Cedarbrook Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Myers, Florida.
- Location
- 1600 Matthew Drive, Fort Myers, Florida 33907
- CMS Provider Number
- 105723
- Inspections on file
- 22
- Latest survey
- November 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedarbrook Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic back pain experienced severe pain due to the facility's failure to provide timely administration of prescribed pain medications. Despite having physician orders for Morphine and Roxicodone, the medications were not in stock, leading to a significant delay in pain relief. The resident reported a high pain level and was unable to start therapy. Staff communication issues contributed to the delay, as the DON was not informed of the resident's needs promptly.
The facility failed to maintain a clean and comfortable environment, with issues such as a strong odor of urine, insects, and unsanitary conditions in resident rooms. Residents reported a lack of clean linen, and the laundry room had broken equipment. The Maintenance Director and Housekeeping Supervisor acknowledged these issues, with no maintenance book or PAR system in place.
The facility failed to provide adequate personal hygiene care for several residents, including those with dementia and other health conditions. Observations and interviews revealed missed showers, unshaven residents, and inconsistent documentation of care. Residents and their families reported dissatisfaction with the care provided, highlighting issues with staff responsiveness and adherence to care plans.
A facility failed to provide sufficient staffing, leading to delayed responses to call lights and inadequate personal care for residents. Observations and interviews revealed long wait times for assistance, unmet hygiene needs, and insufficient documentation of care activities. Family members expressed concerns about staffing levels, particularly in the memory care unit.
A resident's representative was not informed of a dose reduction and discontinuation of Seroquel, an antipsychotic medication, despite the resident's significant other being responsible for healthcare decisions. The resident, with severe cognitive impairment, experienced behavioral changes after the medication was discontinued. Interviews confirmed the lack of documentation and notification, although a discussion occurred during a care plan meeting.
The facility failed to ensure accurate comprehensive assessments of activity preferences for two residents with severe cognitive impairments. Both residents' MDS assessments inaccurately marked all activity preferences as 'very important,' despite their inability to provide accurate responses. The administrator acknowledged issues with the previous Activity Director's documentation.
The facility failed to provide a meaningful, resident-centered activity program for two residents with cognitive impairments. One resident with dementia was often left sitting alone without engagement, despite a care plan outlining various activities. Another resident with Parkinson's and dementia was observed with minimal activity participation, and their significant other noted a lack of staff assistance to activities. The Activity Director, new to the position, acknowledged challenges in providing individualized activities, and the Administrator noted issues with previous staff not completing assessments.
A resident with an indwelling urinary catheter experienced improper catheter care as the drainage bag was repeatedly found on the floor, contrary to facility policy. Despite staff awareness of proper procedures, a lack of supplies led to the use of a makeshift paper clip hook to keep the bag off the floor, resulting in unsanitary conditions.
Two residents in the facility experienced deficiencies in IV therapy management. One resident had a PICC line with an undated dressing and unlabeled IV solution, with no documented care orders. Another resident had an IV catheter in place without current treatment orders, and staff were unaware of the necessary care instructions. Both cases lacked adherence to facility policy and professional standards for IV care.
The facility did not maintain nebulizer machines in a sanitary manner for two residents. Observations revealed uncovered and undated nebulizer masks on nightstands. The facility's policy requires masks to be stored in plastic bags and dated. A Unit Manager confirmed the responsibility lies with the unit nurse.
A resident with Type II Diabetes, Celiac Disease, and malnutrition was not provided with a diet that met her gluten and lactose dietary restrictions. She reported being served oatmeal and grits, which she could not eat. Observations revealed she was served 2% milk, cereal, and non-gluten-free bread, contrary to her dietary needs. The Dietary Manager confirmed these errors.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident with chronic back pain due to spinal stenosis, resulting in the resident experiencing severe pain. Upon admission, the resident had physician orders for Morphine Sulfate and Roxicodone to manage chronic pain. However, the facility did not have the prescribed medications in stock, and the resident did not receive the first dose of Roxicodone until the following day, and the first dose of Morphine was delayed even further. The resident reported waiting 20 hours for pain relief, experiencing a pain level of 7 out of 10, and was unable to start therapy due to the pain. Interviews with staff revealed that the prescription for Morphine was faxed to the pharmacy but was not available at the facility. The resident was offered Tylenol instead, which was not sufficient for her pain level. Communication issues were evident as the Director of Nursing (DON) was not aware of the prescription being available and had not been informed of the resident's needs on the day of admission. The DON began educating staff on the issue only after becoming aware of the situation, indicating a lack of immediate response to the resident's pain management needs.
