Aviata At The Sea - Pompano Beach
Inspection history, citations, penalties and survey trends for this long-term care facility in Pompano Beach, Florida.
- Location
- 2401 Ne 2nd Street, Pompano Beach, Florida 33062
- CMS Provider Number
- 105258
- Inspections on file
- 25
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Aviata At The Sea - Pompano Beach during CMS and state inspections, most recent first.
A resident with multiple mental health diagnoses was hospitalized twice for crisis behaviors and readmitted to the facility without a new PASARR Level I screening being completed, as required by policy. The only PASARR Level I on file was dated prior to these hospitalizations, and Social Services did not document or assess the resident's status following the [NAME] Act discharges.
A resident with a history of mental health disorders and HIV exhibited increased violent and aggressive behaviors, including spitting, kicking, and hitting staff, as well as refusing medications. Despite multiple documented incidents and psychiatric evaluations noting worsening symptoms, the care plan was not updated to address these new behaviors, and interventions remained focused only on medication refusal. Staff interviews confirmed that the care plan was not revised to reflect the resident's current needs.
The facility failed to maintain food safety standards, with improper storage of opened food items and a malfunctioning dishwasher not reaching required sanitization temperatures. The Dietary Manager acknowledged the issues, and the kitchen manager noted recent maintenance on the dishwasher, which remained inadequate.
The facility failed to dispose of refuse in a sanitary manner, as observed during a survey. The garbage area near the back of the main kitchen was found littered with debris, including dirty gloves, food debris, and other refuse. Overflowing garbage bins and scattered debris were also noted around the main dumpster area. Interviews with the Kitchen Manager and the Administrator revealed a lack of clarity regarding responsibility for maintaining cleanliness in the garbage area.
A facility failed to provide dignified eating assistance and privacy during personal care for two residents with severe cognitive impairments. A hospice aide stood while feeding a resident without proper education on maintaining dignity, and another resident was left uncovered during care without privacy curtains. The facility lacked specific policies for feeding assistance and had not replaced missing privacy curtains.
The facility failed to provide a safe, clean, and homelike environment, with deficiencies observed in 8 out of 39 rooms. Issues included peeling toilet seats, holes in walls, broken window cranks, and missing privacy curtains. Interviews revealed compromised privacy for residents, with staff acknowledging the problem. The facility's DES had ordered new curtains but had not received them, indicating a delay in addressing the issues.
A facility failed to include catheter care in the baseline care plan for a resident admitted with a Foley catheter. The resident, with mild cognitive impairment and multiple diagnoses, was unsure of the catheter's purpose. The MDS coordinator acknowledged the omission, noting the baseline care plan was effective until the comprehensive care plan could be printed.
The facility failed to create personalized care plans for four residents, leading to deficiencies in addressing their specific needs. A resident with severe cognitive impairment exhibited combative behavior without a care plan addressing it. Another resident experienced pain during care, leading to an abuse allegation, but the pain was not addressed in the care plan until after the incident. A third resident on anticoagulant therapy lacked a care plan for the medication, and a fourth resident on contact precautions did not have a care plan for these precautions.
A resident with cognitive impairment did not receive timely incontinence care due to fear of mistreatment by a CNA, resulting in a soaked brief. Another resident receiving hospice care for Wernicke's encephalopathy lacked a physician order for hospice services, as acknowledged by the DON.
The facility failed to timely identify and address severe weight loss in three residents, leading to deficiencies in nutritional care. One resident experienced an 8.08% weight loss in a month without consistent weight monitoring. Another resident had a 6.6% weight loss with delayed RD assessment due to hospitalization. A third resident showed a 12.8% weight loss with inconsistencies in receiving prescribed supplements and weight monitoring.
A facility failed to follow physician's orders for tube feeding and its own weight policy, leading to weight loss in a resident with severe cognitive impairment. The resident's tube feeding was inconsistently administered, providing insufficient caloric intake. Additionally, the facility did not record a new readmission weight, contributing to a 4.45% weight loss over a month.
