Encore At Boca Raton Rehabilitation And Nursing Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Boca Raton, Florida.
- Location
- 7300 Del Prado Circle South, Boca Raton, Florida 33433
- CMS Provider Number
- 105506
- Inspections on file
- 29
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Encore At Boca Raton Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
A facility failed to monitor and assess a resident's medication administration accurately, leading to a deficiency in quality of care. The facility did not adhere to its medication administration policy, failing to verify vital signs before administering medication. Additionally, the facility did not document vital signs as required by the doctor's orders, indicating a lack of reassessment and monitoring. Staff interviews revealed inconsistencies in managing changes in a resident's condition.
A facility failed to ensure adequate hydration and nutrition for a resident with good mental cognition and lactose intolerance. The registered dietitian recommended changing the resident's supplement to Ensure Clear, but there was a lack of documentation and monitoring of fluid intake by nursing staff. The multidisciplinary team did not evaluate the resident's nutrition related to medications, and the care plan lacked focus on fluid and nutrition maintenance. Interviews revealed staff did not recall monitoring fluid status, and the physician delayed fluid orders.
A facility failed to adequately monitor and assess medication administration for a resident, leading to a deficiency in care. The resident had orders for vital signs to be checked every shift, but documentation showed gaps in monitoring. Staff interviews revealed inconsistent understanding of procedures for managing changes in a resident's condition, contributing to the deficiency.
The facility failed to maintain food safety standards, with issues including a steamer leak, improper hand hygiene by a dietary aide, and inadequate cooling of pork roasts. The dietary aide was observed using improper glove hygiene and handling food contact surfaces with bare hands, leading to the need for re-sanitization of dishes. The CDM acknowledged these deficiencies.
The facility did not follow its Menu Planning policy, failing to provide the required daily servings of fruit as per national standards during one week of the Spring Summer Menu 2024 cycle. The Registered Dietitian acknowledged the shortfall, which affected the nutritional intake of all residents consuming meals prepared by the facility.
The facility failed to provide adequate access to call devices, functioning air mattresses, and wall lights for several residents. One resident was left in a soiled brief due to an unreachable call bell, while two residents had non-functioning air mattresses. Additionally, several residents faced issues with inaccessible wall lights, and one resident was unable to access the bathroom due to obstructions.
The facility failed to develop comprehensive care plans for residents with PTSD and did not implement interventions for monitoring side effects of psychotropic medications. Two residents with PTSD lacked care plans, and two residents on psychotropic medications were not monitored for side effects as required. Staff interviews revealed non-compliance with care planning policies, leading to deficiencies in resident care.
The facility failed to secure sharps and hazardous items, with an emergency cart left unlocked and a broken sharps container on a med cart. Two residents were found with sharps in their rooms, including a safety razor and scissors, posing safety risks. Staff were unaware of these hazards, and the facility's policy on sharps disposal was not effectively implemented.
A facility failed to maintain proper catheter care and dignity for a resident with an indwelling urinary catheter. Observations showed the drainage bag was often on the floor without a privacy cover, contrary to the facility's policy and the resident's care plan. The resident, who has paraplegia and neuromuscular dysfunction of the bladder, was cognitively intact and had requested monthly catheter changes. A CNA confirmed that catheter care should include hanging the bag with a privacy cover, but this was not consistently done.
The facility failed to monitor the intake of nutritional supplements for two residents, resulting in significant weight loss. One resident, with multiple health conditions, experienced a 13.01% weight loss due to inadequate documentation and monitoring of supplement intake. Another resident, with complex regional pain syndrome, also faced severe weight loss due to a lack of awareness and provision of recommended supplements. Staff interviews revealed a lack of understanding and documentation, contributing to the deficiency.
The facility failed to ensure proper respiratory care and infection control for residents. A resident was observed using oxygen without a physician's order, and respiratory supplies for four residents were not maintained to prevent infection. Observations revealed improper storage of nebulizer masks and outdated oxygen tubing. Interviews with residents and the DON confirmed lapses in following infection control protocols.
The facility failed to identify PTSD triggers for two residents, despite having a policy for trauma-informed care. One resident expressed dissatisfaction with care, and staff interviews revealed a lack of understanding and training. The social services staff did not create care plans addressing PTSD, citing a need to build rapport, while screenings did not address triggers.