Facility Fails to Maintain Sanitary Environment and Adequate Linen Supply
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Upon entrance, a strong odor of urine was detected, and a large brown insect was found crawling in the dining room. Maintenance staff confirmed the presence of the insect, which was alive. Additionally, a resident's indwelling catheter drainage bag was observed on the floor, and the wall in one room had unpainted patches. Another room had a toilet plunger stored in a wash basin, urine in the toilet, black grout, and peeling tiles, with a strong odor of urine reported by a resident's spouse. Several residents reported unsanitary conditions, including sticky floors with crumbs, feces on the bathroom floor, and clogged sinks. One resident's bathroom had a buildup of dirt around the toilet, and another had missing laminate from the sink and brown particles behind the toilet. The Maintenance Director stated that pest control visits weekly, but there was no maintenance book for staff to report issues, relying instead on maintenance rounds. The facility also failed to provide adequate linens, with residents and staff reporting a lack of clean towels and sheets for several months. The laundry room was found to have broken equipment, with one dryer and one washer out of service since August. The laundry aide reported insufficient linen supplies and a broken air-conditioner in the laundry room. The Housekeeping Supervisor confirmed the lack of a PAR system for linen distribution and stated that linen was distributed based on immediate need. Despite purchase orders for linen, the facility's linen closets were inadequately stocked, and the Administrator admitted there was no policy for laundry services.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for several residents, as observed and documented in the report. Resident #8, who has dementia and requires supervision for showers, was found with a strong body odor of urine and unshaven for several days. His wife reported that she often had to shave him herself and that staff were unresponsive to her requests for assistance. Documentation showed missed showers and inconsistent personal hygiene care. Resident #51, who requires substantial assistance with showers, reported infrequent showers despite being scheduled for them multiple times a week. He expressed dissatisfaction with the care provided and had communicated his concerns to various staff members, including the Director of Nursing and the Administrator. Documentation revealed multiple instances where scheduled showers were not provided or documented. Resident #89, who is dependent on assistance for personal hygiene, was observed with unshaven facial hair, long fingernails, and soiled bed sheets. The resident reported long wait times for assistance and inadequate care. Staff interviews indicated a lack of consistent documentation and follow-up on residents' refusals of care. Similar issues were noted for Residents #317 and #95, who also experienced lapses in scheduled showers and personal hygiene care, with inadequate documentation and staff awareness of their care needs.
Inadequate Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, resulting in delayed responses to call lights and inadequate personal care. Observations and interviews revealed that residents experienced long wait times, often over 30 minutes, for assistance after activating their call lights. Some residents reported that staff would turn off the call lights without providing the needed help, particularly during the evening and night shifts. This lack of timely response was compounded by reports of staff being seen watching television instead of attending to residents' needs. Several residents were observed to have unmet personal care needs, such as being unshaven, having long fingernails, and emitting strong odors of urine, indicating a lack of regular hygiene care. Documentation reviews showed that scheduled showers and personal hygiene tasks were frequently marked as not applicable or not documented at all, suggesting that these care activities were not consistently provided. Family members of residents also expressed concerns about insufficient staffing, particularly in the memory care unit, where incidents of resident falls and wandering were reported. The facility's failure to provide adequate staffing and timely care resulted in residents not receiving necessary assistance with activities of daily living, such as bathing, shaving, and toileting. This deficiency was evident across multiple shifts and affected numerous residents, as corroborated by both resident and family member testimonies and the lack of documentation for care activities. The observations and interviews conducted by surveyors highlighted a systemic issue of inadequate staffing and care provision within the facility.
Failure to Notify Resident's Representative of Medication Changes
Penalty
Summary
The facility failed to notify the representative of a resident about changes in the medication regimen, specifically the dose reduction and discontinuation of an antipsychotic medication, Seroquel. The resident, a male with diagnoses including Parkinson's disease, Dementia, and Depression, was admitted from an acute care hospital with a prescription for Seroquel 50 mg twice daily. On 10/15/24, the physician reduced the dosage to once daily, and on 10/21/24, the medication was discontinued. However, there was no documentation in the clinical record indicating that the resident's representative was informed of these changes. The resident's significant other, who was responsible for making healthcare decisions, was unaware of the medication changes until 11/1/24, when she noticed behavioral changes in the resident and inquired about the medication. Interviews with the Director of Nursing and the MDS Coordinator confirmed the lack of documentation and notification to the resident's representative. The MDS Coordinator mentioned discussing the medication change with the spouse during a care plan meeting on 10/24/24, but this discussion was not documented.
Inaccurate Activity Preference Assessments for Residents
Penalty
Summary
The facility failed to ensure that comprehensive assessments accurately reflected the activity preferences of two residents. Resident #83, who was admitted with diagnoses including Cerebral Vascular Accident, Dementia, and Parkinson's Disease, had a severely impaired cognition as indicated by a Brief Interview for Mental Status score of 00. Despite this, the Minimum Data Set (MDS) assessment recorded that all eight questions related to daily and activity preferences were marked as 'very important,' suggesting inaccuracies in the assessment process. Similarly, Resident #95, admitted with Parkinson's disease, Dementia, and Depression, also had a severely impaired cognition with a Brief Interview for Mental Status score of 03. The resident was unable to correctly report the year, month, or day, and could not recall specific words. Yet, the MDS assessment similarly noted that all questions regarding daily and activity preferences were marked as 'very important.' The facility's administrator acknowledged issues with the previous Activity Director's completion and documentation of activity assessments, which contributed to these inaccuracies.
