worsening symptoms and positive wound cultures for infection. Progress notes indicated that the resident's wound deteriorated, showing signs of infection, bone exposure, and purulent discharge, yet there was still no documentation of timely notification to the surgeon. The resident was eventually transferred to the hospital for evaluation, and only after further decline was an appointment with the surgeon arranged. Interviews with facility leadership confirmed the lack of documentation and follow-up, as well as the failure to notify the surgeon of significant changes in the resident's wound status.
Infection Control Deficiencies in Laundry and Glucometer Cleaning
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's infection prevention and control practices. In the medication administration process, a registered nurse failed to properly clean and disinfect a glucometer after use. Instead of wiping the entire surface of the glucometer horizontally and vertically as required by facility policy, the nurse wrapped the device in a disinfectant wipe and allowed it to sit for three minutes, stating she would wipe it down afterward. This method did not align with the facility's written procedures for cleaning and disinfecting the device after contact with blood or body fluids. In the laundry room, several sanitation issues were identified. A broom and pan were found resting on the floor in the dirty area, and there was no gown available for staff to use while sorting laundry in this area. Additionally, one of the dryers had dry, hard residue stuck on the drum, which was visually confirmed and documented with photographic evidence. The Director of Housekeeping acknowledged the condition of the dryer and noted its age and the desire to replace the drum.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple deficiencies in maintenance and housekeeping services. In the lobby/reception area, 14 out of 16 lights were not functioning, and another light was flickering. The main dining room on the second floor had windows with unidentified residue and peeling tint, an accumulation of dust in the air vent above the handwashing sink, and an unfinished ceiling that required sanding and painting. The elevator near the main dining room had peeling paint on the frame and door, and the linoleum flooring inside was damaged and peeling. In the courtyard, a canopy was torn and in disrepair, and a fallen screen from an attached unit remained on the ground throughout the survey. On the second floor, several resident rooms exhibited various issues, including scuff marks, missing paint exposing rust, torn air conditioning filters, residue on furniture, brown spots and debris in air conditioning units, stained privacy curtains, dirty filters, dried fluid on dressers, damaged over-bed tables, constantly running sinks, holes in restroom doors, unsecured baseboards, rub marks on walls, separating floor tiles, exposed adhesive, scratched doors, and holes in walls and baseboards. These findings were acknowledged by the Maintenance Director during an environmental tour, who also confirmed the tacky surface of the windows in the main dining room.
Call Bell Not Maintained Within Reach for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain the call device within reach for one resident with significant cognitive impairment. Record review showed the resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Emphysema, and had a BIMS score of 00, indicating significant cognitive impairment. During multiple observations over several days, the call bell was found on the floor beneath the resident's bed and not within her reach. In an interview, the resident demonstrated understanding of the call bell's purpose and reported having used it before. She was also able to communicate her preferences and operate the bed controls independently. However, the repeated observations confirmed that the call device was not accessible to her during the survey period.
Failure to Timely File Grievance for Missing Resident Belongings
Penalty
Summary
A resident who was admitted to the facility with no cognitive impairment, as indicated by a BIMS score of 14, reported not receiving her clean clothes for almost a month. The resident stated during interviews that she had not had her laundry returned in 3 to 4 weeks and was wearing clothing that did not belong to her. The issue was not known to the Regional Social Worker until it was brought up during the survey, at which point the Social Worker began to investigate the missing clothing. Further investigation revealed that the previous social worker at the resident's prior facility confirmed the resident left with all her belongings, contradicting the documentation at the current facility that stated she arrived with none. There was no inventory sheet found in the resident's chart to verify her belongings upon admission. The grievance process for the missing clothing was not initiated until after the issue was raised by surveyors, and the grievance remained incomplete several days later.
Failure to Complete Required PASRR Level 2 Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to provide a PASRR (Preadmission Screening and Resident Review) Level 2 evaluation for a resident whose Level 1 screening indicated the need for further assessment. The resident, who had a history of anxiety disorder and bipolar disorder, was readmitted to the facility and had a BIMS score indicating no cognitive impairment. Medical records and psychotherapy notes documented diagnoses of bipolar disorder and anxiety. However, the PASRR Level 1 screenings, including the most recent one, did not consistently reflect all current mental health diagnoses, but still indicated the need for a Level 2 evaluation. Despite this, the required PASRR Level 2 was not completed as indicated by the screening results and confirmed by the Regional Social Worker during the survey.
