Bartram Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Florida.
- Location
- 6209 Brooks Bartram Drive, Jacksonville, Florida 32258
- CMS Provider Number
- 105645
- Inspections on file
- 16
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 3 (3 serious)
Citation history
Health deficiencies cited at Bartram Crossing during CMS and state inspections, most recent first.
The facility failed to implement its QAPI program as written by not using adverse incident data to conduct RCAs and develop timely PIPs after two serious fall‑related injuries. One resident, recovering from joint replacement with osteoporosis, muscle weakness, and unsteadiness, fell during OT while performing a laundry task with a COTA and was not wearing a physician‑ordered hinged knee brace locked in extension; she sustained a proximal tibia/fibula fracture, medial meniscus tear, and hemarthrosis. Another high fall‑risk resident with a right femur fracture, brain metastasis, anticoagulant use, and prior falls was placed on the toilet by a PTA and left unattended despite fall‑risk signage and a fall protocol requiring frequent safety checks; she was later found on the bathroom floor and diagnosed with a subarachnoid hemorrhage. In both cases, the QAPI committee did not meet, did not conduct the RCAs, and did not develop PIPs, and leadership confirmed that RCAs and corrective actions were handled informally outside the formal QAPI structure, leading surveyors to cite Immediate Jeopardy with potential impact to all residents.
Two residents experienced serious fall-related injuries when therapy staff failed to follow established orthotic and fall-prevention precautions. In one case, a resident with recent hip surgery and an order for a hinged knee brace locked in extension during all weight-bearing activity was taken through a laundry task without the brace in place; the resident stepped back on the unsupported leg and fell, later found to have a tibia/fibula fracture, meniscal tear, and hemarthrosis. In the other case, a high fall-risk resident on anticoagulation, requiring assistance with toileting and identified by door signage and protocols, was placed on the toilet by a PTA who then left the resident unattended and did not notify nursing or CNAs; the resident was later found on the bathroom floor with head trauma and was diagnosed with a subarachnoid hemorrhage. Surveyors found that therapy staff did not consistently use or follow the EMR precautions, passports, and fall-risk signage, resulting in neglect and Immediate Jeopardy.
Two residents experienced serious injuries when staff failed to follow fall-prevention orders and bathroom safety protocols. One resident with prior hip surgery and documented RLE weakness had a physician order for a hinged knee brace locked in extension and non-weight bearing status, with this requirement noted on her mobility "passport" but not entered into OT/PT precautions. During an OT laundry task, she was ambulating without the brace when a walker basket shifted; she stepped back on her unsupported leg, fell, and sustained a proximal tibia/fibula fracture, meniscal tear, and hemarthrosis. Another high fall-risk resident with a recent fall history, multiple comorbidities, and on anticoagulation was placed on the toilet by a PTA, given a call light, and left unattended despite door signage and facility policy requiring arm’s-length or line-of-sight supervision and prohibiting leaving high fall-risk residents alone on the toilet. A CNA later found this resident on the bathroom floor with head trauma; hospital imaging showed a subarachnoid hemorrhage. Surveyors cited these events as Immediate Jeopardy due to failures in updating and following therapy precautions, orthotic device orders, and toileting supervision requirements.
The facility failed to follow proper sanitation and food handling practices, including not date marking bread, allowing grease buildup in the oven, and not cleaning the mixer properly. Milk served to residents was found at unsafe temperatures. Staff interviews revealed inconsistencies in cleaning practices and adherence to facility policies.
Failure to Use QAPI and Adverse Event Data to Prevent Repeat Serious Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to operate an effective QAPI process that used adverse incident data to conduct root cause analyses and develop timely, effective performance improvement activities after serious resident injuries. The facility’s written QAPI policy stated that the program would encompass all segments of care and services, track and investigate adverse events every time they occur, and use a systematic approach to identify gaps or patterns in care, prioritize high‑risk or problem‑prone issues, and determine which problems would become performance improvement projects (PIPs). Despite this, the QAPI committee did not meet or become involved after two serious fall incidents involving residents, and no PIPs were developed in response to those events. The Administrator, who served as QAPI chair, confirmed that the QA committee had not been involved with either incident and that RCAs and corrective actions were being handled outside the formal QAPI structure. One resident, admitted for aftercare following joint replacement surgery with additional diagnoses including osteoporosis, muscle weakness, presence of a right artificial hip joint, and unsteadiness on feet, was actively being prepared for discharge with goals of walking safely and being independent. Her orthopedic physician had ordered weight bearing as tolerated to the right lower extremity with a hinged knee brace locked in extension for all weight bearing, and an ARNP entered the brace order into the electronic record. However, the brace requirement was not added to the resident’s OT and PT precautions until nine days after she fell. During an OT session practicing a laundry task with a COTA, the resident was filling a basket attached to her walker when the basket started to fall; as the COTA attempted to adjust it, the resident lost her balance and fell. She was not wearing the ordered hinged knee brace locked in extension at the time of the fall and sustained a nondisplaced fracture of the proximal tibia/fibula, a tear of the medial meniscus, hemarthrosis, and associated pain and fear of using the right leg. Although an RCA was discussed informally by the interdisciplinary team, the QAPI committee did not conduct the RCA or initiate a formal PIP. A second resident, admitted with diagnoses including an unspecified right femur fracture, prior fall on the same level, malignant neoplasm of the lung with secondary brain neoplasm, long‑term anticoagulant use, history of TIAs, and severe protein‑calorie