Crystal River Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crystal River, Florida.
- Location
- 136 Northeast 12th Avenue, Crystal River, Florida 34429
- CMS Provider Number
- 105317
- Inspections on file
- 17
- Latest survey
- November 1, 2024
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Crystal River Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors determined that the facility did not maintain required documentation for its automatic sprinkler system. Record review showed the sprinkler system was past due for the mandated 5-year internal inspection, and the facility could not produce the most recent 5-year inspection report. During interview, the Maintenance Director confirmed that this inspection report was missing, and the deficiency was cited as affecting the entire facility.
Surveyors identified that the facility did not fully comply with NFPA 99 requirements for electrical receptacle maintenance and testing. Review of the electrical receptacle testing log showed that only tension testing was documented, with no evidence of polarity testing being conducted. During interview, the Maintenance Director confirmed that staff had never tested receptacle polarity. This deficiency was cited as affecting the entire facility and was noted as potentially causing faulty electrical equipment which can result in fire.
Surveyors identified that the facility did not maintain its fire alarm system in accordance with NFPA 72 when the fire alarm control panel was observed displaying a trouble signal. During the observation, the Maintenance Director confirmed that the trouble condition was related to a faulty heat detector. This unresolved trouble indication showed that the fire alarm system was not being properly maintained to ensure it functioned as designed for the entire building.
Surveyors found that a circuit breaker panel cover in one smoke compartment was improperly fastened with sheet metal screws instead of appropriate blunt-end fasteners, in violation of NFPA 70 requirements. The maintenance director acknowledged the use of sheet metal screws on the panel cover, and the report notes that this noncompliance could result in electric or fire hazards.
Surveyors identified a deficiency when the facility could not provide documentation that backup generator batteries were being tested in accordance with NFPA 110 and NFPA 99 requirements. During record review, no records of generator battery testing were available, and the Maintenance Director confirmed he was unable to locate the requested documentation. This failure concerns the essential electrical system that supports life safety and critical functions during power loss.
Surveyors found that patient-care related electrical equipment was not inspected and maintained in accordance with NFPA 99 requirements. Biomedical inspection records showed that inspections were not current, and an observation in the gym revealed two microwaves, a toaster oven, and an "E Stem" device with overdue inspection stickers from 2024. During an interview, an assistant reported that this equipment was supplied by the corporate office and maintained by a different company, yet the items remained in use in a patient-care area without up-to-date inspections, affecting one of seven smoke compartments.
Surveyors found that gas cylinders were improperly stored and unsecured, with 38 cylinders in an outside storage room lacking the required oxidizing gas signage and with full and empty cylinders comingled, and an additional 25 cylinders stored adjacent to this area without any means to prevent unauthorized access. During an interview, the Maintenance Director acknowledged the issues and reported being unaware of the specific NFPA 99 storage requirements.
Surveyors found that the facility’s emergency preparedness communication plan did not include required information on how to report facility occupancy through the Healthcare Facility Reporting System. During record review and a concurrent interview, the Administrator acknowledged that the plan lacked a specified means of providing occupancy information to the incident commander, resulting in a facility-wide deficiency in the communication plan.
Surveyors found that hazardous cleaning chemicals, including Virex II 256 and Virex TB, were stored in an unlocked, easily accessible lower cabinet in the main dining room, which is open to ambulatory residents throughout the day. The cabinet lacked any locking mechanism or security measures. SDS information for both products indicated they are industrial/institutional disinfectants that can cause eye, skin, and respiratory irritation or burns and must be stored safely to prevent exposure. The Administrator acknowledged the chemicals were not secured and stated that all cleaning products are expected to be secured when not in use by staff.
Surveyors found that several resident rooms were not maintained in a safe, clean, and homelike condition, including missing baseboards, peeling and missing paint, exposed walls, holes near baseboards, loose door handles, missing toilet paper holder mounts, stained floor tiles, cracked and gapped sink walls, and dirty bathroom vents. The Maintenance Director confirmed these conditions, acknowledged awareness of at least one problematic room for about a month, and reported relying on calls and texts for repair requests while awaiting access to the electronic maintenance log. Review of the maintenance work history showed no entries for these needed repairs, despite the DON and Administrator describing processes in which staff should enter issues into the maintenance log or verbally report them, resulting in the identified room deficiencies remaining uncorrected.
A resident was transferred to a hospital for evaluation and treatment of a right hip concern after the attending practitioner directed staff to send the resident to the closest hospital, and non-emergent transport was arranged with the resident’s family in agreement. Although a transfer/discharge notice and a hospital transfer form were completed, surveyors found no documentation that the required written bed-hold notice—detailing the state bed-hold policy, any reserve bed payment policy, and the facility’s bed-hold and return policies—was provided at or before the time of transfer. In interviews, an LPN/medical records staff member acknowledged that the bed-hold notice “must not have been done,” and the DON stated that floor nurses or unit managers are responsible for completing bed-hold forms and obtaining family signatures when present, confirming that this process was not followed for this hospitalization.
A resident with physician orders for PRN O2 at 2 L/min via nasal cannula for shortness of breath was observed receiving oxygen and had multiple progress notes documenting ongoing O2 therapy and corresponding O2 saturations. However, the Significant Change MDS did not code oxygen use in Section O (Special Treatments, Procedures, Programs). An LPN responsible for MDS acknowledged that oxygen use was documented in the record and should have been coded, resulting in an assessment that did not accurately reflect the resident’s respiratory treatment status.
