Blue Palms Health And Rehabilitation Center At Fle
Inspection history, citations, penalties and survey trends for this long-term care facility in Tampa, Florida.
- Location
- 4100 E Fletcher Ave, Tampa, Florida 33613
- CMS Provider Number
- 105351
- Inspections on file
- 28
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Blue Palms Health And Rehabilitation Center At Fle during CMS and state inspections, most recent first.
Two residents with intact cognition and significant mobility and incontinence needs reported long delays in call light response and assistance with toileting and incontinence care, sometimes waiting hours for help and occasionally attempting self‑care due to staff not responding. Grievance forms documented concerns about difficulty obtaining CNA assistance and delayed changing, but the written resolutions focused on unrelated dining room restrictions or staff education and stated the residents were satisfied, even though both residents later reported that no one had discussed the grievance outcomes with them and one denied ever going to the dining room. A family member reported additional unaddressed concerns about soiled clothing and unanswered call lights that were not reflected in the grievance log. Staff interviews revealed inconsistent understanding of the grievance process, and documentation and follow‑up did not align with the facility’s written grievance policy requiring thorough investigation, tracking, and written decisions communicated to residents.
The facility did not adhere to its policy on annual abuse training for staff, as evidenced by two staff members not completing the required training within the stipulated timeframe. The HR Manager confirmed the lack of a system to ensure compliance, and the DON acknowledged the policy should have been followed.
A facility failed to ensure adequate supervision and monitor assistive devices, leading to a resident's unwitnessed fall and serious injury. The care plan was not updated after the first fall, and the overinflated air mattress was not properly checked, contributing to the incident.
The facility failed to implement an effective infection prevention and control program, leading to multiple deficiencies. A resident diagnosed with C-Diff did not have timely contact precautions, and staff were observed not using PPE correctly. Additionally, proper hand hygiene was not ensured for residents before dining, and therapy dogs were allowed in rooms with residents on isolation precautions. Interviews revealed inconsistent practices and a lack of adherence to infection control protocols.
The facility failed to provide sufficient staff, resulting in significant delays in meal service and call light response. Residents on the second floor experienced prolonged waiting times for meals, with some waiting over an hour. Additionally, call lights were not promptly addressed, leaving residents without necessary assistance. Staff interviews confirmed that the current staffing levels were inadequate to meet the residents' needs.
The facility failed to maintain an effective pest control program, resulting in the presence of small flying insects in three resident rooms. Observations included insects on residents' water cups, trash cans, plates, and beds. Interviews revealed that staff were aware of the issue but had not effectively addressed it, and the pest log showed no evidence of reported insects or related work orders.
A resident with multiple diagnoses reported feeling unwell and experiencing a sensation of her skin crawling, which was communicated to staff and her POA. Despite noticeable changes in her condition, such as decreased appetite and increased depression, staff failed to take appropriate action or notify medical personnel in a timely manner. The facility did not adhere to its policy on Notification of Changes.
A resident with severe cognitive impairment and multiple physical ailments experienced two unwitnessed falls, one resulting in a nondisplaced fracture of the second cervical vertebra. The first fall was not reported to the appropriate agencies, violating facility policy. The care plan was not updated after the first fall and was only revised after the second fall, which did not result in new injuries.
The facility failed to develop and implement care plans for two residents, one with severe-profound hearing loss and another with a high fall risk. The lack of appropriate care plans and interventions led to deficiencies in addressing the residents' needs, as confirmed by staff interviews and record reviews.
The facility failed to provide adequate ADL assistance for personal hygiene for two residents, who were observed with unwanted facial hair despite expressing a preference for a clear face. There were no care plans in place to address their needs, and staff were unaware of their preferences.
The facility failed to ensure an order was in place for pressure-relieving boots for a resident and did not follow up on an order for a swallow test for another resident. Observations and interviews revealed that the boots were used without a physician's order, and there was a delay in therapy evaluations due to poor communication during morning meetings.
The facility failed to provide care consistent with professional standards of practice related to oxygen therapy for a resident. Observations revealed the resident was receiving oxygen without a physician's order, and the care plan did not include any interventions related to oxygen therapy. Staff confirmed the lack of a physician order, and the facility's policy on oxygen administration was not followed.