A facility failed to follow a physician's fluid restriction orders for a dialysis resident, providing 16 ounces of coffee instead of the prescribed 6 ounces during breakfast. Despite clear meal ticket instructions and the resident's awareness of her restrictions, the kitchen manager honored the resident's preference for more coffee, leading to non-compliance with the care plan.
A facility failed to provide adequate nursing staff, resulting in delayed care for several residents. One resident, with paralysis and severe arthritis, was improperly repositioned by a CNA without assistance, causing pain and fear. Another resident experienced meal delays due to needing assistance, while a third resident reported waiting hours for incontinent care. These incidents highlight the facility's staffing issues affecting resident care.
The facility did not follow its menu portion sizes for a Regular diet, affecting 39 residents. The menu specified a 2-ounce portion of roast pork, but observations showed servings of 1 and 1.5 ounces. The Dietary Manager and Account Manager confirmed the required portion size, yet the deficiency was noted.
Two residents did not receive meals according to their preferences and dietary needs. One resident with severe cognitive impairment and a diagnosis of malignant neoplasm had missing items on their meal tray, while another resident with mild cognitive impairment and diabetes received an incomplete meal. The kitchen manager acknowledged these errors, highlighting a lapse in the facility's meal preparation process.
The facility did not conduct quarterly QAPI meetings as required, with the last meeting held in December 2024. A meeting in March 2025 lacked attendance from the Medical Director, and no sign-in sheet was available. The Administrator, who started in March, confirmed the absence of the Medical Director at the March meeting.
The facility failed to follow infection control guidelines, with staff not wearing gowns during personal and wound care for a resident with a pressure ulcer, and during medication administration for a resident on Enhanced Barrier Precautions (EBP). PPE was not readily accessible, and contact precautions were not followed per physician orders for another resident. Staff were unaware of gown requirements, and PPE was not available on the floor, leading to deficiencies in infection control practices.
The facility failed to adhere to infection control standards for two residents with midline catheters. A resident who was cognitively intact and another with severe cognitive impairment both had midline catheters observed without caps, leaving the lines open to the bloodstream. An LPN confirmed the lines should have been capped, and the DON acknowledged the oversight.
Failure to Complete PASARR Level I Screening After Psychiatric Hospitalization
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level I screening was completed for a resident with multiple mental health diagnoses following two hospitalizations for crisis states involving violent and aggressive behaviors. The resident, who had a history of Major Depressive Disorder, Mood Disorder, Adjustment Disorder with Mixed Anxiety and Depressive Mood, Bipolar Disorder, and HIV, was admitted, discharged under a [NAME] Act due to behavioral crises, and subsequently readmitted to the facility on two occasions. Despite these significant events and changes in the resident's mental status, the only PASARR Level I on file was dated prior to the hospitalizations, and no new PASARR Level I was completed upon the resident's readmissions. Review of the facility's policy indicated that it is the responsibility of the center, specifically the Social Services department, to ensure that appropriate PASARR screenings are conducted and documented prior to admission or readmission, and that significant changes trigger updated screenings. Interviews with the Director of Social Services and the regional nurse confirmed that the required PASARR Level I was not completed after the resident's returns from the hospital, and there was no documentation or assessment by Social Services regarding the [NAME] Act discharges during the relevant period.
