Cypress Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wildwood, Florida.
- Location
- 490 S Old Wire Rd, Wildwood, Florida 34785
- CMS Provider Number
- 105649
- Inspections on file
- 37
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Cypress Care Center during CMS and state inspections, most recent first.
The facility did not post current nurse staffing information on multiple days, instead displaying outdated data and failing to provide required daily updates. The Administrator confirmed that daily posting was expected but had not occurred.
A facility failed to properly store and label medications, as observed with a resident's medication left unattended at the bedside and multiple medication carts containing insulin pens and vials without open or expiration dates. Staff acknowledged the need for proper labeling and disposal of loose medications, but the facility's practices did not align with its policies, resulting in deficiencies.
The facility was found deficient in kitchen sanitation and food handling practices. Observations revealed improper food storage, dirty equipment, and failure to follow sanitation protocols. A cook was not wearing a beard guard, and clean dishes were not stored properly. Interviews confirmed these issues, highlighting non-compliance with facility policies.
The facility failed to provide accurate assessments for three residents, leading to care discrepancies. A resident of Cuban descent was inaccurately documented as non-Hispanic and English-speaking, causing communication barriers. Another resident was incorrectly marked as dependent on eating despite feeding herself, and a third resident was documented as independent in daily activities despite needing assistance. These inaccuracies highlight a failure in providing reflective evaluations of residents' statuses.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in communication and seizure management. A resident who primarily speaks Spanish faced communication barriers due to the lack of consistent Spanish-speaking staff, and her care plan did not address this need. Another resident with a history of seizures did not have a care plan for seizure management, despite being on medication for it. These lapses were contrary to the facility's policies on comprehensive care planning.
Two residents with gastric tubes did not receive care according to professional standards. An LPN administered medications and nutrition without checking tube placement or residuals, contrary to physician orders and facility policy. The Director of Nursing confirmed the need for these checks.
The facility failed to adhere to professional standards for two residents. A resident with a midline catheter lacked documented orders for dressing changes and flushing, contrary to facility policy. Another resident received medications outside prescribed blood pressure parameters, with both the DON and a doctor acknowledging the need for adherence to physician orders. The facility's policies on IV care and medication administration were not followed.
The facility failed to assess two residents for safe smoking practices, as required by its policy. One resident was observed with cigarettes and a lighter in his room and smoking on the patio, while another was seen smoking in a wheelchair. Both residents kept smoking materials with them, and their assessments lacked documentation of safe smoking practices.
A resident did not receive a scheduled bolus feed as per physician's orders, due to an LPN not having the enteral feeding available and being unaware of the specific order. The resident was supposed to receive a bolus of 325 ml at specific times, in addition to continuous feeding. Another LPN confirmed the oversight and noted the risk of weight loss due to missed feedings.
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. One resident received oxygen at an incorrect flow rate, while another was not provided with continuous oxygen as prescribed. Staff acknowledged these discrepancies, indicating a failure to adhere to physician's orders and facility policy.
A facility failed to obtain a urinalysis for a resident with obstructive and reflux uropathy, despite a physician's order. The resident reported abdominal pain and potential UTI symptoms, stating they informed staff but the specimen was not collected. An LPN confirmed the test should have been done.
The facility did not review or update its Emergency Preparedness Program (EPP) since 2018, failing to meet the annual review requirement. This oversight was confirmed by the Director of Maintenance and acknowledged by the Administrator, leaving the facility potentially vulnerable in emergencies.
The facility's roof was found to have a large amount of combustible materials, including tree vegetation, leaves, Spanish moss, and a small tree, which could reduce the flammability rating of the roof materials. This deficiency was confirmed by the Maintenance Director and acknowledged by the Administrator.
The facility did not maintain the exit discharge as per NFPA 101 standards. The exit from the Spanish Villa corridor lacked a hard-packed all-weather travel surface to the public way, potentially hindering safe evacuation. The Maintenance Director was aware of the requirement but unsure why the exit was not connected to the sidewalk. This was acknowledged by the Administrator and the Director of Maintenance.