malnutrition, had been assessed as a high fall risk and had an active physician’s order for a fall risk protocol with frequent rounding and safety checks. Her care plan identified risk for falls and injury related to medical conditions and documented a prior fall with family present. Despite these identified risks and orders, a PTA transferred the resident to the toilet, placed the call light across her lap, instructed her to pull it when finished, and then left the room without notifying nursing staff or a CNA that the resident was on the toilet. The PTA did not see the sign on the door indicating fall risk. The resident was later found on the bathroom floor with a scalp hematoma and ear injuries and was sent to the hospital, where a CT scan showed a subarachnoid hemorrhage in the right posterior temporal lobe. The QAPI committee did not meet after this incident, did not conduct the RCA, and did not develop a PIP, even though the facility’s own policy required systematic review of adverse events and prioritization of high‑risk, high‑frequency, or problem‑prone issues for performance improvement. Interviews with facility leadership and the risk manager confirmed that RCAs and corrective actions were being handled through informal meetings and daily clinical discussions rather than through the formal QAPI committee structure described in the facility’s policy. The risk manager stated that when incidents with potential for injury occurred, she convened RCA meetings with selected staff within 24–48 hours, separate from QAPI meetings, and that the QAPI/QA committee was not involved in these post‑incident efforts. She also stated that the QA committee primarily reviewed PIPs after they were already developed and did not participate in PIP development or provide substantive input, and that no PIPs were created in response to the two fall incidents. The Administrator and Medical Director acknowledged that the QAPI process was not being followed as intended, and that the governing body was aware that RCAs and PIPs were being created without QA committee involvement. Immediate Jeopardy at scope and severity level L was identified, with the report stating that the failure to develop measures needed to ensure the safety and protection of other residents had the potential to affect all 97 residents should an injury incident occur.
Failure to Follow Orthotic and Fall-Prevention Precautions During Therapy Sessions
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient safeguards and supervision to protect residents from neglect, specifically by not ensuring that rehabilitation staff were aware of and implemented care plan interventions and physician orders related to fall prevention and orthotic use. For one resident with a history of hip replacement and right lower extremity weakness, the orthopedic physician ordered a hinged knee brace locked in extension for all weight-bearing activity, and an ARNP entered an order for non-weight bearing to the right lower extremity with the hinged brace locked in extension when weight bearing. The resident’s passport tip sheet, dated prior to the fall, included instructions for the brace to be locked in extension and specified no walking backwards or pivoting on the right leg. However, the OT and PT precaution sheets did not include the brace instructions until nine days after the fall, and the treating COTA reported that the leg brace was not on the daily notes or schedule and was not on the resident at the time of the incident. On the day of the first incident, the resident, who had been receiving OT and PT and was preparing for discharge home, was engaged in a simulated laundry task with a COTA. The resident was filling a basket attached to her walker when the basket came loose. As the COTA attempted to adjust the basket, the resident stepped back on her unsupported right leg, lost her balance, and fell backward. She was wearing a gait belt and non-skid socks but was not wearing the ordered hinged knee brace locked in extension. Following the fall, she complained of severe right knee pain and was unable to move the knee. Imaging later revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the medial meniscus, hemarthrosis, and swelling. The facility’s investigation concluded that the resident was not wearing her physician-ordered hinged brace, locked in extension, at the time of the accident, despite the brace requirement being present on the passport and in physician documentation. The second incident involved another resident with multiple diagnoses including a right femur fracture, history of falls, anticoagulant use, and moderately impaired cognition. This resident had been assessed as high fall risk, had an active fall risk protocol with frequent safety rounding, and required partial/moderate assistance with toileting and toilet transfers. The resident’s door displayed red rounding signage and a fall-risk star, and staff interviews confirmed that high fall risk residents were not to be left unattended on the toilet. On the day of the fall, a PTA transferred this resident onto the toilet, placed the call light across her lap, instructed her to pull it when finished, and then left the room to treat another resident without notifying a nurse or CNA that the resident was on the toilet. The PTA reported not seeing the fall-risk sign on the door. Shortly thereafter, a CNA responding to the call light found the resident on the bathroom floor with head and ear injuries. An ARNP assessed her and she was sent to the hospital, where a CT scan showed a subarachnoid hemorrhage in the right posterior temporal lobe. The facility’s investigation determined that the PTA left a known high fall risk resident unattended on the toilet and failed to recognize posted fall-risk signage and the requirement for stand-by supervision while toileting. Across both events, the facility did not ensure that therapy staff consistently used available tools and information—such as the passports, EMR precautions, and door signage—to follow physician orders and care plan interventions related to fall prevention and orthotic use. Therapy staff had access to the EMR and passports, which contained key information on weight-bearing status, orthotic devices, and fall precautions, yet in one case the brace order was not incorporated into therapy precautions before the fall, and in the other case the PTA did not heed the fall-risk indicators or the facility’s bathroom safety expectations. These failures resulted in two serious fall-related injuries and were determined by surveyors to constitute neglect and Immediate Jeopardy, with potential risk to all residents requiring orthotic devices and all residents on active therapy caseload.
