Aviata At Rosewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Orlando, Florida.
- Location
- 3920 Rosewood Way, Orlando, Florida 32808
- CMS Provider Number
- 105480
- Inspections on file
- 24
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Aviata At Rosewood during CMS and state inspections, most recent first.
A facility failed to obtain timely physician orders for a resident's surgical site care upon readmission. The resident, with a history of fractures, had specific hospital discharge instructions for wound care that were not transcribed into the EMR until two days later. Observations revealed the surgical site was open to air without a dressing, and the LPN acknowledged the oversight. The DON confirmed the expectation for immediate transcription of hospital orders upon readmission.
A facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including multiple sclerosis and hypertension. After a hospitalization, the resident returned to the facility, but the care plan was not updated to reflect her needs. An error by the previous MDS coordinator led to the cancellation of the existing care plan, leaving the resident without an accurate plan for over a month.
A facility failed to document the care of a surgical pin site for a resident with multiple medical conditions. Physician orders required daily cleaning and dressing of the site, but the Treatment Administration Record (TAR) showed blank spaces on several dates, indicating incomplete documentation. The resident refused treatment on two occasions, but there was no record of physician notification. The facility lacked a specific policy for TAR documentation, contributing to the deficiency.
A resident with multiple health conditions was left with a medication cup on her tray table by an RN who documented the medications as administered. The RN was called away for an emergency and did not return to ensure the resident took her medications. The facility's policy requires nurses to ensure medications are taken and not left at the bedside.
A facility failed to adhere to a podiatry treatment plan and schedule a timely follow-up for a resident with diabetes and vascular issues. The resident's treatment was prolonged beyond the recommended period, and a necessary podiatry referral was not scheduled, leading to potential infection concerns.
A resident with a history of stroke and partial paralysis was not provided with a toileting program or necessary assistance to maintain continence, despite being able to sense the urge to void. The facility lacked appropriate equipment to assist the resident to the toilet, and staff were unaware of the resident's continence needs, leading to a deficiency in care.
A facility failed to provide a resident and his responsible party access to medical records after a written request. The resident's brother was authorized to receive the records, but due to a procedural error, the request was not fulfilled. The medical records staff was new, and the receptionist sent the consent forms to the wrong email address, preventing the legal department from receiving them.
A resident with a history of fractures and unsteadiness experienced multiple falls from their wheelchair, but the facility failed to update the care plan with new interventions. Despite identical incidents occurring on two occasions, no changes were made to the care plan, task list, or nurse aide Kardex, as confirmed by the Administrator and Regional Nurse Consultant.
A resident with cognitive impairments and a history of fractures experienced multiple falls from their wheelchair. Despite these incidents, the facility did not update the care plan with new interventions to prevent further falls, as required by their Fall Management policy.
The facility failed to ensure dishware was properly sanitized according to the manufacturer's instructions. Staff continued to use potentially unsanitized plates for meal service, posing a health risk to residents. The issue was identified and addressed only after meal preparation had begun.
The facility failed to obtain physician orders and provide appropriate IV care for two residents, resulting in a lack of adherence to professional standards of practice. The DON and nursing staff acknowledged the deficiencies and the need for proper documentation and care for IV lines.
The facility failed to obtain physician orders and administer oxygen therapy as prescribed for three residents. One resident was observed without her oxygen nasal cannula, another received oxygen at a lower rate than ordered, and a third resident's oxygen was set incorrectly. Nursing staff acknowledged the discrepancies and the importance of verifying oxygen orders.
The facility failed to monitor a resident on Eliquis for potential side effects such as bleeding. Despite the resident's high-risk status, there were no orders or documentation for monitoring, and the facility's policy on anticoagulant therapy was not followed.
A resident missed fourteen doses of prescribed Cephalexin due to a lapse in the facility's medication administration process. Despite the resident's repeated notifications to staff, the medication was not reordered promptly, and the prescribing physician was not informed in a timely manner. The facility's shift change contributed to the error.