The facility failed to properly store and secure medications, with a resident found with unlabeled and unauthorized medications at the bedside and an unlocked medication cart left unattended in a resident hall. The responsible RN admitted to forgetting to secure the cart due to being busy.
The facility failed to inform residents that signing the arbitration agreement was optional, leading three residents with intact cognition to unknowingly sign away their rights to seek legal action. The arbitration agreement form did not explicitly state that signing was optional, and the Admissions Coordinator confirmed this omission.
The facility failed to maintain a clean and sanitary environment in four resident rooms, with observations of dirt, dust, stains, and insects. Residents reported seeing insects in their rooms and on their drinking cups. Housekeeping staff acknowledged the issues, and the Housekeeping Manager admitted to problems with caulking and infrequent use of showers. An LPN confirmed the presence of flying insects throughout the building. Additionally, another resident room had long scrape marks on the wall and cracked baseboards.
Failure to Properly Investigate and Communicate Grievance Resolutions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to appropriately receive, investigate, document, and communicate grievance resolutions for two cognitively intact residents. The Social Services Director (SSD) described a process in which residents obtain grievance forms from a pamphlet holder, submit them to SSD, and SSD then copies, logs, and routes them to the appropriate department for investigation and resolution, with follow‑up in three to five days. However, an LPN who had been working at the facility for a few weeks did not know the facility’s grievance process and only assumed a form was available somewhere. The facility’s written policy designated a Grievance Officer responsible for tracking grievances through conclusion, leading investigations, keeping residents apprised of progress, and issuing written grievance decisions that include specific required elements. One resident, admitted with multiple mobility‑related diagnoses including a left patella fracture, muscle wasting, gait abnormalities, and a BIMS score of 15, had care plans indicating a need for assistance with ADLs and toileting and a risk for falls, with interventions to assist with all ADLs and toileting and to use the call light for assistance. This resident reported long waits for CNAs to respond to call lights and stated they sometimes went to the bathroom without assistance. A grievance form completed by the Housekeeping Director documented that the resident stated it was hard to get a CNA to help them to the bathroom, but the written “action taken” and “final resolution” on the form focused on the dining room being closed due to an RSV outbreak and indicated the resident was satisfied. The resident and a family member later stated the resident had never been to or wanted to go to the dining room, did not leave the bed except for therapy, and that no one had come to discuss the grievance resolution with them, contradicting the grievance form’s notation that the resident was satisfied. The SSD stated the resident had wanted to go to the lunchroom bathroom and that SSD had explained they could not due to RSV, and also stated there was no concern about the resident’s memory because of the BIMS score of 15. The same resident’s family member reported multiple issues, including finding the resident’s pajamas soiled and call lights not being attended, and stated the facility would say they would file a grievance but nothing would be done. The family member specifically believed there should have been a grievance filed for an incident on a particular date, but review of the grievance log showed no grievances for that date or throughout the resident’s stay other than the one about needing CNA assistance to the bathroom. The Housekeeping Director confirmed that the resident had complained about long waits for call light response for bathroom assistance during angel rounds and did not know where the dining room portion of the grievance form came from, and also stated they did not speak to residents about resolutions. The DON stated that, regardless of which department head did angel rounds, SSD was to conduct the resolution, and that only the administrator or designee needed to sign the grievance, while SSD stated there was no section for other department heads to sign and that SSD always conducted follow‑ups after department heads resolved grievances. Another resident, admitted with polyarthritis, morbid obesity, anxiety, sleep apnea, muscle weakness, muscle wasting, chronic pain syndrome, and a BIMS score of 15, had care plans indicating risk for functional decline in mobility and self‑care, with an intervention to encourage use of the call light, and risk for complications related to bowel and/or bladder incontinence, with an intervention to provide incontinence care with each episode. This resident had a grievance form stating they voiced concern about not getting changed in a timely manner, with the documented action that staff were educated on answering call lights timely and a final resolution stating the resident was satisfied, signed off by SSD. In interview, the resident reported waiting two and a half hours for a brief change on one night and an hour and a half on another night, with staff coming in to turn off the call light and saying they would be right back, and believed there might be an issue with night staffing. During the interview, SSD entered the room and asked if the resident needed anything; after SSD left, the resident stated they had never seen SSD before and that SSD had not come in to discuss the grievance resolution, and they did not know what was done with the follow‑up or receive the form back. These accounts show that the facility did not consistently follow its own grievance policy requirements for investigation, documentation, and communication of written grievance decisions to residents.
