Blue Lake Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Deland, Florida.
- Location
- 991 E New York Ave, Deland, Florida 32724
- CMS Provider Number
- 105262
- Inspections on file
- 18
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Blue Lake Post Acute during CMS and state inspections, most recent first.
Eight residents were found to have long, thick, and discolored toenails, with several reporting pain and discomfort, and none had current or past podiatry care orders. Staff interviews revealed unfamiliarity with nail care policies, lack of documentation, and delays in arranging podiatry services, resulting in residents not receiving necessary foot care.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with moderate cognitive impairment. Despite known behavioral issues and previous orders for increased monitoring, staff failed to provide adequate supervision, resulting in inappropriate sexual contact. Care plans and interventions were not updated promptly, and administrative follow-up was delayed, leaving the resident and others at risk.
A female resident with severe cognitive impairment and behavioral issues was found in another resident's bed with her pants unbuttoned, while a male resident stood beside her with his hand inside her pants. Staff failed to maintain adequate supervision despite escalating inappropriate interactions. The facility's investigation was incomplete and inconsistent, with missing or inaccurate witness statements and a lack of timely interviews. Care plans and monitoring orders were not promptly updated or implemented for either resident following the incident.
Facility staff failed to provide appropriate supervision and implement necessary interventions to protect a cognitively impaired resident from sexual abuse by another resident. Despite clear behavioral warning signs and physician orders for increased monitoring, staff left the residents unsupervised, resulting in an incident of inappropriate sexual contact. Documentation and investigation of the event were inconsistent, and the administration did not ensure protective measures were in place.
A QAA committee failed to develop and implement effective corrective actions after an incident where a female resident with severe cognitive impairment and behavioral issues was found in a male resident's bed with evidence of inappropriate sexual contact. Staff observed escalating inappropriate interactions but did not maintain adequate supervision, and the facility did not promptly update care plans or communicate with the Medical Director. The QAPI process was not followed as required by facility policy.
The facility did not promptly report allegations of abuse and the results of related investigations to the State Survey Agency as required. In one case, a resident with multiple health issues experienced rough treatment by a CNA, which was not immediately reported as abuse. In another case, two residents were involved in inappropriate sexual behavior, but the incident was not reported within the required timeframe. The facility's actions did not align with its own policy or federal reporting requirements.
The facility failed to prevent contamination of refrigerated food due to an unclean evaporator fan in the walk-in refrigerator. Observations revealed a build-up of dust-like debris on the fan, which was not cleaned over several days. This resulted in a tray of sandwiches being exposed to potential contamination after the plastic wrap was blown off by the fan. The certified dietary manager confirmed the issue and identified the Maintenance Department as responsible for cleaning the fan.
The facility failed to provide documentation for its QAPI program during a review with the Administrator and DON. Despite claims of monthly meetings and performance improvement plans, no evidence was available. The only document provided was an outdated sign-in sheet, and the facility's QAPI policy was not presented.
A facility failed to complete and submit MDS assessments for several residents within the required timeframes. An LPN responsible for these tasks was unaware of the overdue assessments until informed during a survey. The residents affected had complex medical conditions, and the deficiency persisted despite the LPN's efforts to manage the workload.
The facility failed to complete quarterly MDS assessments for four residents, as identified during a review of records and staff interviews. An LPN responsible for assisting with these assessments was unaware of the overdue status until informed, acknowledging the late submissions. The assessments were not completed in a timely manner, affecting the comprehensive evaluation of residents' needs and goals.
A facility failed to notify a resident and her representative in writing about an emergency hospital transfer, and did not inform the LTCO. The resident, with a history of mental health issues, exhibited aggressive behavior leading to an involuntary psychiatric admission. The facility did not provide the required AHCA Transfer/Discharge Notice or notify the LTCO, as confirmed by the Social Services Director.
A facility failed to provide a resident and/or their representative with written notification of the bed-hold policy during a hospital transfer. The resident, with multiple mental health diagnoses, was involuntarily admitted to a psychiatric unit due to aggressive behavior. The facility did not document any written notice about the bed-hold policy, as confirmed by the SSD.
The facility failed to refer residents with newly diagnosed serious mental illnesses for PASRR Level II screenings, affecting three residents. A resident with schizoaffective disorder and other mental health diagnoses, another with major depressive disorder and generalized anxiety disorder, and a third with generalized anxiety disorder were not referred for necessary screenings. The Social Services Director noted the absence of a system to review Level I screenings for necessary Level II referrals, despite facility policy requiring such actions upon significant changes in mental health status.