A resident with quadriplegia was found with multiple medications at his bedside without proper evaluation or physician's order. The facility staff acknowledged the lack of proper orders and evaluations, and the facility's policy on self-administration of medication at bedside was not followed, leading to the deficiency.
The facility failed to request PASARR level I and level II evaluations after a resident received a new diagnosis of psychotic disorder with delusions. Despite the responsibility of the SSD and DON to ensure timely PASARR evaluations, the required screenings were not completed as per the facility's policy.
The facility failed to develop and implement person-centered care plans for two residents, one with severe cognitive impairment and another on anticoagulant medication. Observations showed that the residents did not receive individualized activities or monitoring for bleeding risks, despite their medical and psychosocial needs. The facility did not adhere to its policies for establishing care plans within the required timeframe.
The facility failed to provide a resident-centered activities program for a resident with severe cognitive impairment and multiple medical conditions. Despite the resident's preferences for music, fresh air, and religious services, she was observed lying in bed without any engagement or entertainment. The activities staff lacked resources and did not know the resident's specific interests, and there was no comprehensive care plan in place.
A resident with dysphagia following a stroke was given the incorrect enteral feed formula, Glucerna 1.5 calorie instead of the prescribed Glucerna 1.2 calorie, on multiple occasions. This discrepancy was confirmed by both the LPN and the Unit Manager, who acknowledged the need to verify the correct formula at the start of each shift. The error was further corroborated by the Registered Dietician and the DON, emphasizing the importance of following physician orders to meet the resident's nutritional needs.
A resident who experienced significant trauma and life changes did not receive trauma-informed care. Despite being cognitively intact and dependent on staff for daily activities, her care plan lacked a post-trauma care plan. The psychiatric APRN focused on medication management without counseling, and the Social Services Director did not ensure a trauma-informed care plan. The Interdisciplinary Team admitted to communication gaps, leading to the deficiency.
A facility failed to maintain a medication error rate below 5% when an LPN administered incorrect dosages of Folic Acid and Guaifenesin to a resident with multiple diagnoses. The errors were confirmed by the LPN and DON, highlighting a deviation from the facility's medication administration policies.
A resident missed 14 doses of Keflex due to a failure in transferring medication orders accurately to the EMR during a system update and shift change. The error was not promptly reported or addressed, and the resident's grievance was not initiated in a timely manner.
The facility failed to ensure accurate documentation of IV dressing changes for a resident with multiple diagnoses. Nurses signed off on the task without performing the dressing change, and the order was not updated when the resident's peripheral line was replaced with a midline catheter. The DON and other staff confirmed the inaccuracies, and the facility did not provide a policy for medical record accuracy.
A facility failed to implement a physician's order for contact isolation precautions for a resident with ESBL in the urine. Despite the order, the correct signage and PPE were not in place, and Enhanced Barrier Precautions were incorrectly used instead.
Failure to Obtain Timely Physician Orders for Surgical Site Care
Penalty
Summary
The facility failed to ensure that admission physician orders for the immediate care of surgical sites were obtained for a resident who was readmitted. The resident, a female with a history of fractures in the right fibula and tibia, was readmitted with surgical wounds requiring specific care. Hospital discharge instructions specified the use of Aquacel dressings and daily dressing changes, but these orders were not transcribed into the facility's electronic medical record (EMR) until two days after readmission. During the survey, it was observed that the resident's surgical site was open to air without a dressing, contrary to the hospital's discharge instructions. The LPN responsible for the resident acknowledged the lack of completed dressing changes and the absence of physician orders for the surgical site care upon readmission. The Director of Nursing confirmed that the admission nurse should have reviewed and transcribed the hospital's discharge orders into the EMR immediately upon the resident's readmission.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive individualized care plan for a resident who was admitted with multiple diagnoses, including multiple sclerosis, major depressive disorder, anxiety, history of falls, and hypertension. After being re-hospitalized for chest pain, the resident returned to the facility, but the care plan was not updated to reflect her current needs. The only focus in the care plan initiated on 10/24/24 was on nutritional problems, despite the resident's complex medical history and recent hospitalization. The deficiency occurred because the previous MDS coordinator incorrectly noted the resident as 'discharge not anticipated,' which canceled the existing care plan. This error left the resident without an accurate care plan from 10/21/24 until 11/25/24. The facility's Plan of Care policy requires an individualized, person-centered plan that includes the resident's strengths and services to achieve their highest practicable well-being, but this was not adhered to in this case.