Failure to Implement Annual Abuse Training Policy
Penalty
Summary
The facility failed to implement its written policy on resident abuse concerning annual abuse, neglect, and exploitation training for two staff members. Staff B, hired in 2001, last completed the required training in September 2022, while Staff C, hired in October 2022, also completed the training on their hiring date, exceeding the annual requirement. An interview with the Human Resources Manager confirmed the absence of written evidence for the completion of annual abuse training for these staff members and acknowledged the lack of an effective system to ensure compliance with the training requirement. The facility's abuse policy, dated October 2022, mandates annual education for existing staff through planned in-services. This policy requirement was not met for Staff B and Staff C, as confirmed by the Director of Nursing during an interview. The deficiency was identified during a staff record review, highlighting the facility's failure to adhere to its current abuse policy.
Failure to Prevent Falls and Monitor Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent an unwitnessed fall that resulted in serious bodily injury for a dependent resident. The resident, who had a history of falls and severe cognitive impairment, was found on the floor next to her bed on two separate occasions. The first fall resulted in a nondisplaced fracture of the second cervical vertebra, and the second fall occurred despite the implementation of some preventive measures such as fall mats and 15-minute checks. The resident's care plan was not updated after the first fall, which led to a delay in implementing necessary interventions. The air mattress used by the resident was overinflated and not properly monitored by the staff, contributing to the resident sliding off the bed. The Director of Nursing (DON) acknowledged that the air mattress was likely a contributing factor to the fall and that there was no documentation or policy in place for checking the air mattresses. Interviews with staff revealed that there was a lack of communication and proper monitoring of the resident's condition and the equipment used. The DON admitted that the care plan was not updated promptly and that the facility did not have a policy related to checking air mattresses. The facility's failure to provide adequate supervision and properly monitor assistive devices directly led to the resident's injury and subsequent falls.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, leading to multiple deficiencies. One resident diagnosed with Clostridioides difficile (C-Diff) did not have a contact precautions sign displayed timely, and staff were observed entering and exiting the room without donning and doffing personal protective equipment (PPE). The resident's positive C-Diff lab results were reported to a registered nurse, but the resident was not placed on contact precautions until the following day. Staff members were observed not performing hand hygiene and not using PPE correctly when entering rooms with contact precautions, including rooms with residents diagnosed with C-Diff and MRSA (Methicillin-Resistant Staphylococcus Aureus). Interviews with staff revealed a lack of awareness and inconsistent practices regarding the use of PPE and hand hygiene for residents on contact precautions. Additionally, the facility failed to ensure proper hand hygiene for residents before dining. Observations over three days showed that staff did not offer or assist residents with hand hygiene before meals. Staff members, including CNAs and the Director of Nursing (DON), were observed assisting multiple residents with their meals without performing hand hygiene between residents. This included instances where staff used the same hand to assist different residents without sanitizing in between. Interviews with staff indicated a lack of adherence to hand hygiene protocols and inconsistent practices in maintaining infection control standards. The facility also failed to manage the presence of therapy dogs in rooms with residents on isolation precautions. A dog handler was observed entering a resident's room with a diagnosis of MRSA without regard to the isolation kit and sign on the door. The therapy dog physically interacted with the resident and then entered another resident's room. Interviews with staff, including the DON and Activities Director, revealed that therapy dogs should not enter isolation rooms, and there was a lack of clear communication and protocols regarding the presence of therapy dogs in such rooms. The facility's policies on infection control and hand hygiene were not consistently followed, leading to multiple deficiencies in infection prevention and control practices.
