Gardens Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Florida.
- Location
- 190 Ne 191st Street, Miami, Florida 33161
- CMS Provider Number
- 105765
- Inspections on file
- 28
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Gardens Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that food items brought in by visitors and family for residents were stored in nourishment refrigerators without proper labeling or dating. Staff confirmed the items belonged to residents, and facility policy requires labeling with resident names and use-by dates, but this was not followed.
A resident with a history of schizophrenia and psychosis left the facility AMA without the responsible party being successfully notified, despite multiple attempts by the DON and facility policy requiring such notification. The resident's advocate later reported not being informed of the discharge, and documentation confirmed the notification process was incomplete.
A resident with disorganized schizophrenia and a colostomy left AMA without a safe discharge plan, valid destination, or notification to their advocate or representative. Facility staff did not involve social services in the discharge process, failed to promptly inform medical providers, and did not conduct a wellness check or notify authorities. The resident's location remained unknown at the time of the survey.
A resident was unable to have food brought in by family reheated by staff after a prior incident where her food was burnt, leading the dietary manager to refuse further reheating. The facility had removed microwaves from each floor and maintained a policy that only dietary staff could reheat outside food, but staff were not permitted to do so, resulting in multiple resident complaints.
A resident with a history of schizophrenia and psychosis left the facility AMA without the required notification to their designated representative. Despite attempts by the DON to contact the responsible party by phone, no direct communication or documentation of notification occurred, and the resident's advocate later reported not being informed of the discharge.
A facility failed to develop a discharge care plan for a resident with a trimalleolar fracture, who was to be discharged home with family. Despite the resident's independence in some daily activities and a 30-day notice to vacate due to unpaid bills, no discharge plan was created. Interviews revealed confusion among staff about care plan responsibilities, contrary to facility policy.
Two residents in an LTC facility were observed with improperly secured drainage bags, increasing the risk of dislodgement and infection. One resident had severe cognitive impairment and was noncompliant with treatment, while the other had mild cognitive impairment. Staff acknowledged the risks but failed to ensure proper placement and monitoring.
A resident in an LTC facility did not receive a timely Drug Regimen Review (DRR) despite being on high-risk medications. The resident, who was admitted after an accident, was observed with symptoms like drooling and sleepiness, leading to the discontinuation of a medication. The facility failed to conduct the required monthly DRR, resulting in a deficiency.
The facility failed to develop a discharge care plan for a resident with a displaced tri-malleolar fracture, despite the resident's choice to be discharged home. Additionally, two residents were observed with unsecured urinary drainage bags, increasing the risk of complications. The facility did not adhere to its policies requiring comprehensive care plans and proper management of medical equipment.
Two residents in a facility were observed with improperly managed drainage bags, increasing the risk of dislodgement. One resident was seen carrying the bag in his hand and placing it on the floor, while another had the bag and tubing near wheelchair wheels. Staff acknowledged the risks and attempted to educate the residents, but the issues persisted, highlighting a deficiency in providing adequate healthcare.
A LTC facility failed to address a rodent infestation and implement proper infection control measures. Despite reports of rodents, the administration did not act promptly, and food was improperly stored. Infection control lapses included mishandling a Glucometer and inadequate hand hygiene during wound care. The facility also failed to separate soiled and clean laundry, risking cross-contamination. The infection preventionist lacked required training.
The facility's Administrator failed to address a rodent infestation despite being aware of the issue for months. The Administrator did not follow pest control policies, relying on in-house maintenance instead of external services. A resident reported seeing rodents and inadequate housekeeping, while the DON communicated the issue to the Administrator without documenting it. Staff reported multiple sightings, but the Administrator did not take effective action, leading to Immediate Jeopardy due to potential disease spread.
The facility failed to implement an effective pest control program, leading to a rodent infestation that was not addressed in a timely manner. Despite reports from a resident and staff about rodent sightings, the facility did not follow its pest control policy, resulting in a lack of documentation and communication. The pest control technician was not informed of specific areas needing treatment, and the Administrator was unaware of the extent of the issue. This deficiency affected the quality of care for 111 residents.
A resident with a PEG tube experienced severe weight loss due to the facility's failure to follow physician's orders for tube feeding and complete a timely nutritional assessment. The resident's feedings were often delayed or missed, and staff were unclear about feeding schedules. The facility did not adhere to its policies on nutrition and weight management, leading to inadequate care.