Failure to Revise Care Plan for Resident with Escalating Aggressive Behaviors
Penalty
Summary
The facility failed to revise the care plan for a resident who exhibited recent increases in violent and aggressive behaviors towards other residents and staff. The resident, who had a history of major depressive disorder, mood disorder, adjustment disorder with mixed anxiety and depressive mood, bipolar disorder, and HIV disease, demonstrated behaviors such as spitting at and kicking staff, hitting others with her wheelchair, and refusing medications. Despite these significant behavioral changes, the care plan was not updated to address the new or escalating behaviors, and interventions continued to focus only on medication refusal. Documentation showed that the resident had multiple behavioral incidents, including spitting on a nurse, kicking staff, and being combative during morning care. Psychiatry progress notes indicated increased symptoms of bipolar disorder, including mania, psychosis, and refusal to follow staff recommendations. The resident was also noted to have been agitated, aggressive toward her roommate, and required a room change. Despite these documented changes, the last interdisciplinary team meeting and care plan revision occurred prior to the escalation of these behaviors, and the care plan did not reflect the resident's current needs or interventions for the aggressive behaviors. Interviews with facility staff revealed that although behavioral changes were discussed in daily clinical meetings, the care plan was not revised to address the resident's increased aggression. The MDS coordinator and regional nurse both acknowledged that the care plan should have been updated, with the social services director identified as responsible for ensuring care plan revisions. However, no updates were made to the care plan to reflect the resident's behavioral changes and required interventions.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to food safety requirements during a survey of the main kitchen. During the inspection, it was observed that a round garbage can without a lid was present in the food production area, which the Dietary Manager acknowledged. Additionally, the walk-in refrigerator contained several opened bags of food items, including boiled eggs, grapes, cucumbers with white spots and a mold-like substance, raw chicken pieces, raw fish pieces, and raw bacon. There was also a bag of raw meals that was neither dated nor labeled, indicating improper food storage practices that could lead to cross-contamination. Further observations revealed that the hot temperature dishwasher machine was not reaching the necessary high-temperature ranges for sanitization. The rinse cycle was consistently at 150 degrees Fahrenheit, and the wash cycle varied between 145 and 160 degrees Fahrenheit, failing to meet the required 180 degrees Fahrenheit for the final rinse. The kitchen manager mentioned that maintenance had recently checked the dishwasher, but it was still not functioning correctly, indicating a lapse in ensuring proper equipment maintenance and food safety standards.
Improper Disposal of Refuse
Penalty
Summary
The facility failed to dispose of refuse in a sanitary manner, as observed during a survey. The facility's policy on Solid Waste Management, dated 11/30/2014, mandates that solid waste be handled and disposed of to ensure a safe and sanitary environment. However, during an observation on 03/31/25, the garbage area near the back of the main kitchen was found littered with debris, including dirty gloves, food debris, cans of soda, bottled water, medicine cups, supplements, and other refuse. A subsequent observation on 04/1/25 revealed three garbage bins overflowing with garbage bags, with dirty gloves and other debris scattered around the main dumpster area. Interviews with the Kitchen Manager and the Administrator indicated a lack of clarity regarding responsibility for maintaining cleanliness in the garbage area, as the Kitchen Manager was unaware of who was responsible for ensuring the area was cleaned and contained.
Deficiencies in Dignified Care and Privacy
Penalty
Summary
The facility failed to provide eating assistance in a dignified manner for a resident with severe cognitive impairment who required substantial assistance with feeding. The hospice aide assisting the resident was observed standing while feeding, rather than being at the resident's eye level, which is considered undignified. The hospice aide admitted to standing during feeding based on her comfort and confirmed that she had not received any education from the facility staff or hospice nurse regarding proper feeding assistance and maintaining resident dignity. The facility lacked a specific policy related to assistance with feeding and activities of daily living. Additionally, the facility failed to ensure privacy during personal care for another resident with severe cognitive impairment who required maximal assistance for bathing and dressing. During an observation, the resident was uncovered, exposing his adult brief and lower extremities, without privacy curtains or window blinds drawn. The staff member providing care was unaware of when the privacy curtains were removed, and the Director of Environmental Services confirmed that the privacy curtain had been ordered but not yet replaced. The lack of privacy was acknowledged by the staff, who confirmed the importance of providing privacy during care.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed in 8 out of 39 rooms. Observations included a peeling toilet seat, a hole in the bathroom wall filled with gloves and hair, and black spots on the shower floor. Additionally, several rooms had issues with doors, such as laminate coming off, doors not closing properly, and loose baseboards. Some rooms were missing essential items like room separator curtains, and there were broken window crank handles and stained curtains. Interviews with residents and staff revealed that privacy was compromised due to missing or inadequate privacy curtains. A resident expressed the importance of having privacy during bathing, and a CNA confirmed the lack of privacy curtains, stating that housekeeping was aware of the issue. The facility's Director of Environmental Services (DES) had ordered new cubicle curtains but had not received them, indicating a delay in addressing the deficiency. These observations and interviews highlight the facility's failure to provide a safe and homelike environment, impacting the residents' comfort and privacy.