Inadequate Staffing Leads to Delays in Meal Service and Call Light Response
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, particularly during meal times and in responding to call lights. Observations revealed that residents on the second floor experienced significant delays in receiving their meals. For instance, Resident #32 waited approximately one hour and twenty minutes to receive her lunch tray, and Resident #54 waited one and a half hours for breakfast. Staff interviews confirmed that there were not enough CNAs to assist all residents in a timely manner, leading to prolonged waiting times for meal assistance. Hospice staff, who were not familiar with the residents' needs, were observed stepping in to help due to the shortage of facility staff. Additionally, the facility failed to respond promptly to call lights. Resident #20 activated his call light at 12:09 p.m., but it was not addressed until 12:27 p.m., and even then, the CNA turned off the light without providing the needed assistance. The resident had to reactivate the call light and wait further before being attended to. Interviews with staff indicated that during meal times, there were no staff members available to respond to call lights as they were all occupied with assisting residents with meals. The facility's policies and staffing levels were found to be inadequate in meeting the residents' needs. The Staffing Coordinator admitted that staffing numbers were based on a calculation sheet rather than residents' acuity. The Director of Nursing and other staff acknowledged that the current staffing levels were insufficient, especially during meal times, leading to delays in meal service and response to call lights. The facility's failure to provide adequate staffing resulted in residents waiting excessively for meals and assistance, compromising their care and well-being.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of small flying insects in three resident rooms (212, 216, and 218) on one of two floors. Observations were made of these insects on residents' water cups, trash cans, plates, and beds. One resident reported seeing a cockroach in the bathroom and mentioned that the cleaning could be better. Interviews with housekeeping staff revealed that they were unaware of the insect issue, and the Housekeeping Manager stated that no one had reported the problem to her. The facility's pest control contractor visits weekly, but the issue persisted due to infrequent use of showers and potential drain problems. The pest log showed no evidence of reported insects or related work orders or treatments. Further interviews with staff, including an LPN/Unit Manager and the Director of Facilities, confirmed that the issue of small flying insects was known but not effectively addressed. The LPN/Unit Manager acknowledged that insects should not be present on residents' drinking cups or in their spaces and noted that maintenance had been informed but had not resolved the issue. The Director of Facilities mentioned that the pest control contractor had visited the previous week but could not find a breeding place for the insects. The facility's policy on maintaining a safe and sanitary environment was not upheld, as evidenced by the presence of pests and the lack of documented pest control measures.
Failure to Address Change in Resident's Condition
Penalty
Summary
The facility failed to ensure a change in condition was addressed for a resident diagnosed with cerebral infarction, unspecified atrial fibrillation, dysphagia, and needing assistance with personal care. The resident reported feeling unwell and experiencing a sensation of her skin crawling, which she had communicated to the staff and her power of attorney (POA). Despite these reports, there was no documented follow-up or assessment of her condition until much later. Interviews with various staff members, including a CNA, Food Service Coordinator, and RN, revealed that they had noticed changes in the resident's condition, such as decreased appetite and increased depression, but failed to take appropriate action or notify the necessary medical personnel in a timely manner. The POA also reported a noticeable decline in the resident's condition following a move within the facility, which had not been adequately addressed by the staff. The resident's concerns were not documented, and no SBAR (Situation, Background, Assessment, Recommendation) or Change in Condition forms were completed. The LPN/Unit Manager confirmed that the resident had experienced a change in condition related to her blood pressure over the weekend, but there was insufficient follow-up until the day of the interview. The facility's policy on Notification of Changes was not adhered to, resulting in a failure to promptly inform the resident, consult the physician, and notify the resident's representative of the change in condition.