The facility failed to accurately reconcile controlled substances for several residents, leading to discrepancies between medication administration records and controlled drug disposition sheets. This issue affected medications such as Percocet, Oxycodone, Temazepam, Morphine Sulfate, and Tramadol, highlighting a systemic problem in the facility's medication management process.
The facility reported a medication error rate of 12.50%, affecting two residents. One resident did not receive three scheduled medications, with one not ordered, while another resident's insulin pen was improperly primed. Staff B, an RN, admitted to documenting medications as administered when they were not and was shown incorrect priming techniques by another nurse.
The facility failed to secure medications properly, with instances of unsecured medications at residents' bedsides and an unlocked medication cart. Medications were improperly disposed of, with staff discarding pills in sharps containers instead of using the drug buster solution. Residents were found with medications without proper orders or evaluations for self-administration, highlighting issues with medication security and disposal practices.
The facility failed to provide meals that met the dietary preferences, allergies, and intolerances of six residents during dining observations. A resident with slight cognitive impairment did not receive the grits listed on her meal ticket, while another with hemiplegia received a tray missing specified items. A resident with intact cognition received a tray missing a fruit cup and diet ginger ale. A resident with moderate cognitive impairment received a tray missing sugar-free lemonade and ice cream. Another resident with moderate cognitive impairment received a tray missing crackers, mandarin oranges, and diet ginger ale. A cognitively intact resident did not receive a banana listed on the breakfast meal ticket, with grapes substituted instead.
A resident with paraplegia and neuromuscular dysfunction did not receive necessary adaptive eating equipment as prescribed, including a plate guard and spill-proof cups. Observations showed the resident's water and cups were out of reach, and the breakfast tray lacked the correct equipment. Staff interviews confirmed the oversight, and the facility's policy on adaptive equipment was not followed.
The facility's QAPI/QAA failed to implement effective corrective actions for repeated deficiencies in pharmacy services and assistive devices, specifically F755 and F810. These issues, previously cited in a past survey, were observed again, potentially affecting all 146 residents. The Administrator acknowledged the recurrence during an interview.
A facility failed to follow infection control procedures during perineal care, glucose monitoring, and medication cart management. A CNA did not perform hand hygiene or change gloves appropriately while caring for a resident, and a RN improperly disposed of a used lancet. Additionally, a personal drink was found on a medication cart among resident items.
A visitor entered the facility without proper identification when a surveyor was allowed entry through the main entrance without being greeted or identified by staff. The surveyor accessed the second floor without security measures, and interviews revealed that staff did not follow the protocol of verifying visitors via an I-Pad camera. The Administrator acknowledged the lapse in protocol, indicating a failure in the facility's visitation policy during the night shift.
A facility failed to provide proper wound care for a resident with a Stage 3 pressure ulcer, as the wound care nurse did not establish a clean field or change gloves after removing a soiled dressing. The nurse continued to handle clean supplies and apply treatment with the same gloves, risking contamination. Additionally, used items were improperly returned to the treatment cart, contrary to infection control practices.
Failure to Monitor and Assess Medication Administration
Penalty
Summary
The facility failed to provide adequate monitoring and assessment for a resident, leading to a deficiency in quality of care. Specifically, the facility did not adhere to its own medication administration policy, which requires vital signs to be checked and verified before administering medications. For Resident #1, there was a failure to assess the accuracy of medication administration, as evidenced by the administration of a medication without verifying the resident's vital signs as per the prescriber's orders. The orders required that the medication be held if certain vital sign thresholds were not met, but the facility did not document the necessary vital sign checks before administering the medication. Additionally, the facility did not comply with the doctor's orders to obtain and document vital signs every shift for 72 hours, followed by a reassessment for continued monitoring. There were significant gaps in the documentation of vital signs, with no recorded measurements between certain times, indicating a lack of reassessment and monitoring as required. Interviews with staff revealed a lack of consistent understanding and execution of procedures for managing changes in a resident's condition, further contributing to the deficiency.