Failure to Document Catheter Care in Baseline Care Plan
Penalty
Summary
The facility failed to address catheter care in the baseline care plan for a resident who was admitted with a Foley catheter. The resident, who has mild cognitive impairment, was admitted with diagnoses including Hemiplegia, Hemiparesis following Cerebral Infarction, Urinary Tract Infection, and Dysuria. During an interview, the resident expressed uncertainty about the reason for having a catheter, indicating a lack of communication or documentation regarding his catheter care. A review of the resident's baseline care plan showed no documentation about the Foley catheter, which was acknowledged by the MDS coordinator as an oversight. The coordinator noted that the baseline care plan was currently effective, as the comprehensive care plan could not yet be printed, and confirmed that the catheter should have been included in the baseline care plan.
Failure to Initiate Personalized Care Plans for Residents
Penalty
Summary
The facility failed to initiate personalized care plans for four residents, leading to deficiencies in addressing their specific needs. Resident #48, who has severe cognitive impairment and is dependent on staff for personal care, exhibited combative behavior during care. However, there was no care plan addressing these aggressive tendencies, despite staff being aware of the behavior. Interviews with staff revealed that the MDS Coordinator would only create a care plan for combative behavior after an incident occurred, rather than proactively addressing the issue. Resident #74, with a slight cognitive impairment, experienced pain during care, which led to an allegation of physical abuse by a CNA. The care plan for pain was only initiated after the incident, despite the resident's known history of expressing pain during care. Staff interviews indicated that the resident often screamed in pain during care, yet the care plan did not address this issue until after the incident was reported. Resident #2, who is on anticoagulant therapy, did not have a care plan addressing the use of Rivaroxaban, despite having a physician's order for the medication. The MDS Coordinator confirmed the oversight, as the care plan only mentioned medication for Peripheral Vascular Disease. Resident #31, who was on contact precautions due to a bacterial infection, did not have a care plan for these precautions. The Director of Nursing acknowledged the lack of documentation for a repeat urine culture and the continuation of contact precautions, which were not reflected in the care plan.
Deficiencies in Incontinence Care and Hospice Documentation
Penalty
Summary
The facility failed to provide timely incontinence care for a resident with moderate cognitive impairment and multiple medical conditions, including epilepsy and anxiety disorder. The resident, who required assistance with toileting, reported that her adult brief was not changed from 11:00 PM until the morning, resulting in a soaked brief. The resident expressed fear of mistreatment after witnessing a staff member, a CNA, verbally mistreat her roommate. The CNA denied the resident was wet and did not change the brief, while the LPN confirmed the brief was wet during a side-by-side observation. Additionally, the facility failed to obtain a physician order for hospice services for another resident diagnosed with Wernicke's encephalopathy. Although the resident had been receiving hospice care since early February, there was no physician order or documentation of the hospice admission date or diagnosis in the resident's records. The Director of Nurses acknowledged the absence of the required physician order for hospice care.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to identify and address severe weight loss in a timely manner for three residents, leading to deficiencies in nutritional care. Resident #36 experienced an 8.08% weight loss in one month and an overall 11.7% weight loss over six months. Despite being placed on weekly weight monitoring, this was not consistently performed. The Registered Dietitian (RD) acknowledged the significant weight loss but indicated that weekly weights might have been discontinued prematurely. Resident #13 experienced a 6.6% weight loss in one month and a 12.23% weight loss over five months. The RD's assessment was delayed by 16 days after the resident's readmission, partly due to the resident's hospitalization. The RD noted the resident's meal intake was 75% and recommended nutritional supplements, but the delay in assessment contributed to the deficiency. Resident #9 had a severe 12.8% weight loss in one month, with inconsistencies in receiving prescribed nutritional supplements. Observations showed the resident did not consistently receive Nepro supplements as ordered, and weights were not taken as required after readmission. The RD acknowledged the delay in addressing the weight loss and the lack of consistent weight monitoring, contributing to the deficiency in nutritional care.