The facility failed to maintain food safety standards, with issues such as soiled and rust-laden equipment, improper storage of staff items, and incorrect food temperatures. Observations included mold-like substances in the refrigerator, high chemical concentrations in cleaning buckets, and flying insects in food areas. Cold foods were not held at the required temperatures, posing potential risks to residents.
The facility failed to ensure the designated Infection Preventionist (IP) completed required training. The DON, assigned as the IP, had not finished the necessary modules or obtained certification. The ADON completed the training but did not assume the IP role, leaving the deficiency unaddressed.
The facility was found to have significant cleanliness and maintenance issues, including soiled and stained floors, walls, and furniture across various areas. Residents were affected by these deficiencies, with complaints about room conditions, roach sightings, and inadequate furniture. Wheelchairs and Geri chairs were also in poor condition, impacting residents' comfort and safety.
The facility failed to provide residents with reasonable access to private phone use, as observed on the second floor where residents used the nurses' station phone without staff intervention. Conversations, including sensitive financial and medical discussions, were overheard by staff and other residents. Despite the availability of cordless phones for private use, they were uncharged and inaccessible, indicating a lack of awareness and action by the staff to ensure privacy.
The facility did not post current nurse staffing information daily in a prominent location. During a tour, outdated staffing data was observed, and a nurse confirmed the absence of comprehensive staffing data, only knowing assignments for her floor.
The facility failed to administer medications timely for a resident with multiple diagnoses, leading to frequent late administration and missed doses. Another resident received a discontinued medication, and discrepancies in drug records were found for three other residents, indicating failures in medication administration and record-keeping.
The facility failed to properly monitor and document behaviors for residents on psychotropic medications, as evidenced by incomplete records and misunderstandings among staff. Residents with various psychiatric diagnoses were not adequately observed, with behavior monitoring records lacking required documentation. Interviews revealed staff confusion about the documentation process, contributing to the deficiency.
The facility failed to secure medications and biologicals, with a bottle of Dakin's solution found in an unlocked closet and a resident having unauthorized access to Cortisone cream. Additionally, wound treatment carts were left unlocked and unattended, contrary to facility policy. These incidents highlight lapses in medication storage and security protocols.
The facility failed to provide a nourishing, palatable, well-balanced diet to 107 residents, as observed during breakfast meals. Residents were served a watered-down tropical punch instead of the preferred orange juice, and there was a shortage of sausage links and fresh bananas, which were not substituted. The Certified Dietary Manager confirmed the unavailability of orange juice and other citrus juices, and dietary staff noted that bananas were not regularly available.
The facility failed to adhere to approved menus for resident meals, affecting 107 out of 111 residents. For lunch, a smaller portion of chili was served, canned pineapple replaced watermelon, and pureed regular bread was given instead of pureed cornbread. At breakfast, bananas were not provided, and there was an insufficient supply of sausage links. The facility cook admitted to not following the menu and being unaware of specific dietary requirements.
The facility did not adhere to standardized recipes for meal preparation, affecting the quality of food served to 107 residents. The Turkey Patty Melt was prepared with incorrect ingredients and cooking methods, resulting in an unappetizing meal. A staff member admitted to not using the standardized recipe, leading to this deficiency.
The facility failed to implement effective corrective actions for deficiencies in maintaining a safe environment, pharmacy services, QAPI activities, and pest control, affecting 111 residents. Despite having a comprehensive QAPI program, repeated issues were identified during surveys, indicating a lack of adherence to procedures.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect classification of medications. A resident with cardiac conditions was documented as receiving an anticoagulant but not an antiplatelet, despite orders for both. Another resident with cerebral infarction was documented as receiving an anticoagulant, though only antiplatelets were prescribed. A third resident with heart disease was similarly misclassified. The MDS Coordinator's misunderstanding of medication classifications was confirmed by the facility's Consultant Pharmacist.
The facility failed to maintain minimum nursing staff levels, impacting resident safety and care. Staffing records showed nursing staff averages below the required minimum, attributed to late punches. Observations revealed a CNA monitoring residents from inside due to being short-staffed, and another staff member expressed concerns about staffing levels.
A long-term care facility failed to maintain a functioning call light system for residents, affecting their ability to request assistance. Several residents, including those with cognitive awareness and mobility issues, reported non-working call lights, with some issues persisting for months. Staff were aware of the malfunctions, but repairs were delayed due to the need for specific parts. This deficiency compromised residents' ability to communicate their needs effectively.
The facility failed to address grievances related to non-functional call lights for four residents, leading to inadequate care. Residents reported issues with call lights not working, forcing them to find alternative ways to seek assistance. Despite complaints, the facility's grievance log did not document these issues, and staff interviews revealed inconsistencies in the grievance process.