A resident with severe cognitive impairment was found unsupervised, trimming her own toenails despite having a history of onychomycosis and associated pain. The facility lacked an assessment of her ability to safely perform nail care and had no policy on residents' use of nail clippers. Staff were unaware of the resident's possession of clippers and the podiatrist's findings, leading to inadequate supervision and risk of injury.
The facility failed to implement effective infection control practices, as two residents were observed without enhanced barrier precautions (EBP) signage. One resident with a urinary catheter had the collection bag and tubing touching the floor, while another with an enteral feeding tube also lacked EBP signage. Staff interviews revealed inconsistencies in training and communication regarding EBP, highlighting a gap in the facility's infection prevention policy implementation.
Failure to Provide Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide foot care consistent with professional standards of practice for eight residents reviewed. Multiple residents were observed to have very long, thick, and discolored toenails, with some residents reporting pain and discomfort. Interviews with residents and their family members revealed that they had not seen a podiatrist, and photographic evidence was obtained to document the condition of their toenails. Review of medical records and physician's orders for these residents showed no current, past, or discontinued orders for podiatry care, visits, or referrals, except for one resident who had a single podiatry note with no ongoing documentation of foot or toenail care. Staff interviews indicated a lack of familiarity with the facility's nail care policy and procedure. The unit manager stated that while feet are assessed for skin issues, toenail conditions are not documented, and residents with long or damaged toenails are placed on a list for podiatrist visits, which are coordinated by social services. Certified Nursing Assistants reported that they do not cut residents' nails and would report long nails to a nurse. The Social Services Director explained that previous podiatry services required cash payment and that a new contract with a podiatrist had recently been established, but services had not yet started. The appointment book for podiatry visits could not be located when requested. The Director of Nursing confirmed that a new podiatrist had been contracted but was unaware of a start date and was not familiar with the nail care procedure. Overall, the facility did not ensure that residents received necessary foot care or assistance in making appointments with qualified healthcare providers, resulting in multiple residents experiencing prolonged periods without appropriate podiatry care.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident with moderate cognitive impairment. The resident who was unable to consent to sexual activity had a history of aggressive behaviors, severe cognitive deficits, and required significant assistance with personal care. Despite documented behavioral issues and a care plan noting inappropriate sexual advances, the facility did not implement or maintain adequate supervision or interventions to prevent inappropriate contact between the two residents. On the day of the incident, staff observed escalating physical interactions between the two residents, including hand-holding and attempts at physical closeness, but only provided verbal redirection and did not increase supervision. Both residents were left unsupervised for a period, during which time staff later found the resident with severe cognitive impairment in the other resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Documentation revealed that orders for increased monitoring had been discontinued prior to the incident, and there was no evidence of frequent or one-on-one supervision in place at the time of the event. Following the incident, it was noted that care plans and interventions for both residents were not updated in a timely manner to address the risk of further inappropriate contact. The facility's policies required immediate intervention and protection in cases of suspected abuse, but staff interviews and record reviews indicated that administrative follow-up and investigation were delayed. The lack of prompt and effective interventions created an ongoing risk for abuse of the resident and potentially other vulnerable residents.
Failure to Investigate Sexual Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, resulting in a deficiency cited at Immediate Jeopardy level. The incident involved a female resident with severe cognitive impairment, behavioral disturbances, and a history of aggression and wandering, and a male resident with moderate cognitive impairment and no prior behavioral issues. On the day of the incident, staff observed escalating inappropriate interactions between the two residents, including physical contact and attempts to sit together, but did not maintain adequate supervision. Eventually, both residents were found in the male resident's room, with the female resident lying on the bed with her pants unbuttoned and the male resident standing beside her with his hand inside her pants. Both LPNs present at the scene confirmed witnessing this event. The facility's investigation into the incident was incomplete and inconsistent. The Administrator initially failed to obtain statements from all involved staff, provided conflicting information about witness identities, and did not interview the male resident involved. There were discrepancies in the documentation and staff schedules, and the Administrator relied on statements that were later found to be inaccurate or attributed to the wrong individuals. The investigation was not promptly or thoroughly conducted, as required by the facility's own abuse policy, and the Administrator only substantiated the abuse allegation after being confronted with new information from staff interviews days after the incident. Additionally, the facility did not implement or document appropriate supervision or care plan interventions for either resident immediately following the incident. Orders for increased monitoring were either discontinued or not implemented, and care plans were not updated in a timely manner to address the behavioral risks. The lack of a prompt, thorough investigation and failure to ensure resident safety and supervision contributed to the deficiency cited by surveyors.