Deficiency in Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing, meaningful, resident-centered activity program to support the interests and meet the physical, mental, and psychological well-being of two residents. Resident #8, who has dementia with mood disturbance and anxiety, was observed multiple times seated in his wheelchair in the lounge area with the television on but no individualized activities in progress. Despite having a care plan that included various interventions to engage the resident in activities, the resident's spouse reported that her husband was rarely taken to activities and often left sitting alone. The Activity Director, who had recently started, acknowledged the lack of activities on individual units and stated that activities were conducted in the main dining room, making it challenging to provide individualized attention. Resident #95, diagnosed with Parkinson's disease, dementia, and depression, was also observed sitting alone in front of the TV or at a table with minimal engagement in activities. The resident's significant other noted that staff did not often assist the resident to activities. The activity calendar in the resident's room showed no activities listed past 3:30 p.m., and records indicated that the resident had attended activities only a few times in the past 30 days. The Administrator acknowledged issues with the previous Activities Director not completing assessments and documentation, and noted that the current activity staff were new. The facility's activity program was found lacking in providing individualized and meaningful engagement for residents, particularly those with cognitive impairments. The Activity Director confirmed the absence of activities on individual units and the challenges in conducting one-on-one activities for all residents. The Administrator mentioned a separate activity schedule for the memory care unit but could not provide documentation of Resident #95 attending activities there. The lack of a facility policy for the activities program was also noted.
Improper Catheter Care and Sanitation
Penalty
Summary
The facility failed to maintain urinary catheters in a safe and sanitary manner for a resident with an indwelling urinary catheter. The facility's policy on catheter care, revised in January 2024, mandates that infection control guidelines be followed to minimize catheter-associated infections. This includes ensuring that the drainage spigot does not touch the floor, the tubing is free of kinks, and the catheter is kept at an appropriate level to promote urine flow. However, during observations, it was noted that the resident's catheter drainage bag was found on the floor on multiple occasions. On one occasion, a registered nurse confirmed the drainage bag was on the floor and acknowledged it should not be there. The following day, the drainage bag was again observed on the floor, and the nurse admitted to using a makeshift paper clip hook due to a lack of supplies. Interviews with certified nursing assistants revealed that catheter drainage bags should be hung from the bed or wheelchair to prevent them from touching the floor. Despite this knowledge, the facility failed to provide adequate supplies to ensure proper catheter care, leading to the observed deficiency.
Deficiencies in IV Therapy Management for Two Residents
Penalty
Summary
The facility failed to ensure proper care and management of intravenous (IV) therapy for two residents, leading to deficiencies in the administration and maintenance of IV lines. Resident #67, who was admitted with Alzheimer's disease, dementia, and other conditions, was observed with a peripherally inserted central catheter (PICC) in the left forearm. The dressing on the insertion site was undated, and the IV solution bag was unlabeled and undated. There were no documented orders for the care of the catheter, including dressing changes and flushing, as required by the facility's policy and professional standards. Resident #89, who had been readmitted with multiple diagnoses including venous insufficiency and chronic heart failure, had an IV catheter in place without any current orders for its care or removal. The resident reported that the IV had been in place since hospital discharge and was not being used for any current treatment. The facility staff, including registered nurses, were unaware of the orders for the care and flushing of the IV catheter. The medication administration record indicated that the antibiotic therapy was completed earlier, yet the IV remained in place without proper documentation or care instructions.
Failure to Maintain Sanitary Nebulizer Machines
Penalty
Summary
The facility failed to maintain nebulizer machines in a sanitary manner for two residents who required respiratory care. The facility's policy, revised in December 2023, mandates that nebulizer and tubing should be stored hygienically, with the tubing bag labeled with the date it was changed. During an observation, a nebulizer mask was found uncovered and undated on a nightstand in one resident's room. In another resident's room, a nebulizer mask was observed hanging down the side of the nightstand. The Unit Manager, a Registered Nurse, confirmed that nebulizer masks should be covered in a plastic bag and dated when not in use, and that the nurse on the unit is responsible for the care of the nebulizer.
Failure to Accommodate Dietary Restrictions
Penalty
Summary
The facility failed to provide a diet that accommodated the documented gluten and lactose dietary restrictions for a resident with Type II Diabetes, Celiac Disease, and malnutrition. The resident reported being served oatmeal and grits, which she could not eat due to her Celiac Disease. During an observation, the resident's breakfast included a carton of 2% milk and cereal, despite her meal ticket indicating allergies to gluten and lactose. Additionally, the resident was served a slice of bread at lunch, which was not gluten-free. The Dietary Manager confirmed that the resident should not have been served cereal, 2% milk, or non-gluten-free bread.
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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