The facility did not provide proper illumination for egress pathways, as required by NFPA 101. Observations revealed that exit doors from the French Quarter wing, the main entrance, and the Spanish Villa wing lacked necessary lighting for safe egress during darkness. These findings were confirmed by the Maintenance Director and acknowledged by the Administrator.
The facility failed to maintain its sprinkler system as required by NFPA standards. During a tour, it was found that 6 out of 24 sprinkler heads in the kitchen were covered with grease and debris, which could affect their activation. The Director of Maintenance confirmed these findings, and the Administrator acknowledged the issue.
The facility was found non-compliant with NFPA 101 smoking regulations. Observations revealed missing self-closing devices on ashtrays, prohibited plastic bins, and improper disposal of smoking debris in non-designated areas. These deficiencies were confirmed by the Director of Maintenance and acknowledged by the Administrator.
A portable blood pressure machine in the facility was found to be in use without undergoing the required Bio-Medical testing. The machine had been used daily for over two months, as confirmed by a staff nurse and the Director of Maintenance. This deficiency was acknowledged by the facility's administration during the exit conference.
The facility did not provide test results for the annual duct detector sensitivity testing as required by NFPA 101 and NFPA 72. During a record review, it was found that the necessary documentation was missing, and the Director of Maintenance confirmed the inability to locate these documents. This deficiency could result in the duct detectors failing to notify of a fire in the ventilation system, posing a risk to residents and staff.
The facility failed to maintain a class "K" fire extinguisher in accordance with NFPA 10 standards, as it was observed without the required safety seal securing the pull pin. This deficiency was noted during a tour with the Director of Maintenance, who concurred with the findings. The absence of the safety seal could prevent accidental discharge, potentially delaying fire suppression or causing a fire to intensify.
The facility failed to accurately test electrical receptacles in resident care areas and lacked documented performance data. Additionally, improper installation of a power cord passing through the ceiling into interstitial space was observed, with a power strip used as permanent wiring above the fire sprinkler system, posing a potential fire hazard. These issues were confirmed by the Director of Maintenance and acknowledged by the Administrator.
The facility failed to maintain two sets of generator manuals as required by NFPA 110. During a record review with the Director of Maintenance, it was found that the facility did not have evidence of maintaining the necessary documentation. The Director of Maintenance acknowledged the deficiency, indicating a lapse in compliance with essential electrical system standards.
The facility failed to properly inform two residents about changes in their health plan coverage, lacking necessary attestations and a policy for assisting with such changes. This resulted in a violation of residents' rights to be informed and make treatment decisions.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that accurate nurse staffing information was posted on a daily basis as required. During observations on two consecutive days, the posted nurse staffing information was outdated, displaying data from several days prior and lacking current information for the observed dates. Photographic evidence was obtained to document the absence of up-to-date postings. In an interview, the Administrator confirmed that the expectation was for the Staffing Coordinator to update the nurse staffing information daily, and acknowledged that this had not been done as required.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles. During an observation, it was noted that a resident had intravenous medication running and a medication cup with tablets left at her bedside. The resident stated that nurses leave her medication at the bedside because she prefers to take them when she gets out of bed. A CNA confirmed the presence of the medication cup at the bedside, and an LPN admitted to being sidetracked, leaving the medication unattended. Further observations revealed multiple issues with medication carts across different units. Several insulin pens and vials were found without open or expiration dates, and some medications were left loose in the drawers. Staff members acknowledged that insulin pens should be labeled with open and expiration dates and that loose medications should be disposed of. Insulin that is not open should be refrigerated, and expired medications should not be kept in the medication cart. The Director of Nursing confirmed that insulin pens and eye drops should be labeled with open and expiration dates, and expired medications should be disposed of. The facility's policy stated that medications should be stored in a safe, secure, and orderly manner, and discontinued or outdated medications should not be used. However, the observations indicated a failure to adhere to these policies, leading to the deficiencies noted in the report.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and sanitation in the kitchen, as observed during a walk-through tour. A large bulk bin of flour was found with a partially open lid and food particles inside, while three bins had dirt and splashes on their exteriors. A can opener attached to a prep table had a buildup of brown, red, and black particles, and the deep fryer contained dirty oil with food particles. Additionally, dirty rags were left on a food table without being stored in sanitizing buckets, and numerous food serving trays had chipped edges exposing metal. The food-catch-tray under the cooking range's pilot lights had a buildup of black food particles, and lunch food items were placed on the steam table too early. Further observations revealed that a cook was not wearing a beard guard, and clean dishes were not stored inverted, which could lead to contamination. Interviews with the Administrator, Dietary Manager, and President of Dietary and Environmental Services confirmed these issues and highlighted the failure to adhere to policies regarding food preparation, storage, and sanitation. The facility's policies clearly state that food should not be heated on the steam table, utensils and equipment should be kept clean and in good repair, and staff should wear appropriate protective gear to prevent contamination.