A resident left the facility against medical advice (AMA) without proper documentation of family notification. The Assistant DON acknowledged notifying the family but failed to document it. The resident's emergency contact confirmed being informed but questioned the resident's mental capacity to leave AMA.
The facility failed to ensure handrails were securely affixed on the 3rd floor, as observed during a tour. Loose handrails were found in several locations, including near rooms and the elevator. The Administrator acknowledged the issue, noting a similar problem had been addressed on the 2nd floor.
The facility failed to ensure call lights were within reach for four residents, leading to potential safety risks. A resident with slight cognitive impairment fell while trying to use the bathroom without assistance due to an inaccessible call light. Another resident, cognitively intact but dependent on staff, could not reach the call light wrapped around the bed rail. A third resident, rarely understood, indicated the call light was out of reach, and a fourth resident with cognitive impairment had the call light on the floor behind the bed.
The facility failed to implement comprehensive care plans for antipsychotic medications for three residents and an advance directive for one resident. One resident with Alzheimer's and Anxiety Disorder was prescribed Seroquel without a care plan. Another resident with severe cognitive impairment had no care plan for insulin and clonazepam. A third resident with Dementia and Depression was prescribed Olanzapine without a care plan for antipsychotics. Additionally, a resident with a full code status had no care plan for advanced directives.
A resident's smoking care plan was not revised by the interdisciplinary team after each assessment, despite the resident's diagnoses including COPD and Nicotine Dependence. The care plan had not been updated since its target date, and interviews revealed confusion over documentation processes. The DON and ADON acknowledged the lack of revisions and absence of electronic care plans.
A resident with cognitive impairment and dysphagia was left unsupervised with a lunch tray, leading to coughing and regurgitation of food. The resident required maximum assistance with eating and honey-thick liquids, as per her care plan, but was observed eating with her hands. The CNA assigned was unaware of who placed the tray, highlighting a lapse in supervision and adherence to the care plan.
A resident with COPD was inadequately supervised while smoking, as staff monitored from inside and could not see all residents. The smoking patio had scattered cigarette butts and trash in a bin, and the laundry area showed excessive lint buildup due to missed cleaning schedules.
A resident with hypertension was nearly given an incorrect dose of Labetalol due to a medication administration error by an RN. The RN prepared only one 100 mg tablet instead of the prescribed 1.5 tablets (150 mg). The error was caught by a surveyor before administration, and the RN corrected the dose.
A resident with cognitive impairment and dysphagia was found with non-thickened water and eating pureed food unsupervised, leading to coughing and regurgitation. The resident required honey-thick liquids and maximum assistance, but was left with inappropriate food and liquid consistency. Additionally, regular consistency grits and scrambled eggs were served to residents on a pureed diet due to the cook not reviewing the approved menu, violating the facility's policy for thickened liquids.
A resident with Type 2 Diabetes and Iron Deficiency did not receive the prescribed diet of no concentrated sweets, no added salt, double portions, and fortified foods. Observations showed that the resident's meals lacked double portions and fortified foods, contrary to physician's orders. The facility's system for managing dietary orders failed to include the resident, leading to this deficiency.
The facility failed to provide Divided Plates to five residents who required them for self-feeding, despite documented therapy assessments and physician orders. Observations showed that meal trays lacked the necessary equipment, and staff interviews revealed a lack of awareness and availability of adaptive plates.
The facility failed to properly dispose of garbage and refuse, as observed in the outside garbage/refuse area. A large body of stagnant water was found between dumpsters, containing stagnant algae and medical waste such as medication bottles, inhaler tubes, and disposable protective gear. The area was littered with garbage and trash, and four large tires filled with stagnant water were noted, posing a potential source of pest activity. The facility administrator acknowledged awareness of the situation.
The facility failed to offer and document influenza and pneumococcal vaccinations for several residents, leading to deficiencies in immunization records. A resident had no documentation of immunizations or consent/refusal since admission. Another resident's influenza vaccine refusal was not documented, and eligibility for the pneumonia vaccine was uncertain. A third resident's records lacked documentation of vaccines and refusal consents.
The facility failed to provide adequate closet space with privacy doors for several residents. Observations revealed that some residents either shared closets or had closets without doors, while one resident had no closet at all. Staff interviews showed inconsistency in awareness and justification for the lack of closet space, with one CNA acknowledging the absence of closet doors and another resident's lack of a closet due to having no belongings.