Failure to Follow Tube Feeding Orders and Weight Policy
Penalty
Summary
The facility failed to adhere to physician's orders for tube feeding and its own policy regarding resident weights, resulting in weight loss for a resident with a feeding tube. The resident, who was readmitted with diagnoses including Type 2 Diabetes and severe cognitive impairment, had specific orders for Glucerna 1.5 tube feeding at 60 ml per hour for 20 hours daily. However, observations revealed inconsistencies in the administration of the tube feeding, with significant periods where the feeding was not running as ordered. This inconsistency in feeding led to the resident receiving only 18 hours of feeding per day, providing insufficient caloric intake compared to the resident's estimated needs. Additionally, the facility did not follow its policy for weighing residents, as no new readmission weight was recorded for the resident. The Registered Dietitian and Restorative Certified Nursing Assistants were responsible for managing and recording weights, but there was a lack of coordination and communication regarding the weekly and admission weights. This oversight contributed to the resident's weight loss, as evidenced by a recorded weight drop from 184.2 pounds to 176 pounds within a month, indicating a 4.45% weight loss.
Failure to Adhere to Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to adhere to the physician's fluid restriction orders for a resident undergoing dialysis, leading to a deficiency in care. The resident, who has diagnoses of Type 2 Diabetes, Severe Chronic Kidney Disease, and Anemia, was prescribed a fluid restriction of 1000 milliliters per day, with specific allocations for dietary and nursing. However, observations revealed that the resident was provided with 16 ounces of coffee during breakfast on two separate occasions, exceeding the prescribed 6 ounces. This discrepancy was noted despite the meal ticket clearly indicating the fluid restriction and specific fluid amounts allowed. Interviews with the resident and the kitchen manager highlighted a lack of compliance with the fluid restriction orders. The resident, who is cognitively intact, mentioned being aware of her fluid restrictions but believed she was allowed more than prescribed. The kitchen manager admitted to providing two cups of coffee to honor the resident's preferences, despite the meal ticket instructions. The care plan indicated that the resident was non-compliant with dietary restrictions and had been educated on the importance of adhering to fluid restrictions, yet the facility failed to ensure compliance, resulting in the deficiency.
Staffing Deficiencies Lead to Delayed Care and Resident Discomfort
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of several residents, resulting in multiple deficiencies. Resident #2, who was diagnosed with cerebral infarction, diabetes mellitus type 2, and other conditions, required two-person assistance for repositioning due to left-sided paralysis and severe arthritis. However, the resident reported that a CNA attempted to turn her without assistance, causing pain and fear of falling. The CNA admitted to not seeking help due to a lack of available staff, despite the resident's care plan indicating the need for two-person assistance. Resident #52 experienced delays in receiving meals, as staff prioritized delivering trays to residents who did not require assistance. This resident, who had type 2 diabetes and other health issues, expressed frustration and hunger while waiting for assistance with his meal. The CNA responsible for delivering the tray confirmed that she left Resident #52's meal for last because he needed help eating, highlighting a staffing issue that affected timely care. Additionally, Resident #36 reported waiting several hours for incontinent care, indicating a shortage of staff to meet residents' needs promptly. This resident, who had pneumonia and hypothyroidism, experienced delays in receiving necessary care, further demonstrating the facility's failure to provide adequate staffing. These deficiencies collectively affected the quality of care for the residents and highlighted the need for improved staffing levels to meet their needs effectively.
Failure to Follow Menu Portion Sizes for Regular Diet
Penalty
Summary
The facility failed to adhere to its own menu portions for residents on a Regular diet, potentially affecting 39 out of 75 residents. The facility's menu for lunch on Day 4 of Week 1 specified a portion of 2 ounces of roast pork for a Regular diet. However, during an observation of the lunch tray line, it was noted that the portions served were less than the required amount. Specifically, the first slice of pork weighed 1 ounce, and the second slice weighed 1.5 ounces, both falling short of the 2-ounce requirement. The Dietary Manager confirmed that the portion size for the pork should be 2 ounces, and the Account Manager acknowledged weighing the pork slices to ensure compliance, yet the deficiency was observed.