Failure to Supervise and Protect Resident from Sexual Abuse
Penalty
Summary
Facility administration failed to ensure appropriate supervision and protection of a vulnerable resident from sexual abuse. One resident with severe cognitive impairment, aggressive behaviors, and a history of wandering and inappropriate actions was not provided with consistent monitoring as ordered by physicians. Orders for 1:1 and 30-minute monitoring were inconsistently implemented and, at times, discontinued without documentation of increased or frequent monitoring, leaving the resident unsupervised for extended periods. On the day of the incident, staff observed escalating interactions between two residents, including physical contact and attempts at inappropriate proximity. Despite these warning signs, staff left the area to attend to other duties, resulting in both residents being unsupervised. When staff returned, they found the cognitively impaired resident in another resident's bed with her pants unbuttoned and the other resident's hand inside her pants. Both residents were fully clothed, but the situation indicated inappropriate sexual contact had occurred without adequate supervision or intervention. Interviews and record reviews revealed confusion and inconsistencies in staff documentation, witness statements, and the facility's investigation process. The administration did not ensure that interventions for increased supervision were implemented for either resident following the incident, and there was a lack of clear communication and follow-through regarding abuse investigation and reporting. The failure to provide necessary supervision and to implement protective interventions created a situation of immediate jeopardy for vulnerable residents.
Failure of QAA Committee to Address and Correct Quality Deficiencies Leading to Resident Sexual Abuse
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that resulted in adverse outcomes. This failure was evident in the lack of improvement in systems and processes, which contributed to an incident of sexual abuse involving a female resident with severe cognitive impairment and a male resident. The QAA did not initiate or follow through with performance improvement projects or ad hoc QAPI meetings after the incident, and the Medical Director was not promptly informed of the event or the transfer of the involved male resident. The female resident involved had a history of severe cognitive impairment, aggressive behaviors, and required significant assistance with personal care. Her care plan documented behavioral issues, including aggression and inappropriate behaviors, but monitoring orders were inconsistently implemented and discontinued without documentation of increased supervision. On the day of the incident, staff observed escalating inappropriate interactions between the two residents but did not maintain adequate supervision, resulting in the female resident being found in the male resident's bed with evidence of inappropriate sexual contact. The male resident had moderate cognitive impairment and no prior psychiatric diagnoses or behavioral issues documented before the incident. After the event, his care plan was updated to include interventions for hypersexuality, but there was no intervention for increased supervision from the time of the incident until his transfer. Staff interviews revealed that administrative and clinical leadership did not conduct an ad hoc QAPI meeting or ensure timely communication with the Medical Director. The facility's QAPI policy required proactive and comprehensive quality improvement actions, but these were not followed in response to the incident.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure that all alleged violations related to abuse were reported immediately, but not later than two hours after the allegation was made, to the appropriate officials, including the State Survey Agency. Additionally, the facility did not report the results of the investigations to the State Survey Agency within five working days of the incidents. These failures were identified in three residents reviewed for abuse out of a total survey sample of eight residents. The reporting requirements under this regulation are based on real (clock) time, not business hours. One resident, who had multiple complex medical conditions including acute respiratory failure, congestive heart failure, diabetes, morbid obesity, and moderate cognitive impairment, was involved in an incident where his family alleged that a CNA was rough and rude while assisting him with toileting. The incident was initially reported by the resident to his family, who then reported it to the facility. The facility's Social Services Director completed a grievance form, but the incident was not immediately recognized or reported as abuse. The Administrator initially considered the matter a customer service issue and did not file an abuse report until confronted by the family, resulting in a delay in reporting the allegation to the State Survey Agency. In another incident, two residents were found in a situation involving likely inappropriate sexual behavior. Nursing staff discovered the incident and separated the residents, notifying the Administrator in Training. However, the facility did not submit the required 5-day federal report until several days after the incident, with the Administrator stating that submission within five business days was considered timely according to their practice. The facility's own policy required reporting of abuse allegations within two hours, but this was not followed in these cases.