Plan Of Correction
How the corrective action will be accomplished for any resident affected by deficient practice: Resident #1 has been discharged from the facility. LPN D and LPN B and licensed nursing staff involved with Resident #1 care were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions. How we identified other residents/areas that could potentially be affected and what corrective action will be taken: All residents on medications have potential to be by this practice. An audit of all current residents with medications with parameters including was completed to ensure medications are administered in accordance with the prescribers orders and parameters are followed through as per MD order. Any findings were addressed accordingly. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The facility's Medication Administration policy was reviewed by DON and no revision was required. Licensed Nursing staff were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Medication administration competency on following parameters will be conducted with the license nurses. Unit Managers/Supervisors will monitor clinical alerts including, vital signs during the morning meeting and the end of each shift and any abnormality will be reported to MD for immediate interventions. How the corrective actions will be monitored and what quality assurance will be put in place title of person responsible for monitoring: The DON/Designee will audit randomly 10 residents on medications with parameters including weekly x4 then monthly x 3 to ensure that the parameters as ordered is being followed and MD notify as indicated. The results of all audits will be reported to QAPI committee for review and feedback on a monthly basis for the duration of audit until compliance achieved. Responsible party: DON
Failure to Ensure Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure adequate hydration and nutrition for one of the sampled residents. The resident, who was noted to have good mental cognition, was identified as lactose intolerant, and the medical doctor was informed by the registered dietitian to change the resident's supplement to Ensure Clear. However, there was a lack of documentation and monitoring of the resident's fluid intake by the nursing staff, specifically by Staff D, LPN, who did not record progress notes regarding the resident's fluid intake. Additionally, the multidisciplinary team did not conduct a nutritional evaluation related to the resident's medications. The nursing care plan for the resident did not include a focus on fluid and nutrition maintenance or any interventions to maintain the resident's fluid and nutrition status. Interviews with staff revealed a lack of recollection regarding monitoring the resident's fluid status, and the resident's physician indicated that he did not see a need for fluid orders until a later date, despite the resident's condition. This lack of coordinated care and documentation contributed to the deficiency in maintaining the resident's nutritional and hydration status.
Plan Of Correction
How the corrective action will be accomplished for any resident affected by deficient practice: Resident #1 no longer resides at the facility. The facility completed a review of the resident #1 clinical record for any opportunity of improvement in facility clinical services. RD# 1 no longer works at the facility. Staff G. RD#2 was educated on the Facility's policy, titled Resident Hydration and Prevention of and to monitor and assess residents with nutritional risk including risk for evaluation related to receiving medications such as medications and. Facility has hired a second RD that was educated on the Facility's policy, titled Resident Hydration and Prevention of to ensure monitor and assess residents with nutritional risk including risk for evaluation related to receiving medications such as medications and. Staff A, LPN and Staff D, LPN were educated on monitoring residents' fluid intake as per MD order and documenting in medical order, medical records and monitoring CNA task were reviewed to ensure include fluid intake. Resident #1 physician is no longer employed at the facility. How we identified other residents/areas that could potentially be affected and what corrective action will be taken: All residents on medications have potential to be affected by this practice. An audit of residents on medication was conducted to ensure their hydration status and electrolyte balance are monitored. All residents on were audited to ensure they have recent laboratory values that show a balance electrolyte panel. Care plans were updated accordingly, and interventions were implemented where necessary to ensure adequate hydration and nutrition. Any findings were addressed immediately. No additional adverse outcomes were identified audit of all current. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The facility's policy, titled Resident Hydration and Prevention of was reviewed by Director of Nursing and Registered Dietitian and no revision was required. Facility Registered Dietitians, Licensed nursing staff, and IDT team were educated on the above policies and education include: Fluid Intake monitoring protocols and reinforced among staff. Recognition of nutritional/hydration risks, especially related to medications such as. Residents at risk of nutritional/hydration status will be evaluated on a routine basis during the facility risk weekly meeting. Unit Managers/Supervisors will monitor clinical alerts including poor intake during the morning meeting and the end of each shift and any abnormality will be reported to MD and Registered Dietitian for immediate interventions. Registered Dietitian will evaluate residents with nutritional/hydration risks on a monthly basis and as needed as per clinical alerts to ensure their nutritional/hydration needs have been addressed. How the corrective actions will be monitored and what quality assurance will be put in place title of person responsible for monitoring: The Director of Nursing or designee will audit 10 residents with nutritional/hydration risks weekly x 4 then monthly x3 to evaluate that they have an individualized plan of care in place as well as to ensure they maintain a proper hydration status and electrolyte balance. The results of all audits will be reported to QAPI committee for review and feedback on a monthly basis for the duration of audit until compliance achieved. Responsible party: DON
Failure to Monitor and Assess Medication Administration
Penalty
Summary
The facility failed to provide adequate monitoring and assessment of medication administration for a resident, leading to a deficiency in care. The facility's policy on medication administration requires that medications be administered according to prescriber's orders, including checking and verifying vital signs before administration. However, for one resident, the facility did not adhere to these guidelines. The resident had specific orders to have vital signs obtained and documented every shift for 72 hours, followed by reassessment for continued monitoring. Despite this, there were gaps in the documentation of vital signs, indicating that the required monitoring was not performed as ordered. The resident, who had a good mental cognition score, was prescribed a medication with instructions to hold if certain vital sign thresholds were not met. On one occasion, the medication was administered without the necessary reassessment of vital signs, as there was no documentation between specific times on consecutive days. Interviews with staff revealed a lack of consistent understanding and execution of procedures for managing changes in a resident's condition, including when to notify a doctor or reassess vital signs. This lack of adherence to established protocols and documentation requirements contributed to the deficiency in providing adequate and appropriate health care to the resident.