A resident with dementia, seizure disorder, right foot drop, heart failure, and other conditions had a physician order and care plan intervention for bilateral floor mats at the bedside when in bed due to fall risk. Surveyor observations on multiple occasions found only one floor mat placed on the right side of the bed, with no mat on the left side. A CNA reported not knowing the resident should have mats on both sides and stated the resident had always had just one mat, while an RN needed to verify the order. The DON stated that staff are expected to follow physician orders and that the resident should have mats on each side, demonstrating the facility’s failure to implement the comprehensive, person-centered care plan as written.
A resident with a history of HTN and other conditions was scheduled for cataract surgery with pre-op instructions from the surgery center to be NPO after midnight but to continue heart and BP medications, excluding diuretics. The resident had multiple ordered antihypertensives scheduled for morning administration, yet nursing staff held all morning BP medications due to NPO status. An LPN relied on shift report, did not review the MAR or physician orders, and did not contact the physician, while an RN received verbal pre-op instructions but failed to enter them into the system and only communicated the NPO portion. No NPO or related medication orders were entered into the electronic orders, the MAR documented the medications as held for NPO, and the resident’s surgery was cancelled at the surgery center due to elevated systolic BP.
A resident with chronic neuropathic pain and multiple comorbidities did not receive 12 scheduled doses of Lyrica over several days, despite an active physician order and a care plan calling for medication-based pain control. MAR entries cited the drug as unavailable or awaiting insurance approval, yet staff did not document the problem in progress notes, did not effectively communicate with the prescriber about alternatives, and did not utilize an available dose in the automated dispensing machine. The resident reported increased right arm pain and was observed holding the arm protectively while propelling his wheelchair with his feet, as multiple LPNs and a unit manager failed to follow through on obtaining or substituting the ordered pain medication.
A resident had an order for midodrine 5 mg three times daily with instructions to hold the dose if systolic BP exceeded a specified parameter. Review of the MAR showed 13 documented administrations of midodrine outside these ordered parameters. Two LPNs reported that they always check BP before giving parameter-based medications and believed the entries were documentation errors, while the DON stated that nursing staff are expected to follow physician orders, including specific parameters. The discrepancy between the physician order and the documented administrations resulted in a deficiency related to unnecessary drugs.
Surveyors found multiple failures in infection control practices related to respiratory equipment. One resident received O2 via nasal cannula using tubing that had not been changed for an extended period, with additional tubing left unbagged on top of an O2 concentrator and on a wheelchair. Another resident had a nebulizer machine on the floor behind the bed, with an uncovered mask and undated tubing lying across it, despite not having current nebulizer orders. A third resident had a nebulizer on the bedside table with an uncovered mask and undated tubing, and this resident also had no active nebulizer orders. Staff interviews and the facility’s written policy confirmed that tubing and masks were to be changed weekly, dated, covered or bagged when not in use, and removed and cleaned when treatments were discontinued, but these practices were not followed.
The facility did not maintain an effective pest control program, as evidenced by repeated observations of live and dead insects in resident bathrooms, hallways, and areas adjacent to and within the kitchen and dishwashing room where food contact items are processed. Staff reported that pest issues were referred to Maintenance, which coordinated with a contracted pest control company that made weekly visits and reviewed pest logs. Despite these measures and documented exterminator reports noting recurring pest concerns across all wings and the kitchen, staff, including an LPN, continued to see roaches on the units, showing that the facility’s pest control efforts were not successfully preventing ongoing pest activity.
The facility failed to properly store, label, and discard food in the kitchen and nutrition rooms, with unlabeled and undated items found in the walk-in cooler, freezer, and nutrition rooms. The CDM confirmed these issues, acknowledging the need for proper labeling and dating of food items.
A facility failed to ensure an accurate MDS assessment for a resident with chronic venous hypertension and ulcers. The MDS did not document the presence of venous or arterial wounds, despite evidence from a wound assessment report and physician orders. An LPN admitted to overlooking the facility's wound assessment, relying instead on hospital documentation, leading to the inaccurate assessment.
The facility failed to document all relevant diagnoses in the PASRR screenings for two residents. One resident's screening omitted entries for mental illness despite having multiple related diagnoses, while another resident's screening documented schizophrenia but missed an anxiety disorder diagnosis. The DON confirmed these omissions.
A resident with a skin tear did not receive daily dressing changes as ordered by the physician. Observations showed the dressing was not changed for several days, contrary to the daily care instructions. Interviews with staff revealed inconsistencies in wound care responsibilities, with the DON expecting daily completion and documentation of wound care tasks.
The facility failed to secure medications in resident rooms, as observed in two incidents. A resident had nasal spray and lidocaine unsecured on their bedside table, and another resident had a medication cup left on their meal tray. An LPN confirmed that medications should not be at the bedside without proper assessment and physician orders. The DON stated that medications should be administered under supervision and stored in locked compartments.
A resident's wound care was not accurately documented, with observations showing an unchanged dressing despite orders for daily changes. Staff interviews revealed inconsistencies in documentation, and the DON confirmed the expectation for accurate daily records, which was not met.
The facility failed to perform proper hand hygiene during wound care and meal delivery. A CNA did not sanitize hands between handling meal trays for two residents, and an LPN did not wash hands before changing a dressing after using a phone. Both staff members acknowledged the lapses, and facility policies were reviewed, confirming the need for hand hygiene before and after resident contact.