Failure to Document Surgical Pin Site Care
Penalty
Summary
The facility failed to follow physician orders for the care of a surgical pin site for a resident with multiple medical conditions, including a dislocated tibia, diabetes, and anxiety disorder. The resident was admitted with intact cognition and required substantial assistance for daily activities. Physician orders were in place to clean and dress the surgical pin site daily, but the Treatment Administration Record (TAR) showed blank spaces on several dates, indicating the treatment was not documented as completed. Additionally, there was no documentation to show that the physician was notified when the resident refused treatment on two occasions. The Assistant Director of Nursing/Unit Manager and the Director of Nursing acknowledged the documentation gaps and confirmed that the TAR should not have blank spaces. The facility lacked a specific policy addressing documentation on the TAR, although their medication administration policy required topical treatments to be recorded. The absence of documentation and failure to notify the physician of treatment refusals contributed to the deficiency identified by the surveyors.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered per professional standards for a resident. An 81-year-old female resident with diagnoses including end-stage renal disease, diabetes type II, hypertension, chronic pain, and major depressive disorder was observed with a medication cup left on her tray table. The resident stated that the nurse had left the medications there, and she intended to take them momentarily. The nurse, RN A, confirmed that she had left the medications on the resident's tray table and documented them as administered at 9:26 AM. However, RN A was called away for an emergency and did not return to ensure the resident took her medications. The Director of Nursing and the Regional Nurse both stated that medications should not be left at the resident's bedside, and nurses should ensure medications are taken before leaving. The facility's policy on administering medications, revised in April 2019, indicates that if a resident is unavailable to receive medication, the MAR may be flagged, and the nurse should return to administer the medication after completing the medication pass. This incident highlights a failure to adhere to the facility's medication administration policy, as the nurse did not ensure the resident took her medications before leaving the room.
Failure to Follow Podiatry Treatment Plan and Schedule Follow-Up
Penalty
Summary
The facility failed to follow a podiatry treatment plan and ensure a timely follow-up appointment with a podiatrist for a resident with type 2 diabetes mellitus, peripheral vascular disease, and complications following a stroke. The resident had a podiatry visit where a partial nail avulsion was performed, and wound care orders were given for 10 days. However, the facility continued the treatment for 32 days longer than recommended. The Director of Nursing (DON) could not explain why the treatment was prolonged and confirmed that the order should have been discontinued. Additionally, the facility did not schedule a follow-up podiatry appointment despite a referral being made by the attending physician due to concerns about redness on the resident's left great toe. The Social Service Director confirmed that the referral had not been scheduled, and the podiatrist's office stated no service date was set for the facility. An Advanced Practice Registered Nurse (APRN) later examined the resident's toe, noted redness, and suspected remnants of an infection, indicating a need for further medical intervention.
Failure to Provide Continence Care for a Resident
Penalty
Summary
The facility failed to provide appropriate continence care for a resident who was continent of bladder and bowel. The resident, who had a history of stroke, type 2 diabetes mellitus, and partial weakness and paralysis on the left side, was admitted to the facility and was assessed as always incontinent of bowel and bladder. However, no toileting program, such as scheduled toileting or prompted voiding, was attempted upon admission or reentry. The resident expressed that she felt the urge to urinate or have a bowel movement before it happened and would use the toilet if it was offered, but typically went in her adult brief. The MDS Coordinator and the Director of Nursing (DON) were unaware of the resident's ability to sense the need to void before it occurred. The facility lacked mechanical lifts or slings designed to transfer residents to a toilet, which was necessary for the resident who required maximum assistance for toileting. The DON confirmed there was no documentation of a toileting program trial or the offering of a bedpan for the resident since her admission. The failure to implement a toileting program or provide the necessary assistance to maintain the resident's continence led to the deficiency.