The facility did not complete performance reviews for CNAs at least every 12 months. The DON could not provide evaluations for five CNAs due to a recent ownership transition, and HR stated the information was unavailable from the previous owner.
A resident with severe cognitive impairment and a history of wandering eloped from a facility due to inadequate supervision and an unsecured laundry room door. The resident was found by law enforcement at a county dump site, 1.5 miles away, after being missing for several hours. The facility's failure to ensure proper supervision and secure exits led to this incident.
Failure to Label and Date Resident Food in Nourishment Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in both nourishment refrigerators located on the resident units. Specifically, food items brought in by visitors and family members for residents were found in the refrigerators without proper labeling or dating. On one floor, there were multiple unlabeled grocery bags and plastic containers, some of which were dated but lacked resident names, while others had neither dates nor names. Similar issues were found in the refrigerator on another floor, where several plastic bags with food items were also unlabeled and undated. Interviews with facility staff confirmed that these food items belonged to residents and were stored in the pantry refrigerators. The Assistant Director of Nursing acknowledged that food should be labeled with the resident's name and a discard date, and that perishable items should be discarded after three days. Review of the facility's policy indicated that perishable foods must be stored in resealable containers, labeled with the resident's name, item, and use-by date, and that staff are responsible for discarding perishable foods on or before the use-by date. The observed practices did not align with these requirements.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions to be completed by 7/31/2025. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Identified refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names was discarded by the ADON 6/26/2025. Identified third-floor refrigerator with several unlabeled undated plastic bags with food items was discarded by the ADON 6/26/2025. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review to be completed by the DON/designee of the 2nd and 3rd floor refrigerators to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions 7/22/2025. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure food items brought in from outside visitors/family are dated, labeled and stored appropriately under sanitary conditions to be completed by 7/31/2025. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; DON/designee to conduct ongoing quality monitoring of the 2nd and 3rd floor refrigerators through visual observation to ensure food items brought in from outside visitors/family are dated, labeled, and stored appropriately under sanitary conditions twice weekly x four weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months then quarterly and PRN as indicated and modified based on findings.
Failure to Notify Resident Representative of AMA Discharge
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative of a significant change in the resident's condition, specifically when the resident left the facility Against Medical Advice (AMA). The resident, who had diagnoses including Disorganized Schizophrenia and Psychosis, was admitted with a responsible party listed as an advocacy group. The resident was taking antipsychotic medications and had an active discharge plan for return to the community. On the day of the incident, the resident was found missing by staff, later located in another resident's room, and expressed a strong desire to leave the facility. The DON consulted with the physician, who advised allowing the resident to leave AMA. The resident refused to sign the AMA form and subsequently left the facility. Despite the facility's policy requiring notification of the resident's representative when a resident leaves AMA, the responsible party was not successfully notified. The DON reported making three or four phone calls and leaving a voicemail, but no response was received. The Social Services Director confirmed that the health care proxy should be notified about any incident and is the person designated to sign a resident out AMA. The resident's advocate stated during an interview that they were not notified of the resident's departure and expressed concern for the resident's safety and need for medication. Documentation reviewed included the resident's demographic sheet, admission/discharge/transfer list, MDS, physician's orders, care plan, and progress notes. The facility's policy on AMA discharge clearly outlined the requirement to notify the resident's representative and document the notification in the medical record. However, the lack of successful notification and documentation of the responsible party's awareness of the resident's AMA discharge constituted a failure to meet the regulatory requirement for notification of changes.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings. The same monitoring process will be repeated: through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Inappropriate Discharge of Resident with Schizophrenia
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of disorganized schizophrenia and colostomy status left the facility against medical advice (AMA) without a safe and appropriate discharge plan. The resident, who was cognitively intact but had a history of delusional thinking and required ongoing antipsychotic medication, expressed a desire to leave and was presented with an AMA form, which he refused to sign. The facility did not obtain a valid address for the resident's next place of residence, nor did they inform the resident's advocate or representative about the AMA discharge. At the time of the survey, the resident's location was unknown. Facility staff failed to ensure that the resident was safely discharged to a location where ongoing clinical care could be provided. The Social Services Director was not involved in the discharge process and was not notified until after the resident had left. The resident's primary care physician and psychiatrist were not promptly informed of the resident's departure, and the facility did not conduct a wellness check or notify law enforcement, as no police or missing person reports were filed. The facility's own policy required notification of the resident's representative and documentation in the medical record, but these steps were not completed. Interviews with facility staff revealed confusion and lack of coordination regarding the resident's whereabouts and the discharge process. The Director of Nursing and Administrator acknowledged that the resident left without providing a destination and that attempts to contact the advocate were limited to leaving voicemails. The Social Services Director confirmed that she was not involved in the process and did not have a discharge location to perform a wellness check. The resident's advocate and medical providers expressed concern about the resident's safety and the lack of communication from the facility.