Missing 5-Year Internal Sprinkler System Inspection Report
Penalty
Summary
Surveyors found that the facility failed to maintain proper inspection documentation for its automatic sprinkler system in accordance with NFPA 25. During record review at 10:50 AM, the most recent sprinkler system report showed that the facility was past due for the required 5-year internal inspection. The facility was unable to provide the most recent 5-year internal inspection report for review. During a concurrent staff interview, the Maintenance Director acknowledged that the 5-year internal inspection report was missing. This deficiency was determined to affect the entire facility’s sprinkler system coverage. No residents or specific patient conditions were mentioned in the report, and no additional clinical details were provided.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0353 and assure continued compliance, the following plan has been put in place: K0353 - Sprinkler System Testing (5-Year Internal) Immediate Correction: A licensed fire sprinkler vendor was to perform the 5-year internal piping inspection per NFPA 25 to ensure the system is free of obstructions. Identification of Others: All fire protection systems were audited. The internal pipe inspection report is now maintained in the Life Safety binder for immediate surveyor review. Systemic Changes: A Master Regulatory Calendar was implemented to track multi-year NFPA requirements. The service contract was updated to require the vendor to provide 90-day advance notice of all upcoming 3-year and 5-year tests. Monitoring (QA): The Maintenance Supervisor will audit the Master Calendar monthly. Results will be reported to the QAPI Committee quarterly.
Failure to Perform Required Polarity Testing of Electrical Receptacles
Penalty
Summary
The facility failed to properly maintain and test electrical receptacles in accordance with NFPA 99 requirements for electrical systems maintenance and testing. During record review, surveyors found that the facility’s electrical receptacle testing log documented only tension testing of receptacles and did not include any indication that polarity testing was performed. In a concurrent interview, the Maintenance Director acknowledged that facility staff had never tested the polarity of the receptacles. The deficiency was cited as affecting the whole facility and was noted as potentially causing faulty electrical equipment which can result in fire.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0914 and assure continued compliance, the following plan has been put in place. K0914 - Electrical Receptacle Testing Immediate Correction: Re-testing of electrical receptacles in affected patient care areas was performed. Outlets were verified for polarity and grounding continuity in addition to tension requirements. Identification of Others: A comprehensive re-testing of all receptacles in resident care areas was initiated. The Testing Log was revised to include dedicated columns for Polarity, Grounding integrity, and Tension.Systemic Changes: The facility procured UL-listed polarity analyzers. Staff were trained on NFPA 99, Section 6.3.4.1 regarding hospital-grade electrical verification.Monitoring (QA): The Maintenance Supervisor will audit 10% of testing logs monthly. Findings will be reported to the QAPI Committee to ensure all data points are consistently recorded.
Failure to Maintain Fire Alarm System in Proper Working Order
Penalty
Summary
Surveyors found that the facility failed to maintain its fire alarm system in accordance with NFPA 72 requirements. During an observation at 3:30 PM, the fire alarm control panel was noted to be displaying a trouble signal. Upon concurrent interview, the Maintenance Director acknowledged the trouble condition and stated it was due to a faulty heat detector. This unresolved trouble signal on the fire alarm control panel constituted a failure to ensure the fire alarm system was maintained and functioning as designed for the entire facility. No residents or specific patient conditions were mentioned in the report, and no additional clinical details were provided.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0345 and assure continued compliance, the following plan has been put in place. K0345 - Fire Alarm System Maintenance Immediate Correction: A fire alarm provider diagnosed and repaired the trouble signal, restoring the system to a "System Normal" state. Residents in the affected zone were monitored for safety during the repair. Identification of Others: A 100% audit of the Fire Alarm Control Panel (FACP) was conducted to ensure no other trouble or supervisory signals were present facility-wide. Systemic Changes: Maintenance and administrative staff were re-educated on responding to trouble signals within 24 hours and documenting all actions in the maintenance log. Monitoring (QA): The Maintenance Supervisor will conduct daily visual inspections of the FACP. The Safety Committee will review all service reports monthly, reporting findings to the QAPI Committee.
Improper Fastening of Circuit Breaker Panel Cover with Sheet Metal Screws
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of electrical utility equipment in accordance with NFPA 70. During an observation at 3:15 PM, they noted that the cover of a circuit breaker panel was fastened using sheet metal screws instead of appropriate fasteners. This condition was found in 1 of 7 smoke compartments. The facility’s maintenance director, present during the observation, acknowledged that sheet metal screws were being used on the circuit breaker panel cover. The report states that this failure to comply with NFPA 70 could result in electric or fire hazards. No residents or specific patient conditions were mentioned in the report, and no additional events beyond the improper fastening of the circuit breaker panel cover were described.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0511 and assure continued compliance, the following plan has been put in place. K0511 - Electrical Panel Fasteners Immediate Correction: Unauthorized sheet metal screws were removed from the cited circuit breaker panel and replaced with OEM-approved, blunt-end machine screws to prevent internal wire damage. Identification of Others: A facility-wide audit of all electrical panels, sub-panels, and pull boxes was conducted. Any non-compliant fasteners found were immediately replaced with blunt-end hardware. Systemic Changes: The Electrical Safety Policy was updated to prohibit self-tapping or pointed screws. Maintenance staff were trained on NFPA 70 hardware requirements to maintain equipment integrity. Monitoring (QA): "Panel Fastener Integrity" was added to the Monthly Life Safety Walkthrough. Audit logs will be reviewed during quarterly QAPI meetings.