Inaccurate Resident Assessments Lead to Care Discrepancies
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their care plans. Resident #111, who is of Cuban descent and primarily speaks Spanish, was inaccurately documented in her Minimum Data Set (MDS) as not Hispanic and with English as her preferred language. This misrepresentation led to communication barriers, as staff members who spoke Spanish were not always available to assist her. Interviews with staff confirmed the need for Spanish-speaking personnel to facilitate communication with Resident #111, highlighting the inaccuracy in her assessment. Resident #24 was observed feeding herself with setup assistance, yet her MDS documented her as dependent on eating. Additionally, despite a 10.2% weight loss over six months, her MDS inaccurately indicated no weight loss. For Resident #4, the MDS inaccurately documented her as independent in several activities of daily living, despite her comprehensive care plan and staff interviews indicating she required assistance due to impaired mobility and cognitive deficits. These inaccuracies in the residents' assessments reflect a failure to provide accurate and reflective evaluations of their current statuses.
Deficiencies in Communication and Seizure Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in communication and respiratory care. Resident #111, who primarily speaks Spanish, experienced communication barriers due to the lack of Spanish-speaking staff consistently available to assist her. Although some staff members and the Environmental Service Supervisor attempted to bridge the communication gap, Resident #111's comprehensive care plan did not address her communication needs. Interviews with staff revealed that while they were aware of her language barrier, it was not formally documented or addressed in her care plan, contrary to the facility's policy requiring comprehensive assessments and care plans. Resident #91, admitted with a history of seizures and other medical conditions, did not have a care plan addressing seizure management despite being on medication for seizures. The Director of Nursing acknowledged that a history of seizures should be included in the resident's care plan. The facility's policy mandates a person-centered plan of care for residents with seizure disorders, but this was not implemented for Resident #91, indicating a lapse in adhering to established procedures for comprehensive care planning.
Failure to Follow Gastric Tube Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents with gastric tubes. For Resident #147, a Licensed Practical Nurse (LPN) administered medications via the gastric tube without checking the tube's placement or residual, contrary to the physician's orders. The orders specified that the tube placement and residual should be checked before any feeding, flushing, or medication administration, and that medications should be crushed and diluted with water, with a flush of 5 milliliters of water between each medication. The LPN did not follow these instructions, as observed during a medication administration session. Similarly, for Resident #124, the same LPN did not check the gastric tube's placement or residual before flushing the tube with water and administering a Glucerna bolus. The physician's orders required checking the tube placement every shift and flushing with water before and after the bolus. The LPN admitted to forgetting to check the residuals, which was confirmed by the Director of Nursing, who stated that residuals should be checked before any administration via the gastric tube. The facility's policy also emphasized verifying tube placement before medication administration.