Failure to Report Serious Injury from Unwitnessed Fall
Penalty
Summary
The facility failed to report an unwitnessed fall that resulted in a serious bodily injury for a resident. The resident, who had a history of severe cognitive impairment and multiple physical ailments, was found on the floor next to her bed on two separate occasions. The first fall resulted in a nondisplaced fracture of the second cervical vertebra, but this incident was not reported to the appropriate agencies as required by policy. The second fall, which did not result in any new injuries, was reported only after a family member threatened to call the State Agency. The resident was admitted with multiple diagnoses, including a nondisplaced fracture of the second cervical vertebra, dementia, and a history of falls. The resident was dependent on staff for self-care and mobility and had a severe cognitive impairment with a BIMS score of 6 out of 15. The resident's care plan included various interventions to prevent falls, but these were not updated after the first fall that resulted in a serious injury. The care plan was only revised after the second fall. Interviews with staff revealed that the air mattress used by the resident may have been overinflated, potentially contributing to the fall. The Director of Nursing admitted that the air mattress was replaced after the first fall but did not ensure that the incident was reported. The facility's policy on abuse prevention and prohibition clearly states that incidents resulting in serious bodily injury must be reported within two hours, but this protocol was not followed in the case of the first fall.
Failure to Implement Care Plans for Hearing Impairment and Fall Risk
Penalty
Summary
The facility failed to develop and implement a care plan for two residents, leading to deficiencies in their care. Resident #23, who had severe-profound hearing loss, was observed without hearing aids and unable to communicate effectively. Despite an audiology report recommending amplification and a progress note indicating the hearing aids were lost, no care plan or interventions were in place to address the resident's hearing impairment. Staff members were unaware of the resident's hearing issues, and attempts to communicate with the resident were ineffective and inappropriate, as observed in the dining room where a staff member had to yell into the resident's ear multiple times. Resident #670, who had a high fall risk score, experienced a fall in the facility. The resident's fall risk was documented in the Fall Risk Evaluation, but no care plan was initiated to address this risk until after the fall occurred. The resident's baseline care plan did not indicate a fall risk, and the comprehensive care plan for fall risk was only put in place the day after the fall. Interviews with staff confirmed that a fall risk care plan should have been in place prior to the incident, but it was not. The facility's policies on comprehensive care plans, hearing and vision services, and fall prevention were not followed. The policies required the development and implementation of care plans based on comprehensive assessments, but these were not adhered to for the two residents. The lack of appropriate care plans and interventions led to deficiencies in addressing the residents' needs, as confirmed by staff interviews and record reviews.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically related to personal hygiene. Resident #122 was observed on two occasions with white facial hair on her chin, despite expressing a preference for a clear face. The resident's medical records indicated a need for assistance with personal care, but there was no care plan in place to address this need. Interviews with the resident and staff confirmed that the resident had not been offered assistance with removing the facial hair, and the staff were unaware of the resident's preference and need for this specific ADL assistance. Similarly, Resident #123 was observed with white facial hair on her chin on two separate occasions. The resident expressed a desire to have the facial hair plucked and mentioned that she could do it herself if provided with a mirror and tweezers. Despite being cognitively intact and receiving occupational therapy for personal care needs, there was no care plan in place to address her ADL needs related to facial hair. Interviews with the resident, staff, and the Director of Rehabilitation revealed a lack of communication and coordination regarding the resident's personal care needs. The Director of Nursing (DON) and the MDS Coordinator acknowledged that care plans should be in place to address residents' ADL needs and that staff should anticipate and assist with these needs. However, the care plans for Residents #122 and #123 were missing, and the staff did not provide the necessary assistance with personal hygiene. The facility's policies on ADLs and promoting resident dignity were not followed, leading to the observed deficiencies in care.
Failure to Ensure Proper Orders and Follow-Up for Resident Care
Penalty
Summary
The facility failed to ensure an order was in place for pressure-relieving boots being utilized for a resident. Observations revealed the resident in bed with pressure-relieving boots on both feet, but a review of the resident's active physician orders did not show an order for these boots. Interviews with staff confirmed that the boots were used based on nursing judgment without a physician's order, and the Unit Manager acknowledged the oversight in not obtaining a proper order and specific instructions from the doctor for the use of the boots. Additionally, the facility failed to follow up on an order for a swallow test for another resident. The resident was observed with her tube feeding disconnected and later connected, and she expressed a preference to stay in bed. The resident's medical records indicated a need for a swallow test and occupational therapy evaluation, but there was a delay in follow-up due to poor communication during morning meetings. The therapy screen and progress notes confirmed the need for the swallow test and therapy evaluations, but these were not completed in a timely manner. Interviews with staff revealed that the delay in follow-up was related to poor communication during morning clinical meetings. The facility's policy on therapy referrals was reviewed, but the policy and procedure for morning clinical meetings were not provided by the last day of the survey. The lack of timely follow-up and proper documentation for therapy evaluations and physician orders contributed to the deficiencies identified in the report.