Failure to Maintain Required Generator Battery Testing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain and inspect the backup generator batteries in accordance with NFPA 110 requirements. During a record review, surveyors requested documentation of generator battery testing, which is required to ensure the reliability of the prime mover starting system. At the time of review, no documentation was provided to demonstrate that these battery tests had been performed as required. Concurrently, during an interview, the Maintenance Director acknowledged the issue and stated that he could not locate the requested documentation of generator battery testing. The cited regulations include NFPA 99 (2012 Edition) sections 6.4.4.1.3 and 6.4.4.2, and NFPA 110 (2010 Edition) section 8.3.7, which govern maintenance and testing of essential electrical systems, including generator batteries. The report notes that failure to conduct these tests could result in the loss of power to the facility, affecting life support and life safety features.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0918 and assure continued compliance, the following plan has been put in place. K0918 - Generator Battery Testing Immediate Correction: A comprehensive generator battery test, including specific gravity and conductance testing, was performed and recorded in the EPSS Log to ensure peak cranking capacity. Identification of Others: The EPSS was audited to ensure all maintenance components were documented. The Life Safety binder was reorganized to house these records separately for easy retrieval. Systemic Changes: The Generator Maintenance Log was revised to include specific fields for weekly visual checks and monthly battery conductance/voltage testing. Staff were re-trained on NFPA 110 battery maintenance standards. Monitoring (QA): The Maintenance Director will conduct a monthly audit of the generator log. These audits will be presented to the QAPI Committee quarterly to identify any trends in battery degradation.
Failure to Maintain and Inspect Patient-Care Electrical Equipment per NFPA 99
Penalty
Summary
Surveyors identified a deficiency in the facility’s inspection and maintenance of patient-care related electrical equipment (PCREE) as required by NFPA 99. During record review at 10:40 AM, biomedical inspection records showed that patient electrical equipment inspections were not current, indicating that required testing and maintenance had not been performed in accordance with established intervals. The report notes that the facility failed to inspect PCREE in accordance with NFPA 99, which governs testing, maintenance, and documentation of such equipment. During an observation at 2:45 PM in the gym, surveyors found multiple pieces of patient-care related electrical equipment with overdue inspection stickers from 2024, including two microwaves, one toaster oven, and an "E Stem" device. In a concurrent staff interview, the Assistant stated that this equipment was outsourced from the corporate office and that a different company, not the facility, was responsible for the equipment. The deficiency was cited as affecting one of seven smoke compartments and was linked to noncompliance with NFPA 99 (2012 Edition) sections 10.3 and 10.5.2.1.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0921 and assure continued compliance, the following plan has been put in place. K0921 - Electrical Equipment Testing & Stickers Immediate Correction: Non-compliant items (microwaves, toaster, E-Stim machine) were removed and inspected by a licensed Biomedical vendor. All items passed and now bear current 2026 inspection stickers. Identification of Others: A "Wall-to-Wall" audit of all electrical equipment was conducted. Any item found with an expired or missing sticker was sequestered for testing and repair. Systemic Changes: The Master Equipment Inventory (MEI) was updated to track Last Test and Next Due dates. Staff were re-educated on checking for stickers before use and "Red Tagging" expiring equipment. Monitoring (QA): The Maintenance Director will perform monthly spot checks of 10 random electrical items. Results will be presented at the monthly Safety Committee and quarterly QAPI meetings.
Improper Storage and Security of Gas Cylinders
Penalty
Summary
Surveyors identified a deficiency in the storage of gas cylinders in one of seven smoke compartments. During an observation of the outside storage room, they found 38 cylinders stored without the required precautionary signage indicating oxidizing gas storage. The signage was also required to indicate the presence of oxidizing gases and to include the mandated wording, but this was not present. In addition, full and empty cylinders were observed to be comingled, rather than being segregated as required by NFPA 99. Adjacent to this storage area, surveyors observed 25 additional cylinders that were not properly secured from unauthorized use, and the facility did not have any means in place to prevent unauthorized access to these cylinders. During a concurrent staff interview, the Maintenance Director acknowledged these findings and stated that he was not aware of the requirements for gas cylinder storage. The surveyors cited these conditions as noncompliance with NFPA 101 and NFPA 99 standards for gas equipment and cylinder storage.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with K0923 and assure continued compliance, the following plan has been put in place. K0923 - Gas Cylinder Storage & Security Immediate Correction: All 38 cylinders in the storage room were segregated and labeled. The 25 cylinders located outside were moved to a secured, locked enclosure. Identification of Others: All medical gas storage areas were audited. Permanent "Full" and "Empty" signs and "No Smoking" signage were installed at all entrances. Systemic Changes: A lockable enclosure was established for outdoor storage with a new "Key Control" log. Staff were re-trained on Medical Gas Safety and the mandatory requirement for locked storage. Monitoring (QA): The Maintenance Director will perform daily rounds for 30 days, then weekly thereafter, to ensure segregation and security.Findings will be reviewed at monthly QAPI meetings.
Emergency Preparedness Communication Plan Lacked Required Occupancy Reporting Information
Penalty
Summary
Surveyors identified a deficiency in the facility’s emergency preparedness communication plan related to the requirement to provide information on occupancy. During record review at 2:00 PM, the surveyor determined that the written communication plan did not include any information on the Healthcare Facility Reporting System, which is the mechanism used to report the facility’s occupancy. The plan therefore lacked a specified means of providing information about the facility’s occupancy as required by the applicable emergency preparedness regulations. In a concurrent staff interview, the Administrator acknowledged that the communication plan did not contain the required information about occupancy reporting. The Administrator confirmed the absence of this information in the plan. The deficiency was determined to affect the entire facility, as the missing occupancy reporting component related to communication of resident needs to the incident commander during an emergency.