Failure to Provide Access to Medical Records
Penalty
Summary
The facility failed to provide a resident and his responsible party access to his personal and medical records following a written request. The resident, who was cognitively intact, had a healthcare power of attorney and authorization for release of protected health information documents on file, designating his brother as the authorized recipient for his medical records. Despite a signed consent form authorizing the release of the medical records to the resident's brother, the facility did not fulfill the request due to a procedural error. The error occurred because the medical records staff, who was new to the position, did not handle the request, and the responsibility was temporarily assigned to the receptionist. The receptionist sent the consent forms to the wrong email address, resulting in the legal department not receiving them. The facility's policy required requests to be granted within 24 hours, and if the legal department did not respond within 72 business hours, a follow-up was necessary. However, due to the email error, the request was not processed, leading to the deficiency.
Failure to Update Fall Care Plan
Penalty
Summary
The facility failed to revise a fall care plan to include new interventions for a resident who experienced multiple falls. The resident, who had a history of multiple fractures and unsteadiness on feet, was admitted and readmitted with significant injuries. Despite documented incidents on two separate occasions where the resident slid from their wheelchair onto the footrests, the care plan was not updated to reflect these falls or to include any new interventions to prevent recurrence. The deficiency was identified during a review of the resident's medical records and incident reports, which showed that the falls on two different dates were identical in nature. The facility's Administrator and Regional Nurse Consultant confirmed that no new interventions were added to the resident's care plan, task list, or nurse aide Kardex following these incidents. This oversight was acknowledged by the Administrator, who noted that adding an intervention could have reduced the likelihood of the same incident occurring again.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to implement appropriate fall interventions for a resident who experienced multiple falls. The resident, who had a history of multiple fractures and cognitive impairments, was dependent on staff for daily activities and used a wheelchair for mobility. Despite falling on several occasions, including slipping from the wheelchair onto the footrests, no new interventions were added to the care plan or task list to prevent further incidents. The facility's incident log and medical records showed that the resident fell on multiple dates, but the care plan was not updated with new interventions after these falls. Interviews with staff confirmed that the falls were similar in nature, yet no additional measures were taken to address the issue. The facility's Fall Management policy required updating care plans and nurse aide Kardex with interventions, which was not done in this case.
Improper Sanitization of Dishware
Penalty
Summary
The facility failed to ensure dishware was rinsed with the proper level of sanitizer according to the manufacturer's instructions. During a kitchen observation, staff were seen running dishware through a low-temperature dish machine that uses a chemical sanitizer. The Dietary Manager attempted to test the sanitizer level, which should be at 100 parts per million (ppm), but the test strips did not activate. Despite this, Dietary Aide G continued to remove and stack plates from the machine, mixing potentially unsanitized dishware with sanitized ones. The Dietary Manager did not intervene to stop this practice and left to call the chemical supplier instead. Later, kitchen staff were observed preparing meal trays using the potentially unsanitized plates. The Dietary Manager acknowledged the issue and eventually stopped the tray line to switch to disposable containers. He confirmed that the kitchen would need to re-wash everything after lunch and admitted the health risk posed by serving food on improperly sanitized plates. The dish machine was later tested again and registered the correct sanitizer level of 100 ppm. The Dietary Manager could not explain why he did not stop the dietary staff earlier when he became aware of the sanitization issue.