Failure to Provide Physician-Ordered Wound Care After Dermatology Procedure
Penalty
Summary
A deficiency occurred when the facility failed to provide physician-ordered wound care following a dermatology procedure for a resident with a history of cerebral infarction and atrial fibrillation. The resident, who was cognitively intact, underwent a micrographic surgery to remove skin cancer and returned to the facility with specific wound care instructions, including washing the biopsy area, applying Vaseline or mupirocin, covering with Telfa and paper tape, and monitoring for signs of infection. These orders were not transcribed onto the Medication Administration Record (MAR) or Treatment Administration Record (TAR), resulting in the wound care not being performed as prescribed. The issue was identified when the resident reported to surveyors that, during a follow-up visit, the dermatologist noted an infection in the wound due to lack of wound care. The Director of Nursing confirmed that while the orders were entered into the electronic health record, they were not directed to the MAR or TAR, leading to the omission of the required treatment. Subsequent documentation showed that the resident required additional medical intervention, including a new wound care order and an oral antibiotic, after the infection was identified.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards of practice for two residents who required oxygen therapy. For one resident with diagnoses including heart failure, morbid obesity, and COPD, the care plan required oxygen therapy at 2 liters per minute as ordered by the physician. However, multiple observations revealed that the oxygen concentrator was set above the prescribed rate, ranging from 3 to 3.5 liters per minute, contrary to the physician's order. Staff confirmed the oxygen was set higher than ordered during interviews. For another resident with morbid obesity, shortness of breath, and generalized muscle weakness, the physician's order specified oxygen at 2 liters per minute via nasal cannula as needed to maintain saturations above 92%. Observations showed the oxygen concentrator was set below the ordered rate, between 1 and 1.5 liters per minute, and staff confirmed the setting was less than 2 liters per minute. These findings were supported by photographic evidence and staff interviews, demonstrating a failure to follow physician orders for oxygen administration for both residents.
Failure to Complete Required Assessment and Consent Prior to Bed Rail Installation
Penalty
Summary
The facility failed to follow its established procedure for the installation of side rails for a resident. According to facility policy, prior to installing side rails, staff are required to complete a side rail evaluation to assess the resident for risk of entrapment, review the risks and benefits with the resident or their representative, obtain informed consent, secure a physician order, and update the care plan and kardex. Observation revealed that a resident had bilateral one quarter side rails installed on their bed, and both the resident and their sister confirmed that the rails were installed that afternoon at the sister's request due to recent falls. Record review showed there was no documentation of a completed evaluation or signed consent prior to the installation of the side rails. During interviews, the DON stated that the side rails were installed following a verbal request from the resident's mother and believed that a therapy admission evaluation sufficed as the required assessment. However, the DON later provided a side rail evaluation that was completed after the installation, indicating that the required assessment and consent process were not followed prior to the intervention.
Failure to Provide Well-Balanced Diets and Honor Food Preferences
Penalty
Summary
The facility failed to provide a well-balanced diet that met the nutritional needs and honored the food preferences of two residents. One resident, who had a history of acute and chronic respiratory failure, COPD, and pneumonia, was not identified as a vegetarian in his food preference or nutrition assessment forms. As a result, he was repeatedly served meals that did not align with his dietary needs, including being given potato chips as a main dish and lacking adequate protein variety. The registered dietitian was unaware of the resident's vegetarian status until informed by the surveyor, and the kitchen manager acknowledged that there was no specific diet for lacto-ovo-vegetarians, despite having discussed preferences with the resident multiple times. Another resident, admitted with intervertebral disc displacement and on a carbohydrate-controlled, no added salt diet, reported that his meals were consistently overcooked, burnt, and of poor quality. He provided photographic evidence of inedible meals, including being served only potato chips as an entrée when the main dish included pork, which he could not eat for religious reasons. The resident stated that he had repeatedly voiced his concerns to the Certified Dietary Manager (CDM), but the issues persisted and were not resolved. The CDM acknowledged the resident's complaints and confirmed that the meal ticket system failed to capture his need for a pork-free alternative entrée. Both residents were cognitively intact and able to clearly communicate their dietary needs and dissatisfaction with the meals provided. Despite their repeated efforts to address these concerns with dietary staff, the facility did not ensure that their nutritional needs and food preferences were consistently met, resulting in inadequate and inappropriate meal service.