Plan Of Correction
This Plan of Correction constitutes written compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by State and Federal Law. To comply with E0034 and assure continued compliance, the following plan has been put in place. E0034 ~ Communication Plan (HFRS) Immediate Correction: The Emergency Preparedness Communication Plan was updated to include a dedicated section for the Health Facility Reporting System (HFRS), explicitly outlining requirements for reporting emergency status, planning, and operations. Identification of Others: All residents have the potential to be affected by communication failures. The Administrator audited the entire Emergency Plan to ensure HFRS Superuser access, login procedures, and technical support contacts (850-412-4303/4304) were included. Systemic Changes: Administrative and nursing leadership were trained on the AHCA HFRS manual and internal procedures for updating census and .utility data. A screenshot of the facility's HFRS registration was added as an appendix to the Plan. Monitoring (QA): The Safety Committee will review the plan semi-annually to ensure protocols remain current. Results will be documented in the QAPI meeting minutes.
Unsecured Hazardous Cleaning Chemicals in Accessible Dining Room Cabinet
Penalty
Summary
Surveyors observed that the facility failed to keep hazardous cleaning chemicals secured in the main dining room, an area accessible to ambulatory residents throughout the day. During an observation, a lower cabinet in the dining room was found unlocked and accessible, with no locking mechanisms or other security measures in place. Inside the cabinet were two bottles of cleaning chemicals: Virex II 256 One-Step Disinfectant Cleaner and Deodorant and Virex TB Ready-to-Use Disinfectant Cleaner. Review of the Safety Data Sheets (SDS) for these products documented that Virex II 256 is classified as corrosive and may cause eye and skin burns and may be harmful if inhaled, absorbed through the skin, or swallowed, and that Virex TB may cause irritation to the eyes, skin, and respiratory tract via inhalation, ingestion, skin, and eye contact. Both products are labeled for industrial/institutional use and are intended to be handled with appropriate precautions and stored safely to prevent exposure. In an interview, the Administrator acknowledged that the cleaning products in the dining room cabinet were not secured, confirmed that the dining room is open to ambulatory residents throughout the day, and stated that his expectation is that all cleaning chemicals are stored in a secure manner when not in use by staff.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment on one of three units, as required by 42 CFR 483.10(i). During observations of multiple resident rooms, surveyors noted missing baseboards, peeling paint, exposed wall surfaces, holes near baseboards, cracked and gapped walls, loose door handles, missing toilet paper holder mounts, stained floor tiles, and dirty bathroom vents. In one room, the bathroom doorway lacked baseboards, the wall was peeling with black stains, tiles around the toilet were lifting or missing, there was a brown substance on the tiles, and the bathroom vent was covered in gray matter. Other rooms had missing or peeling paint exposing the wall, holes near the baseboard, loose bathroom and room door handles, a missing toilet paper holder mount, and heavily stained floor tiles. The Maintenance Director accompanied surveyors on follow-up observations and confirmed the poor conditions in the identified rooms, describing one room as "horrible" and acknowledging that the vent looked filthy and that the sink appeared to be coming off the wall. The Maintenance Director stated that he had been informed about one problematic room about a month earlier and had been looking for a plumbing company to address it, but he had not been able to determine which room it was. He also acknowledged that the door handle needed adjustment and the toilet paper holder needed replacement in another room. The Maintenance Director reported that he had taken over the position in January and was focusing on large projects, delegating smaller details to his assistant. Record review and staff interviews revealed that the facility’s system for reporting and tracking maintenance issues was not effectively used for these deficiencies. Review of the electronic maintenance system work history from January through March showed no entries for the needed repairs in the affected rooms. The Maintenance Director stated he typically received calls or text messages about repairs and was waiting for a laptop to access the maintenance repair log, making it difficult to look back and verify reported issues. The DON reported that she typically entered items into the maintenance repair log and also communicated verbally or via messages to maintenance and unit managers when repairs were needed, and the Administrator stated that staff were expected to enter needed repairs into the maintenance log during rounds or communicate directly with maintenance. Despite these processes and the facility’s written policy on maintaining resident environment quality and preventive maintenance, the needed repairs in the identified rooms were not documented in the maintenance system and remained unaddressed at the time of survey.
Failure to Provide Required Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide a required written bed-hold notice to a resident who was transferred to the hospital. Federal regulations at 42 CFR 483.15(d)(1)-(2) require that, before a resident is transferred to a hospital or goes on therapeutic leave, the facility must provide written information specifying the duration of the state bed-hold policy, any reserve bed payment policy, the facility’s bed-hold policies, and related return information, and must again provide written notice at the time of transfer specifying the duration of the bed-hold policy. Surveyors reviewed the record of one resident who was sent to the hospital and found no documentation of a 3‑day bed-hold policy or bed reserve payment notice in the resident’s chart. Record review showed that on 01/28/2026 the resident’s physician office requested that the resident be sent to a named hospital for evaluation of the right hip. The facility contacted the hospital’s orthopedic floor, which stated they could not accept the resident without a direct admission. The facility then contacted the physician, who instructed staff to send the resident to the closest hospital for assessment of the right hip. A non-emergent transport company picked up the resident at 5:45 PM and transported the resident to the hospital emergency room for evaluation and treatment. The resident’s son was at the bedside and was documented as agreeable with the plan of care. A Nursing Home Transfer and Discharge Notice and a Hospital Transfer Form were completed, indicating the resident was sent to the hospital emergency room for evaluation and treatment. Despite the transfer documentation, the surveyors determined that the required bed-hold notice was not provided. During interview, the LPN/Medical Records staff member stated there was no 3‑day bed-hold policy or bed reserve payment notice for this resident in the paper chart and concluded it “must not have been done.” In a separate interview, the Director of Nursing explained that the floor nurse or unit manager is responsible for completing bed-hold forms when a resident leaves the facility and that, if family is present at the bedside, staff should have the family sign the bed-hold form. The absence of any such form or written bed-hold notice for this resident’s hospitalization led surveyors to cite noncompliance with the federal bed-hold notice requirements.