Refrigerated Food Contamination Risk Due to Unclean Fan
Penalty
Summary
The facility failed to store refrigerated food in a manner that prevents contamination by airborne matter. During an initial tour of the kitchen, the walk-in refrigerator's evaporator fan was observed with a build-up of thick, dark matter resembling dust on the grates of the fan cover. This debris was moving due to the fan blowing cold air around, posing a risk of contamination to exposed food. A subsequent inspection revealed that the fan remained uncleaned, with visible dust-like debris on all surfaces. A tray of sandwiches in the refrigerator was found with its plastic wrap blown off, exposing the food to potential contamination. The certified dietary manager confirmed the soiled condition of the fan and the risk to the uncovered food, stating that the Maintenance Department was responsible for cleaning the fan.
Lack of Documentation for QAPI Program
Penalty
Summary
The facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. During a QAPI review with the Administrator and the Director of Nursing, no current documentation was provided to verify the development, implementation, and maintenance of an effective, comprehensive, data-driven QAPI program. The only document provided was a QAPI Plan Review form dated over two years prior, which was merely a sign-in sheet with staff signatures. Additionally, policy and procedure manuals were presented, but they did not pertain to the QAPI program. The Administrator claimed that monthly QAPI meetings were held and that there were two current performance improvement plans in place, but no documented evidence was available to support these claims. Furthermore, the Administrator mentioned an annual review of facility policies and procedures with the QAPI committee, yet no documentation was provided to verify this review. The facility's QAPI policy was also not provided during the survey.
Deficiency in Timely MDS Assessments
Penalty
Summary
The facility failed to comprehensively assess residents' strengths, needs, preferences, and goals within the required timeframes for five residents out of a sample of nine whose Minimum Data Set (MDS) assessments were reviewed. This deficiency was identified during a survey of 34 residents. The residents affected included those with complex medical conditions such as congestive heart failure, dementia with behavioral disturbances, schizoaffective disorder, encephalitis, encephalomyelitis, hemiplegia/hemiparesis following a cerebral infarction, metabolic encephalopathy, and diffuse traumatic brain injury. The assessments in question were either incomplete or not finalized and electronically submitted, as required. The issue was primarily linked to the actions of an LPN who was responsible for initiating and transmitting the MDS assessments. The LPN had been assisting with these assessments for about 90 days and was unaware of the outstanding or overdue assessments until informed during the survey. Despite acknowledging the overdue assessments, the LPN stated she was doing her best to manage the workload. The Director of Nursing was responsible for reviewing and locking the assessments, but the deficiency persisted, indicating a lapse in the timely completion and submission of the required assessments.
Incomplete Quarterly MDS Assessments
Penalty
Summary
The facility failed to comprehensively assess residents' strengths, needs, preferences, and goals quarterly for four of nine sampled residents whose Minimum Data Set (MDS) assessments were reviewed. This deficiency was identified during a review of resident records and an interview with staff. Specifically, the quarterly Minimum Data Set (QMDS) assessments for Residents #15, #14, #9, and #42 were not completed in a timely manner. Resident #15's QMDS initiated on 5/30/24 was still in progress, Resident #14's QMDS was also incomplete, Resident #9's most recent QMDS was still in progress, and Resident #42's QMDS was not completed. These assessments were initiated by Licensed Practical Nurse (LPN) J. During an interview, LPN J confirmed that she had been assisting with MDS assessments over the last 90 days and acknowledged the late submissions. She stated that once the assessments were done, the Director of Nursing reviewed and locked them, and then she transmitted them electronically. However, she was not aware of any outstanding or overdue assessments until informed of the findings. LPN J admitted to the late submissions and expressed that she was doing her best to help, indicating a lack of awareness and oversight in the timely completion of these assessments.