Plan Of Correction
How the corrective action will be accomplished for any resident affected by deficient practice: Resident #1 has been discharged from the facility. LPN D and LPN B and licensed nursing staff involved with Resident #1 care were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions. How we identified other residents/areas that could potentially be affected and what corrective action will be taken: All residents on medications have potential to be by this practice. An audit of all current residents with medications with parameters including completed to ensure medications are administered in accordance with the prescribers orders and parameters are followed through as per MD order. Any findings were addressed accordingly. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The facility's Medication Administration policy was reviewed by DON and no revision was required. Licensed Nursing staff were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Medication administration competency on following parameters will be conducted with the license nurses. Unit Managers/Supervisors will monitor clinical alerts including vital signs during the morning meeting and the end of each shift and any abnormality will be reported to MD for immediate interventions. How the corrective actions will be monitored and what quality assurance will be put in place title of person responsible for monitoring: The DON/Designee will audit randomly 10 residents on medications with parameters including weekly x4 then monthly x 3 to ensure that the parameters as ordered is being followed and MD notify as indicated. The results of all audits will be reported to QAPI committee for review and feedback on a monthly basis for the duration of audit until compliance achieved. Responsible party: DON
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food safety standards during food preparation and handling, as observed during a series of inspections. Initially, a leak was noted at the filter from the steamer, which the Certified Dietary Manager (CDM) acknowledged and stated that Maintenance would address. Additionally, a dietary aide was observed using improper hand hygiene practices by rinsing gloved hands in a food preparation sink before handling ready-to-eat lettuce. The aide was instructed to remove the gloves and perform proper hand hygiene. Further observations revealed additional deficiencies. The dietary aide was seen stacking bowls with bare hands, directly touching the food contact surfaces, which required the bowls to be rewashed and sanitized. Moreover, the internal temperatures of pork roasts intended for a meal were found to be significantly below safe levels, indicating improper cooling after cooking. The CDM confirmed that the roasts were not cooled properly. The dietary aide was also observed washing gloved hands at a hand sink, which was not appropriate, and was again instructed to remove the gloves and perform hand hygiene. The CDM acknowledged these findings at the conclusion of the inspection.
Deficiency in Menu Planning and Nutritional Standards
Penalty
Summary
The facility failed to adhere to its Menu Planning policy, which is designed to meet the nutritional needs of residents in accordance with established national standards. During one week of the Spring Summer Menu 2024 cycle, the facility did not provide the required daily servings of fruit as outlined in their guidelines. Specifically, the menu was supposed to provide 2 to 2.5 cups of fruit per day, but the actual servings fell short, with some days offering only 1/2 cup of fruit. This discrepancy was observed over a week, affecting the nutritional intake of all residents consuming meals prepared by the facility. Interviews with the Registered Dietitian, Staff C, revealed that the menus were created and reviewed by the Corporate Dietitian. Staff C acknowledged that the facility's menus did not meet the required fruit servings as per the national standards. Although fruit servings could be provided upon request from residents, the standard menu did not fulfill the dietary guidelines. This oversight in menu planning and execution had the potential to impact the nutritional well-being of the residents.