Inaccurate MDS Coding for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessment for a resident receiving respiratory services. The resident had a physician’s order dated 2/2/2026 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. On observation, the resident was lying in bed receiving oxygen at 2 liters per minute via nasal cannula. Progress notes documented oxygen therapy, including entries on 2/21/2026 noting oxygen at 2 liters via nasal cannula with an oxygen saturation of 90%, and on 2/22/2026 noting pulmonary/respiratory service with oxygen therapy at 2 liters and an oxygen saturation of 95%. Despite this documented and observed oxygen use, the resident’s Significant Change MDS dated 2/23/2026 did not code oxygen under Section O, Special Treatments, Procedures, Programs. During an interview, the LPN responsible for MDS acknowledged that oxygen use had been documented in the notes several times and stated it should have been coded as in use on the MDS. The facility’s RAI policy required comprehensive, accurate, and standardized assessments of each resident’s functional capacity using the RAI specified by the state, but the resident’s oxygen therapy was not accurately reflected in the MDS assessment.
Failure to Implement Care-Planned Bilateral Floor Mats for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a person-centered comprehensive care plan and physician orders for a resident with identified fall and seizure risks. The resident was re-admitted with diagnoses including right foot drop, bradycardia, heart failure, dementia, abnormal auditory perceptions, psychotic disturbance, mood disturbance and anxiety, and absence epileptic syndrome. A physician order dated 6/2/2025 directed that bilateral floor mats be in place at the bedside when the resident was in bed. The resident’s care plan, initiated 4/11/2025 and updated 3/23/2026, identified a focus on potential for falls, seizure disorder, and foot drop, and included an intervention for bilateral floor mats at the bedside when in bed. Multiple observations on different days showed that only one floor mat was consistently placed on the right side of the resident’s bed, with no mat on the left side, despite the order and care plan specifying bilateral mats. During these observations, the bed was in the low position with side rails up, but only a single mat was present. A CNA stated that he did not know the resident should have floor mats on both sides and reported that the resident had always had just one mat. An RN also indicated she would need to check the orders to verify whether bilateral mats were required. The DON stated an expectation that staff follow physician orders and confirmed the resident should have fall mats on each side of the bed. The facility’s “Person Centered Care Plans” policy states that care plan interventions outside of routine care are to be entered into the electronic record to provide CNAs with individualized information, but the observations and staff interviews showed that the bilateral floor mat intervention was not implemented as ordered and care planned.
Failure to Administer Antihypertensive Medications Prior to Scheduled Surgery
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary care and services related to medication administration for blood pressure control prior to a scheduled surgery. A resident admitted with diagnoses including hypertension, anxiety, depression, and anemia was scheduled for right cataract surgery with pre-operative instructions from the surgical center specifying NPO after midnight and to continue heart and blood pressure medications (excluding diuretics) the day of surgery. The resident’s physician orders included multiple antihypertensive medications (Amlodipine, Metoprolol tartrate, Hydralazine, and Lisinopril) to be administered at specific times, including morning doses. Nursing documentation from an earlier consultation noted orders for NPO after midnight and to continue medications as ordered except diuretics. However, there were no NPO orders entered into the physician order system. On the morning of surgery, the resident’s MAR showed that all ordered antihypertensive medications were held due to NPO status, despite the pre-operative instructions to continue these medications. An LPN reported holding the resident’s morning medications, including blood pressure medications, based solely on shift report information that the resident was NPO, without reviewing the physician orders or MAR and without contacting the physician for clarification. An RN stated that she had received the pre-operative instructions verbally from the eye center but did not enter the orders into the computer and only recalled the NPO instruction, which she communicated during shift reports. The written pre-operative instructions, which included the directive to continue blood pressure medications, were later found in the resident’s room after the surgery was cancelled due to elevated systolic blood pressure readings, and the DON confirmed that no NPO or related medication orders had been entered into the system.
Failure to Provide Ordered Neuropathic Pain Medication Due to Communication and Follow-Through Gaps
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective pain management for a resident with chronic pain, as required by physician orders, the care plan, and facility policy. The resident, admitted with diagnoses including epilepsy, history of traumatic brain injury, multiple muscle contractures, parkinsonism, and chronic pain, reported right shoulder/arm pain and was observed propelling himself in his wheelchair using only his feet while holding his right arm protectively against his body. His care plan identified chronic pain and a need for pain management related to impaired mobility, contractures, and muscle spasms, with goals that he would not have unrelieved pain and approaches including administering medications as ordered and referral to pain management. Review of the physician’s orders and MAR showed that the resident was prescribed Lyrica (pregabalin) 25 mg orally twice daily for neuropathic pain, with the order active from 01/10/2026 through 04/01/2026. However, from 3/26/2026 through 3/31/2026, 12 scheduled doses of Lyrica were not administered. The MAR documented these missed doses as due to “Drug/Item Unavailable,” “Drug/Item Unavailable ODS,” and comments indicating the medication was awaiting insurance approval. During this same period, progress notes contained no documentation that the medication was not administered or that any alternative scheduled pain medication was provided, despite the resident’s MDS indicating frequent pain that limited day-to-day activities and the use of high-risk medications including anticonvulsants for pain control. Interviews revealed multiple staff inactions and communication failures that contributed to the missed pain medication. The resident stated he had more pain in his right arm and had not received his routine pain medication for several days. The Unit Manager acknowledged she had not documented discussions with the pharmacy or efforts to obtain an alternative. The DON stated nurses were expected to contact the pharmacy and then the physician if there were problems obtaining medications, but the APRN and PA managing the resident’s pain reported they had not been contacted about the lack of Lyrica or the need for an alternative, and there was no prior authorization request noted. One LPN reported receiving notice from the pharmacy that the medication was not covered and that the facility would need to pay, but he did not withdraw the available e-kit dose, did not administer Lyrica, and did not seek an alternative medication. Another LPN called the pharmacy and was told there was an insurance issue but did not document the call or contact the physician herself. A third LPN, in training, followed instructions to simply request a refill in the electronic record when the medication was unavailable. Additionally, a report showed that pregabalin 25 mg was available in the automated dispensing machine, but it was not used for the resident during the period when doses were missed.