Failure to Provide Meals According to Resident Preferences
Penalty
Summary
The facility failed to provide meals that met the preferences and dietary requirements of two residents, leading to deficiencies in their care. Resident #78, who has a severe cognitive impairment and a diagnosis of malignant neoplasm of the lower respiratory tract, was observed to have missing items on their meal tray, including margarine, syrup, and gravy, which were listed on their meal ticket. This oversight occurred despite the presence of a system where two staff members are responsible for checking meal tickets and trays. Similarly, Resident #77, who has mild cognitive impairment and a diagnosis of benign intracranial hypertension and diabetes mellitus with hyperglycemia, received a meal tray that was missing one slice of bacon, contrary to the meal ticket specifications. The kitchen manager acknowledged the errors in both cases, indicating a lapse in the facility's meal preparation and delivery process, which failed to ensure that residents received meals according to their documented preferences and dietary needs.
Failure to Conduct Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were conducted quarterly and that the necessary staff members attended those meetings for three of the six months reviewed. The facility's policy, dated November 30, 2014, required that Quality Assessment and Assurance Committee (QAA) meetings be held at least quarterly, with members including the Executive Director, Medical Director, Director of Nursing, and Infection Preventionist. However, records revealed that the last QAPI meeting was held on December 18, 2024, and there was no evidence of a meeting in March 2025 or a sign-in sheet with all necessary staff members. During an interview on April 3, 2025, the facility's Administrator, who started in March of that year, stated that a QAPI meeting was held on March 20, 2025, with attendees including the Director of Nursing, Activities, Maintenance, Rehab, Social Services, Admission, and Housekeeping, but not the Medical Director. The Administrator was unable to provide a sign-in sheet from all the necessary members for the QAPI meeting held on March 20, 2025.
Infection Control Deficiencies in PPE Usage and Precaution Adherence
Penalty
Summary
The facility failed to adhere to infection control guidelines, resulting in multiple deficiencies related to the use of Personal Protective Equipment (PPE) and adherence to Enhanced Barrier Precautions (EBP). Specifically, staff did not wear disposable gowns during personal care and wound care for a resident with a pressure ulcer, nor during medication administration for a resident on EBP. Additionally, PPE was not readily accessible for residents on EBP, and contact precautions were not followed per physician orders for another resident. One resident, who was cognitively intact, had a physician order for contact precautions due to an ESBL-positive urine culture. However, the facility did not conduct a repeat urine culture, and the contact precaution order was not discontinued. The Director of Nursing acknowledged the oversight. Another resident with a PEG tube did not have a gown worn by the staff during medication administration, despite the high-contact nature of the activity. The staff member was unaware of the requirement to wear a gown and noted that gowns were not readily available on the floor. Furthermore, a resident with a stage four pressure ulcer did not have an EBP sign, and staff did not wear gowns during personal and wound care. The Wound Care Nurse and a CNA both failed to wear gowns during high-contact activities, citing a lack of instruction or signage indicating the need for such precautions. The facility's failure to provide accessible PPE and ensure staff compliance with infection control protocols posed a risk to residents on EBP and contact precautions.
Infection Control Deficiency: Uncapped Midline Catheters
Penalty
Summary
The facility failed to meet infection control standards of practice related to the use of midline catheters for two residents. Resident #2, who was cognitively intact and required substantial assistance with activities of daily living, had an order for a midline catheter to be flushed with saline every shift. During an observation, it was noted that Resident #2's midline catheter IV line was without a cap, leaving it open to the bloodstream. Staff A, an LPN, confirmed that the catheter should have had a cap, and Resident #2 was unaware of the need for a cap. Similarly, Resident #3, who had severe cognitive impairment and was dependent on assistance for activities of daily living, also had an order for a midline catheter to be flushed with saline every shift. An observation revealed that Resident #3's midline catheter IV line was also without a cap. Staff A acknowledged that the line should have been capped. The Director of Nursing confirmed that midline catheter IV lines should have caps, indicating a lapse in infection control practices.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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