Deficiencies in Resident Care and Accessibility
Penalty
Summary
The facility failed to ensure access to call devices for two residents, leading to significant issues in their care. One resident, with a cognitive response, was observed with the call bell on the floor and out of reach, resulting in her being unable to request assistance for a soiled adult incontinent brief. Another resident, with severe cognitive impairment, was found with the call bell device inaccessible, requiring intervention from the Director of Nursing and the Director of Maintenance to make it reachable. The facility also failed to ensure the proper functioning of air mattresses for two residents. Despite documentation indicating that the mattresses were checked every shift, observations revealed that the mattresses were not plugged in and therefore not functioning. This oversight was only discovered during a side-by-side observation with a Licensed Practical Nurse, who admitted to not noticing the issue until that moment. Additionally, the facility did not provide adequate access to wall lights for several residents, with pull cords being too short or inaccessible. This issue was compounded by the placement of privacy curtains obstructing access to shared wall lights. Furthermore, one resident was unable to access the bathroom due to obstructions and was without paper towels for several days, while another resident was left with an unmade bed for several hours despite requests for clean linens.
Deficiencies in Care Planning and Medication Monitoring
Penalty
Summary
The facility failed to develop comprehensive care plans for residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Two residents, both with PTSD diagnoses, did not have care plans addressing their condition. One resident was admitted with PTSD, but the social services staff did not create a care plan, citing the resident's initial denial of anxiety and depression and the need to build rapport. Another resident was diagnosed with PTSD after admission, and although a stress for life screening was conducted, a care plan was only created after the surveyor's inquiry. The facility also failed to implement care plan interventions for residents on psychotropic medications. Two residents on such medications did not have their side effects monitored as required. One resident was prescribed Alprazolam for anxiety, but there was no order to monitor its side effects, despite pharmacy recommendations. The care plan for this resident included monitoring for side effects, but there was no evidence of implementation. Another resident on antidepressants also lacked monitoring for potential side effects, as indicated by the physician's orders and medication administration records. Interviews with facility staff revealed gaps in the care planning process and a lack of adherence to policies. The MDS Coordinator and Social Service Director acknowledged the absence of care plans for PTSD and the need for monitoring psychotropic medication side effects. The facility's policy requires comprehensive, person-centered care plans to be developed within specific timeframes, but these were not followed, leading to deficiencies in resident care.
Failure to Secure Sharps and Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by several observations of unsecured sharps and hazardous items. One emergency cart was found unlocked and unattended, containing safety razors, scissors, and a box of lancets. Additionally, a medication cart was observed with a broken sharps disposal container, leaving sharps unsecured. These observations were confirmed by staff members present at the time, who acknowledged the issues but did not take immediate corrective action. Two residents were found with sharps in their rooms, posing potential safety risks. Resident #88, who has a cognitive score indicating full cognitive function, was observed with a safety razor in a Styrofoam cup on his nightstand. Resident #108, who has moderate cognitive impairment and Parkinson's disease, was seen using regular scissors to cut paper towels. The facility's care plan for Resident #108 did not include an assessment for scissors safety, and staff were unaware of the presence of scissors in her room until it was brought to their attention. Interviews with staff revealed a lack of awareness and adherence to safety protocols regarding sharps and hazardous items. The Director of Nursing and other staff members were not aware of the presence of these items in residents' rooms, and there was no immediate action taken to secure the environment. The facility's policy on sharps disposal was not effectively implemented, as evidenced by the unsecured sharps and the lack of a comprehensive policy addressing accident hazards.
Failure to Maintain Catheter Care and Dignity
Penalty
Summary
The facility failed to maintain the drainage bag for a resident with an indwelling urinary catheter in a manner that prevents infection and maintains dignity. The facility's policy on catheter care, revised in August 2022, specifies that catheter tubing and drainage bags should be kept off the floor to prevent urinary catheter-associated complications, including infections. However, observations revealed that the drainage bag for a resident with paraplegia and neuromuscular dysfunction of the bladder was found lying on the floor without a privacy cover on multiple occasions. This is contrary to the physician's orders and the resident's care plan, which emphasized keeping the drainage bag below the bladder level, checking placement and function every shift, and ensuring the bag is covered for privacy. The resident, who was cognitively intact with a Brief Interview of Mental Status score of 14, expressed that she was informed her catheter would be changed every six months, but she insisted on monthly changes. Despite the facility's policy and the resident's care plan, the observations indicated non-compliance with infection control and dignity protocols. A Certified Nursing Assistant confirmed that catheter care is documented daily, and the bag should be hanging with a privacy cover, yet these practices were not consistently followed for the resident in question.