Failure to Provide and Document Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services as recommended for two residents with significant medical needs. One resident with paraplegia, who was cognitively intact, reported receiving restorative therapy infrequently due to staff shortages. There were no active therapy orders in the resident's record, and the Director of Physical Therapy was initially unaware of the resident's therapy status. Documentation provided indicated the resident was part of the Restorative Nursing Program (RNP), but there was no evidence of therapy orders or records of services provided. The Director of Nursing confirmed that the facility did not have a functioning RNP due to insufficient staffing, and acknowledged that documentation of restorative services was lacking, despite the expectation that such documentation should be maintained in the electronic medical record. A second resident, also cognitively intact and with a history of cerebral infarction and atrial fibrillation, reported inconsistent receipt of restorative therapy after being discharged from physical therapy due to insurance issues. The Director of Physical Therapy had referred this resident to restorative therapy, but the facility did not have an active restorative program in place. The only restorative aide, Staff C, was responsible for 29 residents but had not documented any restorative services provided, citing lack of access to a documentation kiosk and not keeping written records. The Director of Nursing confirmed that the facility previously had a restorative program but currently lacked the necessary staff to operate it effectively. Interviews with staff revealed that restorative therapy recommendations were being made and residents were identified for the program, but there was no systematic tracking or documentation of services rendered. The sole restorative aide selected therapy days based on her work schedule and attempted to see all assigned residents, but admitted it was difficult to provide adequate time to each due to workload. The lack of documentation and insufficient staffing led to the failure to provide and record restorative therapy as required for the residents.
Inaccurate Documentation of Narcotic Administration
Penalty
Summary
The facility failed to accurately document the administration of narcotic medications for two residents. For one resident with encephalopathy and moderate cognitive impairment, there was an active order for Lorazepam 0.5mg as needed. Documentation discrepancies were found between the paper Medical Monitoring/Control Record (MMCR) and the electronic Medication Administration Record (MAR), including a dose recorded on the MMCR but not on the MAR, and mismatched administration times between the two records. The nurse responsible admitted to making errors in documenting the date and time of administration. For another resident with hemiplegia and a history of cerebral infarction, who was cognitively intact, there was an active order for Lacosamide 100mg twice daily for seizures. The MMCR showed three administrations of Lacosamide on one day and one on the following day, while the MAR reflected only two administrations on the first day and one on the second. The nurse involved acknowledged a mistake in documenting the date on the paper narcotic log, stating she did not work on the day in question. The DON confirmed the discrepancies and agreed that accurate documentation is essential, especially for narcotics.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to provide a pneumococcal vaccination to a resident who had consented to receive it. The resident, who had severe cognitive impairment and multiple diagnoses including dementia, congestive heart failure, and type 2 diabetes mellitus, was admitted to the facility and had a signed consent for the pneumonia vaccine on file. Upon review of records and interviews with the Infection Preventionist and DON, there was no documentation in the electronic health record that the vaccine had been administered. The DON and Infection Preventionist were unable to locate any evidence that the vaccine was given following the initial consent.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident identified as being at risk for wandering and elopement. The resident had a history of exit-seeking behaviors, multiple prior elopement attempts, and was assessed as an elopement risk due to cognitive impairment, poor decision-making skills, and independent ambulation. The resident's care plan included interventions such as frequent monitoring, 1:1 supervision, room relocation away from exits, and the use of an electronic monitoring device. Despite these interventions, the resident was able to exit the facility through an alarmed door and was found by staff and law enforcement outside the facility after being missing for nearly an hour. On the night of the incident, staffing was compromised due to a CNA not showing up for the shift, resulting in only three CNAs present instead of the scheduled four. The remaining CNAs implemented an hourly rotation for 1:1 supervision of the resident. However, lapses in supervision occurred during shift changes and when CNAs attended to other residents, leaving the resident unsupervised. Staff interviews confirmed that the CNA assigned to supervise the resident was not present at the time of elopement, and the LPN on duty was unaware of the resident's whereabouts until the door alarm sounded. The resident, who had multiple medical diagnoses including hypertension, diabetes, hip fracture, seizure disorder, and dependence on dialysis, was found outside the facility and returned safely. Documentation and interviews revealed that the facility's elopement policy did not specifically address 1:1 supervision, and staff decisions regarding supervision rotations were made without notifying facility leadership. The deficiency was directly related to inadequate supervision and failure to maintain consistent monitoring as outlined in the resident's care plan.