Failure to Provide Appropriate IV Care and Services
Penalty
Summary
The facility failed to obtain physician orders and provide intravenous (IV) care and services according to professional standards of practice for two residents. Resident #209 was admitted with multiple diagnoses, including sepsis and end-stage renal disease, and had a Peripherally Inserted Central Catheter (PICC) line. The admission nurse did not obtain orders for the care of the PICC line, and the facility staff did not provide any care for the PICC line for 21 days. The resident's dialysis center confirmed they were not responsible for the PICC line care, and the facility staff failed to notice and address the PICC line's presence and care needs. The Director of Nursing (DON) acknowledged the oversight and the lack of care provided for the PICC line during this period. Resident #79 was admitted with diagnoses including left above knee amputation, dysphagia, and end-stage renal disease. The resident had a physician order for IV dressing changes every 72 hours and flushes every shift. However, the facility staff documented dressing changes every shift instead of every 72 hours as ordered. The resident's midline catheter dressing was not changed according to professional guidelines, and the DON confirmed that the physician's order was not adjusted when the midline was inserted. The facility's Treatment Administration Record (TAR) indicated that dressing changes were being checked off as completed every twelve hours, which was not accurate. The facility's failure to provide appropriate IV care and services for both residents resulted in a lack of adherence to professional standards of practice. The DON and other nursing staff acknowledged the deficiencies and the need for proper documentation and care for IV lines. The facility's policies and procedures were not followed, leading to potential risks for the residents involved.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to obtain a physician order for oxygen therapy and did not administer oxygen therapy as ordered for three residents. Resident #11 was admitted with multiple diagnoses including COPD and was observed multiple times without her oxygen nasal cannula in place, despite the concentrator being set at 2.5 LPM. There was no physician order for oxygen in her medical record, and the nursing staff acknowledged the oversight in entering the order into the electronic medical record (EMR). Resident #2, diagnosed with COPD and other conditions, was observed receiving oxygen at 2 LPM, contrary to the physician's order of 3 LPM. The LPN and Unit Manager confirmed the discrepancy and acknowledged the responsibility of the nursing staff to ensure the oxygen flow rate matched the physician's order. The DON reiterated the importance of verifying oxygen orders at the beginning of each shift. Resident #310, with diagnoses including heart failure and chronic respiratory failure, was observed receiving oxygen at 1.5 LPM instead of the prescribed 3 LPM. The LPN and Unit Manager confirmed the incorrect setting and emphasized the nurse's duty to monitor and adjust the oxygen flow rate as per the physician's order. The DON confirmed the necessity of administering oxygen as ordered to prevent respiratory complications.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to provide adequate monitoring for potential side effects of anticoagulant medication for a resident who was on Eliquis. The resident, who had a history of sepsis, respiratory failure, and other serious conditions, was observed with bleeding on his left cheek and forearm. Despite the resident's high-risk status and the known side effects of Eliquis, there were no orders or documentation indicating that nurses monitored for signs of bleeding from the time the medication was prescribed until the deficiency was noted. A registered nurse confirmed that there were no orders to monitor for bleeding, and the Director of Nursing stated that the nurse who entered the anticoagulant order should have included monitoring instructions. The facility's policy on anticoagulant therapy required monitoring for signs of bleeding, but this was not followed in the case of this resident. The lack of monitoring was evident in the nursing progress notes and medication administration records, which showed no evidence of monitoring for side effects of the anticoagulant medication.
Significant Medication Error Due to Lapse in Administration Process
Penalty
Summary
The facility failed to provide care and services to prevent a significant medication error for a resident prescribed oral antibiotic therapy. The resident, who had multiple diagnoses including atherosclerosis, embolism, and thrombosis, was prescribed Cephalexin (Keflex) 500 mg twice daily for an infection. Despite the prescription, the resident missed fourteen doses of the medication due to a lapse in the facility's medication administration process. The resident was readmitted to the facility after hospitalization and initially received the medication, but it was stopped after five days without proper justification or communication with the prescribing physician. The resident repeatedly informed the staff about the missing medication, but no immediate action was taken. The resident even contacted the Infectious Disease physician's office himself to confirm the medication's stop date and brought this information to the nursing staff. Despite this, the medication was not reordered until several days later, resulting in the resident missing fourteen doses. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) were aware of the issue but failed to notify the Infectious Disease physician promptly. The facility's internal processes, including a shift change from 8-hour to 12-hour shifts, contributed to the medication order being dropped from the resident's electronic medical record. The DON and ADON acknowledged the error but did not take immediate steps to rectify the situation or inform the prescribing physician. The resident expressed frustration and concern over the lack of communication and accountability from the facility staff, highlighting a significant lapse in medication administration and oversight.