Failure to Monitor Nutritional Supplement Intake
Penalty
Summary
The facility failed to adequately monitor the intake of nutritional supplements for two residents, leading to significant weight loss and potential health risks. Resident #52, who had multiple health conditions including heart failure, renal insufficiency, and malnutrition, was dependent on staff for eating and required nutritional supplements as part of their care plan. Despite being on a regular diet with puree texture and nectar thickened liquids, the resident experienced a significant weight loss of 13.01% over a short period. Interviews with staff revealed a lack of documentation regarding the resident's intake of supplements, and discrepancies in weight measurements were noted without proper follow-up or verification. Resident #98, diagnosed with complex regional pain syndrome and obstructive uropathy, also experienced severe weight loss over several months. The resident's dietary plan included nutritional supplements like Magic Cup and Ensure Plus, but there was a lack of documentation and monitoring of the intake of these supplements. Observations showed that the resident was not provided with the recommended fortified foods, and staff failed to ensure the resident received the correct nutritional supplements during meals. Interviews with staff indicated a lack of awareness and understanding of the nutritional supplements, further contributing to the deficiency. The facility's failure to document and monitor the intake of nutritional supplements for these residents highlights a significant deficiency in the care provided. The lack of proper documentation and staff awareness led to inadequate nutritional support for residents at high risk of malnutrition and weight loss. This deficiency was identified through observations, interviews, and record reviews, revealing a systemic issue in the facility's approach to managing residents' nutritional needs.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen had a physician's order, affecting one of the four sampled residents reviewed for respiratory care. Specifically, Resident #111 was observed wearing oxygen without any evidence of a physician's order for oxygen administration. This oversight was noted during an observation on December 2, 2024, when the resident was seen sitting up in bed with an oxygen concentrator set at 2 liters. The resident had been admitted with diagnoses including acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Additionally, the facility did not maintain respiratory supplies in a manner that prevents infection for four sampled residents. Resident #6's nebulizer mask was observed on top of a personal cart and later on a nightstand, not stored in a plastic bag as required. Resident #17's oxygen tubing had not been changed since November 11, 2024, despite a physician's order for weekly changes. Resident #8's oxygen cannula and tubing were observed with a date tag of November 18, 2024, and were found on the floor, not stored in any plastic containment. Interviews with the residents and the Director of Nursing (DON) revealed inconsistencies in the facility's adherence to infection control protocols. The DON confirmed that residents need a physician's order for oxygen and that oxygen tubing should be changed weekly. The DON also stated that nebulizer masks should be stored in plastic bags when not in use. These observations and interviews highlight the facility's failure to follow its own infection prevention policies related to respiratory care equipment.
Failure to Identify PTSD Triggers in Residents
Penalty
Summary
The facility failed to identify triggers for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), specifically for two residents sampled for mood and behavior. The facility's policy on trauma-informed care emphasizes the importance of identifying and minimizing triggers for trauma survivors. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and care planning for the residents' PTSD triggers. Resident #28 was admitted with diagnoses including PTSD and had a Brief Interview of Mental Status (BIMS) score indicating intact cognition. Despite this, there was no care plan addressing PTSD, and the resident expressed dissatisfaction with the facility's response to his needs. Interviews with staff revealed a lack of understanding and training regarding trauma-informed care, with staff unable to identify or address PTSD triggers effectively. The social services staff admitted to not having created a care plan for PTSD, citing a need to build rapport with the resident first, despite the resident's admission being several months prior. Similarly, Resident #72, who also had a diagnosis of PTSD, did not have documented triggers in their care plan. The social service director acknowledged that the stress for life screenings conducted did not address or ask about triggers, and there was no proactive approach to identifying them. The resident mentioned having triggers related to control and possession of items but was not able to articulate them clearly. The facility's failure to document and address these triggers indicates a deficiency in providing trauma-informed care as per their policy.
Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substance medications for six residents, leading to discrepancies in medication administration records and controlled drug disposition sheets. For Resident #10, there was a mismatch between the documented administration of Percocet and the actual count of tablets, indicating potential errors in medication tracking. Similarly, Resident #51's records showed an undocumented administration of Oxycodone, which was not reflected in the controlled drug disposition sheet, highlighting a lack of proper reconciliation. Resident #73's records revealed inconsistencies in the documentation of Temazepam administration, with a missing entry on the disposition sheet despite the correct count of capsules. This suggests a failure in maintaining accurate records of medication administration. For Resident #88, the records showed discrepancies between the medication administration record and the controlled drug disposition sheet for Morphine Sulfate, indicating a lack of proper reconciliation and documentation. Residents #345 and #346 also experienced similar issues, with discrepancies between the medication administration records and the controlled drug disposition sheets for Tramadol and Oxycodone, respectively. These inconsistencies point to a systemic issue in the facility's process for reconciling controlled substances, as acknowledged by the Director of Nursing, who noted that the current plan in place was not effective in addressing these discrepancies.