Failure to Implement Fall-Prevention Orders and Bathroom Supervision Leading to Serious Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices to prevent falls, resulting in serious injuries to two residents. One resident with a history of hip replacement and documented right lower extremity weakness had an orthopedic follow-up visit where the physician specified weight bearing as tolerated with a walker and a hinged knee brace locked in extension with all weight bearing until quadriceps strength returned. An ARNP subsequently entered an order for the right lower extremity to be non‑weight bearing with a hinged knee brace locked in extension when weight bearing, every shift. The resident’s passport, dated several days before the fall, instructed that the brace be locked in extension, with hip precautions and no walking backwards or pivoting on the right lower extremity. However, the brace requirement was not added to the OT/PT precautions until nine days after the fall, and on the day of the incident the resident was not wearing the physician‑ordered hinged knee brace. During an OT session, the resident participated in a simulated laundry task with a COTA. The resident was filling a basket attached to her walker when the basket started to fall. As the COTA attempted to adjust the basket, the resident stepped back on her unsupported right leg, lost her balance, and fell to the floor. She was wearing a gait belt and non‑skid socks but did not have the hinged knee brace in place. She immediately complained of right knee pain and was unable to move the knee. Initial x‑rays were negative, but an MRI later revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the body and posterior horn of the medial meniscus, moderate hemarthrosis, and mild subcutaneous edema. The facility’s investigation concluded that the resident was not wearing her physician‑ordered hinged brace, locked in extension, at the time of the accident, and that the brace order had not been incorporated into therapy precautions or the daily therapy schedule prior to the fall. The second resident involved had multiple diagnoses including a right femur fracture with routine healing, a history of fall on the same level, malignant neoplasm of the lung with secondary brain neoplasm, long‑term anticoagulant use, history of TIAs, and severe protein‑calorie malnutrition. A fall risk assessment identified this resident as high risk, and she had active orders for Xarelto and a fall risk protocol including frequent rounding and toe‑touch weight bearing to the right lower extremity. She was care‑planned for risk of falls and injury related to falls, with interventions such as assessing footwear, observing for unsteadiness, and maintaining a clutter‑free environment. After an earlier fall event with family present outside the facility, her passport color was changed to indicate a fall, and red rounding signage was placed on her door to denote high fall risk and the need for frequent safety checks. On the day of the second incident, a PTA took this high‑risk resident to the bathroom at her request before therapy. He transferred her to the toilet, placed the call light across her lap, and instructed her to pull it when she was finished, then left the room to treat another resident without remaining in arm’s length or line of sight and without notifying the nurse or CNA that she was on the toilet. The PTA later stated he did not see the fall‑risk sign on the door. Staff interviews and facility policies confirmed that residents with a STOP sign or high fall‑risk indicators required staff to remain in the bathroom within arm’s length or line of sight and that high fall‑risk residents were not to be left unattended on the toilet. Shortly after the PTA left, a CNA responding to the call light found the resident on the bathroom floor with a hematoma to the left forehead, an abrasion and hematoma to the left ear, and additional abrasions. A CT scan at the hospital revealed a subarachnoid hemorrhage in the right posterior temporal lobe, and the resident was admitted. The facility determined that the PTA failed to recognize posted fall‑risk signage and the requirement for stand‑by supervision while toileting and failed to inform nursing staff that the resident was in the bathroom alone before leaving. The surveyors determined that these failures to ensure therapy orders were current, to integrate orthotic device orders into therapy precautions and passports, and to ensure therapy staff followed care‑plan safety interventions and bathroom safety protocols resulted in Immediate Jeopardy. The identified issues affected residents who required orthotic devices and those on the active therapy caseload, as the systems in place for communicating and implementing fall‑prevention measures, including passports, signage, and therapy precautions, were not consistently followed or updated.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices, which could potentially lead to foodborne illness among residents. During a kitchen tour, surveyors observed numerous open bundles of bread on the bread rack without date markings, grease buildup inside and around the door area of the convection oven, and food debris stuck on and around the safety guard of the mixer. Additionally, milk served to residents was found at unsafe temperatures, with one carton measuring 56 F and another at 62 F, both of which were discarded. Interviews with kitchen staff revealed inconsistencies in cleaning practices and adherence to the facility's policy for date marking bread and cleaning equipment. The Executive Chef and Certified Dietary Manager confirmed that the facility's policy required bread to be labeled, dated, and discarded after three days, and that kitchen equipment should be cleaned nightly, with deeper cleaning every two weeks. However, observations indicated that these practices were not consistently followed. The facility's policy and procedure review highlighted the importance of maintaining high standards of cleanliness and adhering to the First-In-First-Out (FIFO) method for food storage to prevent pathogen growth. Despite these policies, the facility's failure to implement them properly was evident in the observed deficiencies.
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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