Failure to Ensure Proper Evaluation and Physician's Order for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure an evaluation for self-administration of medication was completed, failed to obtain a physician's order for self-administration of medications, and failed to ensure medications were not stored at the resident's bedside. Resident #95, who was admitted with diagnoses including quadriplegia and chronic obstructive pulmonary disease, was found with multiple medications at his bedside without proper authorization or evaluation. The resident's cognition was intact, but he was dependent on staff for activities of daily living and mobility needs. The medications included Calazime skin protectant, Diclofenac sodium topical gel, Biofreeze gel, anti-itch cream, and analgesic balm, which the resident stated he brought from a previous rehabilitation facility and had been using for approximately one week without staff intervention or proper storage protocols being followed. The resident also mentioned that the medications provided by the facility did not alleviate his pain and spasms, prompting him to use his own medications. However, there was no documentation or physician's order for self-administration or bedside storage of these medications in the clinical records. The facility's staff, including the LPN, Unit Manager, and DON, acknowledged the lack of proper orders and evaluations for the medications found at the resident's bedside. The DON confirmed that medications should not be kept at the bedside without a physician's order due to safety concerns, and the facility's policy required medications to be stored in a lock box if kept at the bedside. The resident's inability to self-administer medication due to his physical limitations was also noted, and it was revealed that a family member had brought the medications to the facility. The facility's policy on self-administration of medication at bedside was not followed, leading to the deficiency.
Failure to Complete PASARR Evaluations for New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluation after a new major mental disorder diagnosis for one of the residents. The resident was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, major depressive disorder, and cocaine abuse. On a later date, the resident received a new diagnosis of psychotic disorder with delusions. Despite this new diagnosis, the facility did not complete an updated PASARR level I or trigger a PASARR level II evaluation as required by their policy and federal/state guidelines. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) confirmed that it was their responsibility to ensure PASARR evaluations were completed timely. Both acknowledged that the resident should have had another PASARR level I completed due to the new diagnosis and that a PASARR level II was triggered but not performed. The facility's PASARR policy mandates that all residents with serious mental illness or intellectual disability receive appropriate pre-admission screenings and follow-up evaluations if new diagnoses are made after admission.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, one with severe cognitive impairment and another on anticoagulant medication. Resident #11, who had multiple diagnoses including Alzheimer's disease and hemiplegia, did not have a comprehensive care plan for activities despite her preferences for listening to music, going outside, and participating in religious services. Observations over several days showed that she remained in bed without any diversional activities, and staff did not offer her any activities or get her out of bed. The Activity Director and Activities Assistant confirmed that there was no comprehensive care plan in place for her activities, and the MDS nurses validated that the care plan should have been initiated but was not individualized to her preferences or goals. Resident #209, who was cognitively intact and on high-risk medications including an anticoagulant, did not have a care plan addressing the need for staff to monitor for signs or symptoms of bleeding. The resident was observed with drops of blood on his cheek and forearm, and he mentioned that he bled easily due to the blood thinner. The MDS nurse confirmed that a comprehensive care plan for anticoagulant monitoring should have been initiated but was not. The facility's policies and procedures required an individualized person-centered plan of care to be established within seven days after the completion of the comprehensive assessment, but this was not done for either resident. The lack of comprehensive care plans for both residents indicates a failure to meet their medical, nursing, mental, and psychosocial needs as identified in their assessments. This deficiency was observed through multiple instances of inaction by the staff, including the lack of individualized activities for Resident #11 and the absence of monitoring for bleeding risks for Resident #209. The facility's failure to adhere to its own policies and procedures for developing and implementing care plans contributed to these deficiencies.