Failure to Adhere to Professional Standards in Medication and IV Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents. For Resident #267, a single lumen midline was observed with a transparent dressing dated 3/7/2025, but there were no physician orders documented for intravenous catheter dressing changes or flushing the intravenous central line. The Director of Nursing acknowledged that IV dressing changes should be done every 7 days and that there should be orders in the system for flushes and dressing changes to ensure staff compliance. The facility's policy requires sterile dressing changes at least weekly, which was not adhered to in this case. For Resident #118, the facility failed to administer medications according to the physician's parameters. Losartan was given despite the resident's systolic blood pressure being below the prescribed threshold on multiple occasions. Additionally, Clonidine was administered when the resident's systolic blood pressure was below the required level for administration. The Director of Nursing and Medical Doctor #1 both stated that nursing staff should follow physician orders and parameters for medication administration. The facility's policy mandates that medications be administered as prescribed by the physician, which was not followed in this instance.
Failure to Assess Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not assessing two residents for safe smoking practices. Resident #77 was observed with cigarettes and a lighter on the bedside table and was later seen smoking on the patio. Interviews with the resident and a Certified Nursing Assistant (CNA) confirmed that the resident kept cigarettes and a lighter with him. A review of the admission nursing assessment for Resident #77 revealed that the section on smoking safety was incomplete, with several questions left unanswered. The facility's smoking policy requires a smoking assessment to be completed before or upon admission, which was not adhered to in this case. Similarly, Resident #139 was observed smoking on the patio while sitting in a wheelchair. Staff confirmed that this resident also kept cigarettes and a lighter with him. The nursing admission assessment for Resident #139 indicated that he was a past smoker, but there was no documentation of a smoking screen or safe smoking assessment in his clinical record. This lack of assessment and documentation demonstrates the facility's failure to implement its policy on maintaining safe smoking practices for residents.
Failure to Administer Prescribed Enteral Feeding
Penalty
Summary
The facility failed to provide the prescribed enteral feeding care for a resident, identified as Resident #134, who was receiving tube feeding services. During an observation, it was noted that the resident did not receive a bolus feed at 2:00 PM as per the physician's orders. The orders specified that the resident should receive a bolus of 325 ml via enteral feeding tube at 6 am and 2 pm, in addition to continuous feeding at 100 cc/hr for 12 hours. Staff I, an LPN, admitted to not having the enteral feeding available to administer and was unaware of that portion of the order. Another LPN, Staff N, acknowledged that the resident should have received the feeding and noted that not receiving the ordered feedings could result in weight loss.
Failure in Oxygen Therapy Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. Resident #124 was observed receiving oxygen at a flow rate of 3.5 liters per minute, despite having a physician's order for 2 liters per minute to maintain oxygen saturation levels at or above 92%. This discrepancy was noted over several days, and staff acknowledged the incorrect flow rate, indicating a failure to adhere to the physician's orders and facility policy, which requires verification of respiratory procedures and oxygen use. Resident #91, who had a history of metabolic encephalopathy, altered mental status, and other conditions, was observed multiple times without the prescribed continuous oxygen therapy. Despite a physician's order for continuous oxygen at 2 liters per minute, the resident was not wearing oxygen during several observations. Staff confirmed the resident was not on oxygen, highlighting a failure to follow the physician's orders and ensure the resident received necessary respiratory support.
Failure to Obtain Ordered Urinalysis for Resident
Penalty
Summary
The facility failed to obtain a urinalysis when ordered by the physician for a resident diagnosed with obstructive and reflux uropathy. The physician's order for a urinalysis with culture and sensitivity was dated 3/12/2025, but a review of the resident's medication administration record, treatment administration record, nursing progress notes, and laboratory results showed no documentation of the test being completed or any refusal by the resident. During an interview, the resident reported experiencing abdominal pain and symptoms suggestive of a urinary tract infection, and stated that they had informed the staff several days prior, but the urine specimen had not been collected. A Licensed Practical Nurse confirmed that the urinalysis should have been collected on the date of the order.