Medication Administration Errors and Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 12.50 percent. This deficiency affected two residents, one of whom was Resident #63. During a medication administration observation, it was noted that three medications scheduled for 9:00 AM were not administered during the med pass. Staff B, a Registered Nurse, documented that these medications were given, but later admitted that one of the medications, Ferrous Sulfate, was not available and had not been ordered. The Director of Nursing confirmed that these medications were omitted during the med pass. Another incident involved Resident #32, who was prescribed Fiasp FlexTouch insulin for diabetes management. During a med pass, Staff B was observed priming the insulin pen incorrectly by holding it upside down, contrary to the manufacturer's instructions. This improper technique could potentially affect the accuracy of the insulin dosage. Staff B stated she was shown this method by another nurse, indicating a possible gap in training or adherence to proper procedures. These observations highlight significant lapses in medication administration practices, including failure to administer prescribed medications and incorrect priming of an insulin pen. These errors were identified through direct observation and interviews with staff, revealing issues with both medication availability and staff training or adherence to protocols.
Medication Security and Disposal Deficiencies
Penalty
Summary
The facility failed to secure medications properly, as evidenced by several observations and interviews. Medications were found unsecured at the bedside for three residents, and a medication cart was left unlocked and unattended. Specifically, a Registered Nurse left an insulin pen on top of an unlocked and unattended medication cart. Additionally, a resident with severe cognitive impairment was found with a bottle of Tums on her nightstand without an evaluation for self-administration of medication. Another resident, who had intact cognition, had two bottles of artificial tears on her overbed table without documentation of administration or evaluation for self-administration. The facility also failed to properly dispose of medications during medication observations. A Licensed Practical Nurse disposed of a pill in a sharps container instead of using the drug buster solution as per facility policy. Another incident involved a Registered Nurse improperly discarding spilled Senna Plus tablets into a sharps container, despite being advised by a wound care nurse to use the drug buster located in the medication room. The Director of Nursing acknowledged that discarding medications in the sharps container was a bad habit among the nurses. Furthermore, a resident with moderate cognitive impairment was found with over-the-counter medications on her nightstand, including expired nasal spray, without any orders for self-administration. The Director of Nursing admitted that residents' families often bring in medications, complicating efforts to keep medications out of residents' rooms. Despite recent inspections, the facility continued to struggle with ensuring medications were not left unsecured in residents' rooms.
Failure to Meet Residents' Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide meals that met the dietary preferences, allergies, and intolerances of six residents during dining observations. Resident #122, who has slight cognitive impairment, reported not receiving the grits listed on her meal ticket and was unable to get a turkey sandwich as requested. Resident #54, with a diagnosis of hemiplegia, received a meal tray that did not match the no added salt diet specified on her meal ticket, missing apple juice and ginger ale. Resident #39, who has intact cognition, received a meal tray missing a fruit cup and diet ginger ale, contrary to the regular diet specified on the meal ticket. Resident #69, with moderate cognitive impairment, received a meal tray missing sugar-free lemonade and ice cream, as noted by her private aid who frequently observed discrepancies between meal tickets and trays. Resident #44, with moderate cognitive impairment, received a meal tray missing crackers, mandarin oranges, and diet ginger ale, which were specified on her no added salt diet meal ticket. Resident #46, who is cognitively intact, did not receive a banana listed on the breakfast meal ticket, with grapes substituted instead. The Food Service Assistant, who had been working at the facility for a short period, acknowledged the absence of documented preferences for Resident #46 in the meal tracker system. The facility's process for ensuring meal accuracy, involving a starter and checker, was not effectively implemented, leading to these deficiencies.