Failure to Provide Proper Oxygen Therapy
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice related to oxygen therapy for a resident. Observations revealed that the resident was receiving oxygen via a nasal cannula with the oxygen concentrator set at two liters per minute. However, the oxygen tubing was found touching the floor, and the storage bag was outdated. Further review of the resident's records showed no physician orders for oxygen therapy, and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not document the administration of oxygen therapy. Additionally, the resident's care plan did not include any focus, goal, or interventions related to oxygen therapy. Interviews with staff confirmed that there was no physician order for the observed oxygen use. The facility's policy on oxygen administration requires that oxygen be administered under the orders of a physician, except in emergencies, and that staff document the initial and ongoing assessment of the resident's condition and response to oxygen therapy. The policy also mandates that the resident's care plan identify interventions for oxygen therapy based on the resident's assessment and orders. The facility's failure to adhere to these policies resulted in the deficiency noted in the report.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to appropriately store and secure medications on the 1st floor and the 200 hall. In Resident #120's room, a white cream in a medicine cup, a bottle of eye drops, and a container of Icy Hot were found on the resident's over bed table and nightstand without proper labeling or physician orders. The resident indicated that the items were personal purchases, but there was no documentation or assessment for self-administration of these medications. Staff G, an RN, was unaware of the substances and discarded the creams, but returned the eye drops to the resident. The DON later confirmed that the resident now has an assessment and physician orders for the medications, but initially, there was no proper storage or documentation for these items. Additionally, an unlocked medication cart was observed on the 200 unit with keys hanging from the open lock and no staff members in sight. Staff V, the RN responsible for the cart, confirmed that it should always be locked when not in use and admitted to forgetting to secure it due to being busy. This lapse in protocol left medications unsecured and accessible in a resident hall, posing a potential risk to residents.
Failure to Inform Residents of Optional Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement explicitly informed residents or their representatives of their right to not sign it. This deficiency was identified for three residents who were their own responsible parties and had intact cognition as indicated by their BIMS scores. During interviews, all three residents stated they were not aware that the arbitration agreement was optional and that signing it meant giving up their right to seek legal action. They indicated that had they known the agreement was optional, they would not have signed it. The facility's arbitration agreement did not include an explicit statement informing residents or their representatives that signing the agreement was optional. The Admissions Coordinator confirmed that while the arbitration agreement is verbally explained to residents, the form itself did not indicate that signing was optional. This lack of explicit information on the form led to the residents unknowingly signing away their rights to seek legal action, believing it was a mandatory part of the admission process.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in four resident rooms (212, 216, 217, and 218) on one of the two floors. Observations revealed dirt, dust, and stains in the bathrooms, with brown matter around the toilet bases and a plastic storage bin under the toilet covered in dust. Residents reported seeing insects, including cockroaches and small flying insects, in their rooms and on their drinking cups. Housekeeping staff acknowledged the cleanliness issues and mentioned notifying their supervisor about stains and bugs. The Housekeeping Manager admitted to problems with caulking around toilet bases and stated that the facility had a pest control contractor who visits weekly. However, the issue with small flying insects was attributed to infrequent use of showers and potential drain problems. A Licensed Practical Nurse (LPN) confirmed the presence of flying insects throughout the building and expressed concern about insects on residents' drinking cups and plates, noting that maintenance had been informed but the issue persisted. Additionally, an observation of another resident room revealed long scrape marks on the wall behind the head of the bed and cracked baseboards with missing chunks of wood. The facility's policy on daily resident room cleaning and resident environment quality emphasized maintaining a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. However, the observed conditions in the resident rooms and bathrooms indicated a failure to adhere to these policies, resulting in an unsanitary and uncomfortable living environment for the residents.
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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