Medication Documentation Failures
Penalty
Summary
The facility failed to ensure consistent implementation of a medication record system for controlled medications, leading to discrepancies in documentation for three residents. For Resident #1, the nurses did not consistently document the administration of Dilaudid, resulting in 12 undocumented doses in August and 6 in September. This inconsistency allowed for the medication to be administered more frequently than prescribed, with instances of doses given within 3.5 to 6 hours instead of the prescribed 8-hour interval. Resident #2's records showed similar issues with Tramadol administration, where 7 doses in August and 5 in September were not documented on the Medication Administration Record (MAR). The discrepancies between the Medication Monitoring/Control Record and the MAR were confirmed by the Director of Nursing, who acknowledged the failure of nurses to document medication administration consistently. For Resident #3, the administration of Oxycodone was not consistently documented, with 12 doses missing from the MAR in September. The Director of Nursing was informed of the ongoing pattern of documentation failures, highlighting the discrepancies between the Control Record and the MAR. These failures indicate a lack of adherence to proper medication administration and documentation protocols.
Incomplete Investigations into Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence of thorough investigations into allegations of abuse and neglect for two residents. In the first case, a resident alleged neglect and verbal abuse by a CNA, who reportedly yelled at the resident and left him in a soiled brief for two hours. The investigation lacked comprehensive interviews and statements, including those from the nurse on duty and the resident's roommate, who witnessed the incident. The facility did not file a report regarding the verbal altercation, and there was no follow-up on the roommate's statement. In the second incident involving the same resident, the resident alleged neglect when his call light went unanswered for two hours. The investigation was incomplete, with missing statements from key staff members, including the nurse who was on duty. The facility suspended the CNA involved but failed to document a complete investigation or confirm the resident's care during the alleged neglect period. Additionally, a separate grievance was filed by another resident, who alleged a violation of privacy when the facility's administrator discussed his financial matters in a therapy room in the presence of other residents and therapists. The investigation into this grievance was also incomplete, lacking statements from all individuals present during the incident and failing to follow up with the resident to identify other witnesses.
Failure to Provide Timely Pain Medication Refills
Penalty
Summary
The facility failed to provide effective pain management for a resident by not obtaining pain medication refills in a timely manner. The resident, who had multiple diagnoses including intervertebral disc displacement, peripheral vascular disease, and diabetic neuropathy, was prescribed Dilaudid and Xtampza ER for pain management. However, there were lapses in medication administration, with the resident missing doses of Xtampza ER for two days and Dilaudid for another two days, resulting in extended periods without pain relief. The Medication Monitoring/Control Record showed discrepancies in the administration of the prescribed medications. The records indicated that the resident did not receive the routine Xtampza ER doses on two consecutive days and missed six possible doses of Dilaudid over another two-day period. Despite the nurse signing the Medication Administration Record, the Director of Nursing confirmed that Xtampza ER was not available in the facility's emergency medication kit, and there was no evidence of Dilaudid being accessed from the emergency kit during the shortage. Interviews with the resident and the Director of Nursing revealed that the resident experienced significant pain during these periods without medication, reporting pain levels as high as 9 on a scale of 1-10. The resident expressed frustration over the lack of urgency in reordering medications and described being in constant pain, resorting to using ice packs for relief. The facility had previously identified a concern regarding the resident's pain management and had revised the care plan to address the risk of pain related to chronic illness, but the interventions were not effectively implemented.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident at risk for elopement. The resident, who was cognitively intact and required partial/moderate assistance with activities of daily living, was assessed and care planned for elopement risk. Despite having interventions in place, the resident exited the facility at approximately 5:00 AM and was returned by staff at 5:15 AM. However, no additional interventions were implemented following this initial elopement. Later that day, at 11:00 AM, the resident exited the facility again and was returned by law enforcement at 12:30 PM. The Regional Nurse Consultant indicated that the Nursing Home Administrator and Director of Nursing should have been notified, and the resident should have been placed on 1:1 observation to prevent the second elopement.
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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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