Failure to Update Emergency Preparedness Program
Penalty
Summary
The facility failed to comply with the requirement to review and update their Emergency Preparedness Program (EPP) annually, as mandated by 42 CFR 483.73(a). During a record review conducted with the Administrator and the Maintenance Director, it was discovered that the facility's EPP had not been reviewed or updated since 2018. This lack of action resulted in the facility presenting an outdated EPP that did not meet the established requirements for a comprehensive emergency preparedness plan. The deficiency was confirmed during an interview with the Director of Maintenance, who concurred with the findings. The failure to maintain an updated EPP could potentially leave the facility and its occupants vulnerable in the event of a disaster or emergency. These findings were acknowledged by both the Administrator and the Director of Maintenance during the exit conference.
Roof Maintenance Deficiency Due to Combustible Materials
Penalty
Summary
The facility failed to maintain the roof in a clean and safe condition, as observed during a tour of the exterior. On the roof, there was a significant accumulation of combustible materials, including tree vegetation, leaves, Spanish moss, and even a small tree growing. These materials pose a fire hazard by potentially reducing the flammability rating of the roof materials, which could endanger residents and staff. The Maintenance Director confirmed these findings during the inspection, and the issue was acknowledged by both the Administrator and the Maintenance Director during the exit conference.
Exit Discharge Deficiency
Penalty
Summary
The facility failed to maintain the exit discharge in accordance with NFPA 101 standards. During an observation conducted with the Maintenance Director, it was noted that the exit door leading from the Spanish Villa corridor to the west exit discharge did not have a hard-packed all-weather travel surface extending to the public way. This deficiency could impede safe evacuation in an emergency. The Maintenance Director acknowledged the requirement but was unsure why the exit was not connected to the sidewalk. These findings were confirmed by the Administrator and the Director of Maintenance during the exit conference.
Failure to Illuminate Egress Pathways
Penalty
Summary
The facility failed to provide proper illumination for means of egress walkways and exit passageways leading to the public way, as required by NFPA 101. During a tour conducted with the Director of Maintenance, it was observed that several exit areas lacked the necessary egress lighting. Specifically, the exit doors from the French Quarter wing to the courtyard and smoking patio, the exit doors to the left of the main entrance and administrative hallway, and the exit doors at the end of the Spanish Villa wing did not have adequate lighting to ensure safe egress during hours of darkness. These deficiencies were confirmed by the Maintenance Director during an interview and acknowledged by both the Administrator and the Director of Maintenance at the exit conference.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA standards, specifically regarding the condition of the sprinkler heads. During a tour of the kitchen area, it was observed that 6 out of 24 sprinkler heads were covered with grease and foreign debris. This condition could potentially cause the sprinkler heads to activate prematurely or not at all, depending on the manufacturer's temperature ratings. The Director of Maintenance confirmed these findings during an interview, and the issue was acknowledged by the Administrator during the exit conference.
Non-Compliance with Smoking Area Safety Regulations
Penalty
Summary
The facility failed to maintain designated smoking areas in compliance with NFPA 101 regulations, resulting in several deficiencies. During an inspection, it was observed that the designated smoking area had three ashtrays missing their self-closing devices, which are required for safety. Additionally, plastic smoking bins, which are prohibited, were present and should have been removed. Furthermore, smoking debris was improperly disposed of in a regular trash can instead of the mandated metal safety can, posing a potential fire hazard. An area outside the Sable Palms wing, not designated for smoking, was found to have a significant amount of smoking debris discarded in the mulch and yard debris. This area lacked appropriate containers for the disposal of smoking debris, further indicating non-compliance with safety regulations. These observations were confirmed by the Director of Maintenance during the inspection and acknowledged by both the Administrator and the Director of Maintenance at the exit conference.
Failure to Test Electrical Equipment Before Use
Penalty
Summary
The facility failed to provide documentation for the electrical testing of fixed and portable medical equipment, specifically a portable blood pressure machine. During a tour of the facility, it was observed that the machine was connected to an electrical outlet for charging and was ready for use without having undergone the required Bio-Medical testing before being placed into service. This oversight was confirmed by the Director of Maintenance during the tour. Interviews conducted during the tour revealed that the portable blood pressure machine had been in use daily for over two months without the necessary testing. The staff nurse confirmed the machine's usage, and the Director of Maintenance acknowledged the lack of testing documentation. These findings were discussed and acknowledged by the Administrator and the Director of Maintenance during the exit conference.