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide a resident-centered activities program that met the individual interests and needs of a resident, leading to a deficiency. Resident #11, who had severe cognitive impairment and multiple medical conditions including hemiplegia, Alzheimer's disease, and chronic pain, was observed lying in bed without any form of entertainment or engagement such as a TV or radio. Despite her preferences for listening to music, going outside for fresh air, and participating in religious services, there was no documentation of evaluations, progress notes, or care plans regarding activities for her. Repeated observations over several days showed that the resident remained in bed, fidgeting and restless, with no staff offering any diversional activities or getting her out of bed. The activities staff were not observed attending to her needs, and the assigned CNA and LPN did not provide any meaningful engagement or activities tailored to her preferences. Interviews with the Activities Director and Activities Assistant revealed that they were aware of the resident's preferences but lacked the resources to provide individualized activities, such as bedside radios. The Activities Assistant admitted to not knowing the resident's specific interests in reading material or music. The MDS nurses confirmed that there was no comprehensive care plan in place for the resident's activities, despite the psychosocial evaluation indicating her preferences for church on TV, oldies music, romance movies, comedy shows, religious services, news, politics, and current events. This lack of a tailored activities program and the absence of a comprehensive care plan contributed to the deficiency in meeting the resident's needs and interests.
Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate care and services by not following physician orders for a resident with a gastric tube feeding. The resident, who was admitted with diagnoses including dysphagia following a stroke and required tube feeding, was observed to have been given the incorrect enteral feed formula. Specifically, the resident was prescribed Glucerna 1.2 calorie formula to be administered at a rate of 79 ml per hour, but was instead given Glucerna 1.5 calorie formula on multiple occasions. This discrepancy was confirmed by both the Licensed Practical Nurse (LPN) and the Unit Manager, who acknowledged that the correct formula should have been verified at the start of each shift. The error was further corroborated by the Registered Dietician and the Director of Nursing (DON), who emphasized the importance of administering the correct enteral feed formula to meet the resident's nutritional needs. The facility's policy on enteral feeding also mandates that nurses administer the feeding as ordered by the physician. The failure to follow these orders resulted in the resident not receiving the prescribed nutrition, which is critical for their health and well-being.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident who experienced trauma received trauma-informed care. The resident, who was admitted with multiple fractures and later diagnosed with anxiety and major depressive disorder, was cognitively intact and dependent on staff for activities of daily living. Despite her traumatic experience and significant life changes, her electronic medical record did not contain a post-trauma care plan. The resident expressed that no one had talked to her about her trauma, and she did not want to rely solely on medications for her mental health needs. The psychiatric APRN primarily focused on medication management and did not provide counseling, while the Social Services Director acknowledged the resident's significant life changes but did not ensure a trauma-informed care plan was in place. The resident's care plan contained inappropriate interventions and did not address her trauma. The Regional MDS Director confirmed the absence of a trauma-informed care plan and acknowledged the inappropriate intervention in the resident's care plan. The Interdisciplinary Team (IDT) reviewed the psychological progress notes and found that they contained valuable insights into the resident's thoughts, feelings, and preferences, which were not incorporated into her care plan. The team admitted to gaps in communication that led to the failure to provide appropriate trauma-informed care. The facility's policy on Trauma Informed Care was not followed, resulting in the deficiency identified by the surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below 5% by not administering the correct dosage of medications per physician's orders for one resident. Specifically, a Licensed Practical Nurse (LPN) administered 400 micrograms of Folic Acid instead of the prescribed 1 mg and 400 mg of Guaifenesin instead of the prescribed 600 mg to a resident with multiple diagnoses, including chronic embolism, thrombosis, acute respiratory failure, bipolar disorder, schizophrenia, anxiety disorder, and thiamine deficiency. The errors were observed during a medication administration session and later confirmed by the LPN and the Director of Nursing (DON). The resident's physician orders were reviewed, and it was acknowledged that the wrong dosages were administered. The facility's policy on administering medications states that medications should be administered in a safe and timely manner as prescribed, and any medication errors should be documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee. Despite these policies, the errors occurred, leading to a medication error rate above the acceptable threshold.