Failure to Notify Resident and LTCO of Emergency Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and her representative regarding an emergency hospital transfer, as well as failing to notify the Office of the State Long-Term Care Ombudsman (LTCO). The resident, who had a history of type 2 diabetes mellitus, schizoaffective disorder, dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and seizure disorder, exhibited aggressive behavior on the day of the incident. She was pacing, yelling, and threatening other residents, which led to her being removed from the area. Despite these actions, she returned and continued to display aggressive behavior. A clinical psychologist completed a Certificate of Professional Initiating Involuntary Examination, noting the resident's refusal for voluntary examination and her potential to cause harm due to her mental illness. Consequently, the resident was admitted to a psychiatric ward with police assistance. However, the facility did not provide an AHCA Transfer/Discharge Notice to the resident or her representative, nor did they inform the LTCO in writing about the transfer. An interview with the Social Services Director confirmed the absence of written notice and notification to the LTCO, indicating a lapse in the facility's protocol for handling such transfers.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to a resident and/or the resident's representative regarding the bed-hold policy and the duration for which the bed would be held during the resident's transfer to a hospital. This deficiency was identified during a review of resident records and staff interviews, specifically concerning a resident who was transferred to a psychiatric unit under an involuntary admission. The resident's medical record lacked evidence of any written notice about the bed-hold policy, which is a requirement. The resident involved had multiple diagnoses, including type 2 diabetes mellitus, schizoaffective disorder, dementia, and other mental health conditions. On the day of the incident, the resident exhibited aggressive behavior, threatening other residents and staff, which led to her being transported by police to a psychiatric unit. Despite these events, the facility did not provide the necessary written information about the bed-hold policy to the resident or her representative, as confirmed by the Social Services Director during an interview.
Failure to Refer Residents for PASRR Level II Screening
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental illnesses for a Pre-Admission Screening and Resident Review (PASRR) Level II screening, which is necessary to ensure appropriate care and services. This deficiency was identified for three residents out of a sample of 34. Resident #25 had diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder, but was not referred for a Level II screening upon admission or after new diagnoses. Similarly, Resident #40, admitted with major depressive disorder and later diagnosed with generalized anxiety disorder, was not referred for a Level II screening. Resident #47, diagnosed with generalized anxiety disorder, also lacked a Level II screening referral. The Social Services Director (SSD) acknowledged that there was no current system in place to review Level I screenings for new or existing diagnoses that would necessitate a Level II review. The SSD had previously been responsible for monitoring PASRRs and submitting Level II review requests, but this responsibility was shifted to nursing staff without a clear process in place. The facility's policy requires referrals for Level II reviews upon significant changes in residents' mental health status, but this was not adhered to, leading to the deficiency.
Failure to Supervise Resident's Nail Care
Penalty
Summary
The facility failed to identify and minimize the risk of accidents and provide adequate supervision to prevent accidental injury for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including unspecified dementia and schizoaffective disorder, was observed performing her own toenail care unsupervised, despite having a history of onychomycosis and associated pain. The resident's medical record lacked an assessment of her ability to safely perform her own nail care, and there was no facility policy or protocol regarding the use of nail clippers by residents. The resident was seen by a podiatrist who noted the risk of soft tissue damage due to her thickened, elongated toenails. Despite this, the resident was found trimming her toenails with a metal nail clipper without staff supervision. Interviews with staff revealed a lack of awareness regarding the resident's possession of nail clippers and the podiatrist's findings. The Director of Nursing and other staff members were unaware of any policy or protocol for assessing residents' safe use of sharp grooming implements. Staff interviews indicated that the resident was known to reject assistance with activities of daily living, and there was confusion among staff about who was responsible for toenail care. The resident's guardian was informed of the situation, and staff attempted to retrieve the nail clippers from the resident, who refused to relinquish them. The lack of communication and clear protocols contributed to the oversight in the resident's care, leading to the deficiency noted in the report.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of enhanced barrier precautions (EBP) for two residents. Resident #38, who was admitted with an indwelling urinary catheter and had a history of urinary tract infections, was observed multiple times with his catheter collection bag and tubing touching the floor, without any EBP signage on his room door. Interviews with staff revealed that while they had received some training on catheter care, there was a lack of consistent implementation of preventive measures, such as ensuring the catheter bag did not touch the floor. Similarly, Resident #22, who had an enteral feeding tube, was observed on several occasions without EBP signage on his room door. Staff interviews indicated confusion about how they were informed of residents requiring EBP, with reliance on electronic records and shift change reports rather than visible signage. The Infection Preventionist/Director of Nursing confirmed that signage should be present to alert staff and visitors of necessary precautions. The facility's infection prevention and control policy aimed to prevent the transmission of infections and manage nosocomial infections, but the observed deficiencies highlighted a gap in the implementation of these policies. The lack of EBP signage and improper catheter care practices for the sampled residents demonstrated a failure to adhere to the facility's stated procedures, potentially increasing the risk of infection transmission.
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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