Failure to Provide Duct Detector Testing Results
Penalty
Summary
The facility failed to provide test results for the annual duct detector sensitivity testing, which is a requirement under NFPA 101 and NFPA 72. During a record review, it was found that the facility did not have evidence that the annual duct detector differential testing was conducted. This deficiency was confirmed during an interview with the Director of Maintenance, who was unable to locate the necessary documentation. The absence of these test results could lead to the duct detectors failing to perform as designed, potentially resulting in no notification of a fire in the ventilation system, which could cause injury to residents or staff. These findings were acknowledged by the Administrator during the exit conference.
Failure to Maintain Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards. During a tour of the facility, a class "K" fire extinguisher located to the left of the main entrance to the cooking facility was observed without the required safety seal securing the pull pin. This deficiency was noted during an observation conducted with the Director of Maintenance, who concurred with the findings. The absence of the safety seal could prevent accidental discharge of the fire extinguisher, potentially delaying fire suppression or causing a fire to intensify, which could result in injury during an emergency to residents, staff, and visitors. These findings were acknowledged by the Administrator and the Director of Maintenance during the exit conference.
Deficiencies in Electrical System Testing and Installation
Penalty
Summary
The facility failed to conduct accurate testing of electrical receptacles in resident care rooms and bed locations, as well as failed to provide documented performance data for these receptacles. This deficiency was identified during a record review, which revealed that the testing report did not include individual testing of receptacles in resident rooms, bed locations, and GFCI outlets in resident restrooms. The Director of Maintenance confirmed these findings during an interview, acknowledging the lack of proper documentation and testing. Additionally, during a facility tour, it was observed that a power cord was improperly installed, passing through the ceiling into the interstitial space, where a power strip was being used as permanent wiring above the fire sprinkler system. This improper installation could potentially result in a fire hazard. The Director of Maintenance also confirmed these observations, and the findings were acknowledged by the Administrator during the exit conference.
Failure to Maintain Required Generator Manuals
Penalty
Summary
The facility failed to maintain two sets of generator manuals as required by NFPA 110, Section 8.2.2. This deficiency was identified during a record review conducted on March 18, 2025, at 10:30 a.m. with the Director of Maintenance. The review revealed that the facility did not have evidence showing that two sets of generator manuals were maintained on-site, which is a requirement for compliance with the National Fire Protection Association (NFPA) standards. During an interview conducted at the same time, the Director of Maintenance concurred with the findings, acknowledging the absence of the required documentation. This lack of compliance with NFPA 110 and related standards indicates a failure in maintaining essential documentation for the facility's electrical systems, specifically the generator manuals, which are crucial for ensuring the proper operation and maintenance of the emergency power systems.
Failure to Inform Residents of Health Plan Changes
Penalty
Summary
The facility failed to ensure that two residents were properly informed and guided regarding changes in their health plan coverage, which is a violation of their right to be informed and make treatment decisions. For Resident #2, the medical record included disenrollment paperwork signed by the resident, but lacked documentation of an attestation by facility staff confirming that the resident or their representative requested the change and understood the necessary information. The Community Liaison/Admissions Director admitted that no such attestation was signed by the staff. Additionally, the facility did not have a written policy and procedure for assisting beneficiaries with changing their health care coverage. Similarly, for Resident #1, the medical record showed a request signed by the resident for disenrollment from their current health insurance coverage, but there was no documentation of an attestation by facility staff. The Community Liaison confirmed that there was no signed attestation verifying that the facility reviewed all the information with the resident and that the resident requested the change. This lack of documentation and policy indicates a failure to comply with the requirement to inform residents about their health status and treatment options.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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