Unnecessary Drug Administration Due to Failure to Follow Midodrine Parameters
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications involving one resident whose drug regimen included midodrine 5 mg, ordered to be given orally three times daily at 8:00 AM, 12:00 PM, and 5:00 PM, with instructions to hold the dose if the systolic blood pressure was over 110. Review of the resident’s March 2026 Medication Administration Record (MAR) showed that midodrine was documented as administered 13 times outside of the physician-ordered blood pressure parameters. During interviews, two LPNs who administered the medication stated that they always check blood pressure prior to giving medications with parameters and would not administer midodrine if the blood pressure was outside the ordered range, attributing the MAR entries to documentation errors. The DON stated that her expectation is that nursing staff follow physician orders, including specific parameters, before administering medications. The documented administrations outside ordered parameters formed the basis of the cited deficiency under the requirement that each resident’s drug regimen be free from unnecessary drugs.
Improper Handling and Maintenance of Respiratory Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to respiratory equipment for multiple residents receiving or previously ordered to receive oxygen or nebulizer treatments. For one resident with a PRN order for oxygen at 2 liters per minute via nasal cannula, oxygen tubing dated 3/14/2026 was observed coiled on top of an oxygen concentrator without being bagged when the resident was out of the room. On a subsequent observation, the same resident was in bed receiving oxygen via nasal cannula using tubing still dated 3/14/2026, and an additional nasal cannula was seen coiled around the armrest of the resident’s wheelchair, also not bagged. Staff interviews revealed inconsistent knowledge about how often oxygen tubing should be changed, with one LPN unsure and stating it was done on night shift, while a unit manager stated tubing was changed weekly on Fridays. The DON later stated tubing was changed weekly, dated, and stored in a bag when not in use, which did not align with the observed practice. For another resident, a nebulizer machine was observed lying on the floor behind the bed, with the nebulizer mask and tubing lying across the machine on the floor and the tubing not dated. This condition was observed on two consecutive days. The resident reported not having used the nebulizer “in forever.” The DON stated that the mask must be covered when not in use, tubing must be dated when changed, and that this resident did not have current orders for nebulizer treatments and had not been receiving them. The DON also stated the machine and mask should have been removed, cleaned, and stored, which contrasted with the observed condition of the equipment remaining in the resident’s room on the floor. A third resident’s room was observed to contain a nebulizer machine on the bedside table with an uncovered nebulizer mask lying across it and tubing that was not dated, with the same conditions noted on two separate days. An RN stated that nebulizer masks should be covered after each use, tubing should be changed weekly and dated, and that if a resident no longer had nebulizer orders, the machine should be removed, cleaned, and stored, and the tubing discarded. The RN further stated that this resident did not have current orders for nebulizing treatments and had not received such treatments since October 2025. Review of the facility’s “Oxygen Administration” policy dated 1/13/2026 indicated that cannulas and masks should be changed weekly and stored in a plastic bag when not in use, which was not followed in the observed instances for these residents.
Failure to Maintain Effective Pest Control in Resident and Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of live and dead insects in resident care and food service areas. Surveyors observed live brown-colored insects on a wall and a dead insect on a windowsill in a training room adjacent to the kitchen and dining area, as well as a live insect under a cabinet in the dining area. Additional observations included a live insect on the floor outside a resident’s doorway in the West Wing near the kitchen entrance, a dead insect on the floor near the exit door from the kitchen food preparation area, and a live insect around the drain area of the dishwashing machine where food contact items are processed. In resident areas, a live brown-colored insect was seen by the baseboard in one resident’s bathroom, and three small dark brown insects were seen running toward the baseboard when another resident’s bathroom door was opened and the light turned on. Interviews and record review showed that, although a pest control process was in place, it was not effective in preventing ongoing pest activity. The Dietary Manager reported that pest concerns were relayed to Maintenance, which was responsible for contacting the pest control company. The Maintenance Director stated that each wing maintained a pest log and that a contracted pest control company conducted weekly visits, reviewed logs, and provided service reports, which he said were reviewed with corrective actions taken as needed. However, exterminator reports over several months documented repeated pest concerns in the kitchen and all three resident wings, and an LPN stated that although spraying occurred weekly for roaches, it did not seem to be helping and roaches were still seen on the unit. The Administrator confirmed the expectation that the environment be pest-free, and the facility’s “Resident Environment Quality” policy required maintaining an effective pest control program so the facility is free of pests and rodents, which was not achieved based on the ongoing observations and documented activity.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure that food was safely stored, covered, labeled, or discarded in the kitchen's walk-in cooler, walk-in freezer, and nutrition rooms. During a tour of the main kitchen, surveyors observed opened and undated containers of potato salad, ricotta cheese, and sour cream with an expired date in the walk-in cooler. Additionally, there were unlabeled and undated trays of vegetables and frozen pizzas without any opened, use by, or expiration dates in the walk-in freezer. The Certified Dietary Manager (CDM) confirmed these findings, acknowledging that the foods should have been labeled and dated. In the nutrition rooms, similar issues were found. In one room, there were opened, unlabeled bottles of sport hydration drink, take-out sandwich bags with half-eaten sandwiches, and a grocery store bag containing various food items, all unlabeled and undated. The microwave in this room was also found to be unsanitary. In another nutrition room, there were opened, unlabeled, and undated food items in the freezer. The CDM confirmed these findings and stated that all foods should be labeled with the resident's name, room number, and the date it was brought in. The facility's policies on food preparation and storage were reviewed, but no specific policy for unlabeled and undated foods in the kitchen was provided.