Failure to Provide Adaptive Eating Equipment to Resident
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment to a resident, identified as Resident #46, who required such equipment due to medical conditions including paraplegia and neuromuscular dysfunction of the bladder. The resident had a physician's order for a plate guard, spill-proof cup with two handles, and weighted utensils for all meals. However, observations revealed that the resident did not receive the appropriate equipment during meals. On one occasion, the resident's water and cups were out of reach, and on another, the breakfast tray included a one-handled cup without a spill lid and a two-handled cup with a loose lid, contrary to the prescribed adaptive equipment. Interviews with staff members, including a CNA, a Food Service Assistant, and the Director of Rehab, confirmed the oversight. The CNA acknowledged the improper use of cups and lids, while the Food Service Assistant admitted that the resident did not receive the correct adaptive equipment. The Director of Rehab confirmed the resident's need for adaptive equipment due to tremors and the necessity for stability and spill prevention. The facility's policy on adaptive equipment was not adhered to, resulting in the resident not receiving the required assistance to safely consume meals.
Repeated Deficiencies in Pharmacy Services and Assistive Devices
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to effectively implement corrective actions for identified quality deficiencies. This was evidenced by repeated deficient practices in pharmacy services and assistive devices, specifically related to F755 and F810. These deficiencies were previously cited during a recertification survey with an exit date of 08/24/23 and were observed again during the current survey. The repeated deficiencies have the potential to affect all 146 residents residing in the facility at the time of the survey. During an interview, the facility's Administrator acknowledged the recurrence of these deficiencies.
Infection Control Deficiencies in Resident Care and Equipment Handling
Penalty
Summary
The facility failed to adhere to standard infection control procedures during perineal care for a resident with intact cognition and multiple diagnoses, including Type 2 Diabetes Mellitus and Dysphagia following Cerebral Infarction. During the observation, a CNA did not perform hand hygiene after glove removal and before donning a new set of gloves. The CNA also failed to change gloves between different tasks, such as washing the resident's perineal area and then touching other parts of the resident's body and bed controls. Additionally, the CNA used the same water to wash different areas of the resident's body, including the back anal region and upper back, without changing gloves or performing hand hygiene. The facility also failed to properly dispose of contaminated lancets used for glucose monitoring. A RN encapsulated a used lancet in a glove and disposed of it in an open trash container next to a resident's bed, believing it was safe because the needle retracted. Furthermore, a personal drink was observed on a medication cart among items used for residents, which was acknowledged by the staff member as inappropriate. These actions demonstrate a lack of adherence to infection control protocols, potentially compromising resident safety.
Visitor Entry Without Proper Identification
Penalty
Summary
The facility failed to provide a safe environment for its residents by allowing a visitor to enter the premises without proper identification. On the morning of June 25, 2024, a surveyor was able to enter the facility at 6:14 AM through the main entrance after ringing the doorbell, which automatically opened the door. The surveyor proceeded to the reception desk and completed the registration process without being greeted or identified by any staff member. The surveyor then accessed the second floor, where the long-term care units are located, without encountering any security measures such as an elevator code. Interviews with various staff members revealed that none of them had opened the door for the surveyor, and there was no designated supervisor during the night shift. Staff members indicated that the facility's protocol involved checking an I-Pad camera at the nurse's station to identify visitors before granting entry. However, this protocol was not followed, as no staff member verified the surveyor's identity or purpose of visit. The facility's Administrator acknowledged the lapse in protocol and stated that the staff should have come to the door to identify the surveyor, highlighting a failure in the facility's visitation policy and security measures during the night shift.
Failure to Adhere to Wound Care Protocols
Penalty
Summary
The facility failed to provide wound care consistent with professional standards for a resident with severe cognitive impairment and multiple medical conditions, including quadriplegia and diabetes. The resident had a Stage 3 pressure ulcer on the right buttock, acquired while in the facility, which required specific wound care treatment. During an observation, the wound care nurse (WCN) did not establish a clean field for the wound care supplies and failed to change gloves after removing the soiled dressing, which is against the facility's wound care policy. The WCN continued to handle clean supplies and apply treatment to the wound with the same soiled gloves, increasing the risk of contamination. Additionally, the WCN placed the soiled dressing on the bed pad underneath the resident and later retrieved it with the same gloves. The WCN also placed used items, such as a Medihoney tube and scissors, back into the treatment cart after using them in the resident's room, which the Assistant Director of Nursing (ADON) confirmed should not occur due to infection risk. These actions demonstrate a failure to adhere to proper infection control practices during wound care, as outlined in the facility's policy.
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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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