Medication Transfer Error in EMR
Penalty
Summary
The facility failed to effectively use its resources to ensure medications were transferred accurately and completely to the facility's Electronic Medical Records (EMR), leading to a significant medication error for one resident. The resident, who had multiple serious diagnoses including atherosclerosis, embolism, and hypertension, was prescribed Keflex for an infection by his Infectious Disease physician. Upon readmission to the facility, the resident was given Keflex for five days before it was stopped, despite the physician's order for the medication to be continued for 180 days. This resulted in the resident missing 14 doses of the medication over a period of several days. The Director of Nursing (DON) acknowledged that the medication error occurred due to a system update and shift change from 8-hour to 12-hour shifts, which required orders to be updated in the EMR. However, no one reviewed the EMR to ensure all medications were transferred accurately and completely. The DON was not aware of the issue until it was brought to her attention by the Assistant DON. The incident was not reported to the Consultant Pharmacist, the Medical Director was not informed in a timely manner, and the issue was not discussed in any Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting. The facility's Incident Log and Grievance Log did not initially reflect the medication error, and the resident's grievance was not addressed promptly. The Social Services Director (SSD) confirmed that the resident expressed concerns about the missed doses, but the investigation was still ongoing, and the grievance was not initiated when the issue was first identified. The DON admitted that the facility did not follow its policy for administering medications, which required medication errors to be documented, reported, and reviewed by the QAPI committee to inform process changes and additional staff training.
Inaccurate Documentation of IV Dressing Changes
Penalty
Summary
The facility failed to ensure documentation in the medical record was complete and accurate according to accepted professional standards and practices regarding intravenous (IV) dressing change for a resident. The resident had multiple diagnoses, including left above the knee amputation, dysphagia, acute respiratory failure, diabetes type II, gastrostomy, and end-stage renal disease. The physician's order required the IV dressing to be changed every 72 hours and as needed. However, the Treatment Administration Record (TAR) indicated that the IV dressing was signed off as changed every shift, which was not accurate. Nurses acknowledged signing off on the task without actually performing the dressing change, and the order for the IV dressing change was not updated when the resident's peripheral line was replaced with a midline catheter. The Director of Nursing (DON) and other nursing staff confirmed that the documentation was inaccurate and that the IV dressing change order should have been clarified. The DON admitted that she did not know what the nurses were actually signing off on, and the Medical Director stated that he expected accurate documentation in clinical records. The facility did not provide a policy for the accuracy of medical records when requested. This deficiency highlights a significant lapse in maintaining accurate and complete medical records for the resident's IV care.
Failure to Implement Contact Isolation Precautions
Penalty
Summary
The facility failed to implement the physician's order for contact isolation precautions for a resident diagnosed with Extended Spectrum Beta-Lactamase (ESBL) in the urine. Despite the order being placed on 4/18/24, observations on 4/22/24 and 4/23/24 revealed that the appropriate Contact Isolation signage was not posted on the resident's door. Instead, an Enhanced Barrier Precaution sign was in place, which did not meet the requirements for Contact Isolation. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged the oversight and confirmed that the correct signage and Personal Protective Equipment (PPE) were not in place as required by the physician's order. The Licensed Practical Nurse (LPN)/Unit Manager on the 100 Unit stated that the resident had previously been on Contact Isolation in March 2024, which was later discontinued and replaced with Enhanced Barrier Precautions. However, the LPN was unaware of the new order dated 4/18/24 for Contact Isolation. The discrepancy between the physician's order and the implemented precautions was identified by the surveyor, highlighting a lapse in the facility's infection prevention and control program.
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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.
Trusted data from CMS and state health departments
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