Inaccurate MDS Assessment for Resident with Venous Ulcers
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with skin conditions. Specifically, the MDS for a resident with chronic venous hypertension and ulcers on both lower extremities did not document the presence of venous or arterial wounds, despite evidence to the contrary. The resident's wound assessment report indicated a venous ulcer on the left lower leg with specific measurements and treatment orders, yet this was not reflected in the MDS. The deficiency was identified during an interview with an MDS Licensed Practical Nurse (LPN), who admitted to overlooking the wound assessment conducted by the facility's nurse and instead relied on hospital documentation. This oversight led to an inaccurate MDS assessment, which is a violation of the facility's policy and procedure for conducting comprehensive and accurate resident assessments as required by federal regulations.
PASRR Documentation Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the Preadmission Screening and Resident Review (PASRR) for two residents. Resident #83's Level I PASRR screening, dated July 17, 2023, lacked entries in Section I: PASRR Screen Decision-Making under Section A for Mental Illness (MI) or suspected MI, despite the resident having diagnoses of generalized anxiety disorder, brief psychotic disorder, and other specified persistent mood disorders. Similarly, Resident #107's Level I PASRR screening, dated August 18, 2024, documented schizophrenia but omitted the diagnosis of other specified anxiety disorders, which was present on the resident's face sheet. The Director of Nursing confirmed these omissions during an interview on October 24, 2024.
Failure to Follow Daily Wound Care Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident with a skin condition. During observations on two consecutive days, it was noted that a resident had a pink gentle border foam dressing on her right lower leg, dated several days prior. The resident had a physician's order for daily dressing changes, which included specific instructions to cleanse the wound with normal saline and cover it with a medipore dressing. However, the dressing had not been changed daily as per the order, indicating a lapse in following the prescribed wound care protocol. Interviews with staff revealed inconsistencies in the execution of wound care responsibilities. A Licensed Practical Nurse (LPN) admitted to changing the dressing on the day of the interview, noting that the previous dressing was dated four days earlier. The Wound Care Nurse described a routine where she communicated her wound care activities to other nurses, but it was unclear if this process ensured compliance with daily dressing changes. The Director of Nursing expressed an expectation that nurses assigned to residents with daily wound care orders would complete and document these tasks daily, highlighting a gap between expectations and actual practice.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely, as observed in two separate incidents involving residents. In the first incident, a bottle of nasal spray and a bottle of 4% lidocaine were found unsecured on the bedside table of a resident's room on multiple occasions. The resident stated that they kept these medications at their bedside because they needed them frequently. A Licensed Practical Nurse (LPN) confirmed the presence of the unsecured medications and acknowledged that medications should not be at the bedside unless the resident has been assessed for self-administration, and even then, they must be secured. The Director of Nursing reiterated that facility policy requires a physician's order for self-administration and that medications should not be in the resident's room unless these conditions are met. In the second incident, a resident was observed with a medication cup containing a thick brown liquid on their meal tray while eating breakfast in their room. The resident indicated that the medication was left by the nurse for consumption after breakfast. An LPN explained that the resident preferred to take their medication after eating and would become upset if pressured to take it immediately. The Director of Nursing stated that medications should not be left at the bedside and should be administered under supervision. The facility's policy on medication storage specifies that bedside medications require a physician's order and should be stored in a locked compartment within the resident's room.
Inaccurate Documentation of Wound Care
Penalty
Summary
The facility failed to accurately document wound care dressing changes for a resident with a skin condition. During observations on two consecutive days, the resident was found with a dressing dated several days prior, despite physician orders for daily dressing changes. The treatment administration history inaccurately documented that the dressing changes were completed on those days, which was contradicted by the physical evidence of the unchanged dressing. Interviews with staff revealed inconsistencies in the documentation and execution of the wound care orders. A Licensed Practical Nurse admitted to changing the dressing on a later date, acknowledging the discrepancy with the documented dates. The Director of Nursing confirmed that the expectation was for daily dressing changes to be completed and accurately documented, which was not adhered to in this case. The facility's policy emphasized the need for concise, accurate, and complete documentation, which was not followed, leading to the deficiency.
Failure in Hand Hygiene During Wound Care and Meal Delivery
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during wound care and meal delivery, as observed in two separate incidents. In the first incident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between handling meal trays for two residents. The CNA placed a meal tray in one resident's room, assisted with repositioning the resident, and then proceeded to another resident's room to deliver and assist with feeding without using hand sanitizer or washing hands in between. This lapse in hand hygiene was acknowledged by the CNA during an interview. In the second incident, a Licensed Practical Nurse (LPN) failed to perform hand hygiene before donning gloves and changing a dressing on a resident's wound. The LPN was observed texting on a cellular phone before entering the resident's room and proceeded to change the dressing without washing hands. The Infection Control Preventionist and the Director of Nursing both confirmed that hand hygiene should be performed before and after resident contact, and that gloves do not substitute for hand hygiene. The facility's policies on hand hygiene and dressing changes were reviewed, which clearly outlined the need for hand washing before and after resident contact and during dressing changes.
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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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