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident isft AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quailty review over the last 30 days by the DON/designee to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings. Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Follow Policy for Reheating Outside Food
Penalty
Summary
The facility failed to follow its own policy regarding the reheating of food brought in by family or visitors for one resident. Observation revealed that the resident, who was seated in her wheelchair at the bedside, reported a disagreement with the dietary manager after her food was burnt when staff previously warmed it in the kitchen. As a result, the dietary manager refused to warm her food in the kitchen. The resident further explained that microwaves had been removed from each floor and that residents were required to have outside food warmed in the kitchen. Interview with the dietary manager confirmed that there were no microwaves available for residents and that staff were not permitted to reheat outside food, a longstanding policy despite multiple resident complaints. Review of the facility's policy indicated that only dietary staff are allowed to reheat outside food to prevent injury.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident Council Meeting to be held 7/2/2025 to review the policy r/t Food Brought in from Outside Visitors/Family. A copy of the Food Brought in from Outside Visitors/Family policy was placed in the admission packet by the ED 7/23/2025 and will be reviewed with new admissions, re-admissions and/or the resident representative as part of the admission process. Resident #13 grievance initiated and resolved 6/26/2025. Resident #13 educated on the policy r/t Food Brought in from Outside Visitors/Family by the ED 6/26/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of grievances received over the last 30 days from residents/visitors and/or staff with concerns related to not being able to have their food re-heated to be completed by the ED 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current facility staff re-educated by the ED/designee on the components of this regulation and the policy titled "Food Brought in from Outside Visitors/Family" to be completed by 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The ED/designee to conduct ongoing quality monitoring through morning meeting r/t grievances regarding food not being able to be re-heated to ensure residents/visitors and staff have been provided education on the policy titled "Food Brought in from Outside Visitors/Family" 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Notify Resident's Representative of Change in Condition During AMA Discharge
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition when the resident, who had a diagnosis of Disorganized Schizophrenia and Psychosis, left the facility Against Medical Advice (AMA). The resident was admitted with a responsible party listed as an advocacy group and was taking antipsychotic medications. Documentation showed that the resident had no cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, and was actively involved in discharge planning for a return to the community. On the day of the incident, the resident insisted on leaving the facility, and the physician advised allowing the resident to leave AMA. The resident refused to sign the AMA form, and the responsible party was not present or notified in person. Interviews and record reviews revealed that the Director of Nursing attempted to contact the responsible party by phone several times and left voicemails, but no response was received. The Social Services Director confirmed that the health care proxy should be notified and is the person authorized to sign a resident out AMA, but this did not occur. Facility policy requires notification and documentation of the resident's representative when a resident leaves AMA, but this was not completed as required. The resident's advocate stated they were not informed of the resident's departure and expressed concern for the resident's safety and need for medication.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Develop Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a discharge care plan for a resident, which was identified during a survey. The resident was admitted with a diagnosis of a displaced trimalleolar fracture of the right lower extremity and was expected to be discharged home with family. Despite the resident's choice to be discharged and the absence of any medical equipment or home health requests, the facility did not create a discharge care plan. The resident's clinical records indicated that they were independent in some activities of daily living, such as eating and personal hygiene, but required assistance with others, like bathing and dressing. The facility's records showed that the resident was given a 30-day notice to vacate due to an unpaid bill, yet there was no evidence of a discharge care plan being developed to facilitate the transition home. Interviews with facility staff revealed a lack of clarity regarding responsibilities for care plan development. The Social Services Director stated that they were not responsible for care plans, while the MDS Coordinator acknowledged the absence of a discharge care plan for the resident. This oversight was contrary to the facility's policy, which mandates the development of a comprehensive care plan within seven days of a resident's comprehensive assessment.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 was discharged home. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the MDS Coordinator/Social Service Director/designee of current residents to ensure a discharge care plan is developed within 48 hours of admission/re-admission to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; MDS Coordinator/Social Service Director re-educated by the Chief Clinical Reimbursement Officer on the components of this regulation and to ensure residents have a discharge care plan developed within 48 hours of admission/re-admission to be completed by. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; MDS Coordinator/Social Service Director/designee to conduct ongoing quality monitoring through morning clinical meeting to ensure a discharge care plan is developed within 48 hours of admission/re-admission 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Improper Placement of Drainage Bags
Penalty
Summary
The facility failed to ensure the secure placement of drainage bags for two residents, leading to potential risks of dislodgement and infection. Resident #7 was observed in the hallway with his drainage bag resting on his lap and at times placing it on the floor without a privacy bag. Despite staff performing 15-minute checks, the bag was not noticed on the floor, indicating a lapse in monitoring. The resident's medical records revealed a history of severe cognitive impairment and noncompliance with treatment regimens, which included allowing the drainage bag to drag on the floor. Resident #8 was similarly observed with his drainage bag and tubing positioned in a manner that increased the risk of dislodgement. The tubing was noted to be on the wheelchair's wheels, and the resident was seen moving around with the bag in close proximity to the wheels. The resident's medical records indicated mild cognitive impairment and a history of prostatic hyperplasia, with no toileting program in place. The care plan for Resident #8 included interventions to manage the drainage bag properly, but the resident sometimes allowed the bag to drag on the floor. Interviews with staff, including an LPN and the DON, acknowledged the risks associated with the improper placement of the drainage bags. Despite efforts to educate the residents about the risks, compliance was inconsistent. The facility's failure to secure the drainage bags properly and monitor the residents' behavior led to the deficiency, as evidenced by the observations and interviews conducted during the survey.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #7: The drainage bag was properly placed on the frame of the bed by the Director of Nursing. Resident #7 did not suffer any adverse effects r/t the drainage bag being on the floor. Resident #8: Nursing staff to provide a bag when out of bed to mitigate risk of tubing getting caught in the wheelchair wheel spokes and so the resident does not place the drainage bag on his lap. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the DON/designee of current residents with an indwelling catheter to ensure drainage bags are secure and the drainage bag is not on the floor and the drainage bag is covered, to be completed by [date]. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current licensed nurses are re-educated by the DON/designee on the components of this regulation and to ensure drainage bags are secure, the drainage bag is not on the floor and the drainage bag is covered to be completed by [date]. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: DON/designee to conduct ongoing quality monitoring through visual observation of residents with an indwelling catheter to ensure drainage bags are secure, the drainage bag is not on the floor and the drainage bag is covered 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Conduct Timely Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a Drug Regimen Review (DRR) was completed for a resident, identified as Resident #13, within the required time frame. This resident was receiving a combination of medications, including a relaxer and other high-risk medications, which have the potential to cause serious interactions and side effects. Despite the requirement for a monthly review by a licensed pharmacist, the necessary review was not conducted, leading to a deficiency in compliance with federal regulations. Resident #13, who was admitted to the facility following an accident, was observed to be taking multiple medications, including high-risk ones, without a documented attempt at a Gradual Dose Reduction (GDR). The resident's Minimum Data Set (MDS) indicated that no GDR had been attempted, and there was a lack of assessment or follow-up information regarding the medication regimen. The psychiatrist involved in the resident's care acknowledged the effectiveness of the medications but also noted that recommendations for GDR were typically only followed when mandated by the pharmacy. Interviews with the Director of Nursing (DON) revealed that the resident had been observed with symptoms such as drooling and excessive sleepiness, which led to the discontinuation of one of the medications. However, the Medication Regimen Review Log showed no completed reviews for the resident, highlighting a failure in the facility's processes to ensure timely and appropriate medication management. This oversight in conducting the required DRR and addressing potential medication interactions contributed to the identified deficiency.
Plan Of Correction
F 756 Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #13 the psychiatrist reviewed the residents, medications listed below: decreased on from 45mg to 30mg. was decreased from 300mg to 200mg 1mg continue current dose; no changes. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the DON/designee of current residents receiving medication(s) to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen medications to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; DON and ADON reeducated by the Chief Nursing Officer on the components of this regulation and to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen medications to be completed by. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure Drug Regimen Reviews are acted upon to include: a medication review by the physician and/or psych provider indicating an attempt at a gradual dose reduction (GDR) and/or a failed GDR to support the rationale for continuing the current medication regimen r/t medications 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing, Schedule to be modified PRN based on findings.
Deficiencies in Discharge Planning and Urinary Drainage Bag Management
Penalty
Summary
The facility failed to develop and implement a discharge care plan for a resident who was discharged home with family. The resident had a clinical diagnosis of a displaced tri-malleolar fracture of the right lower extremity and required orthopedic aftercare. Despite the resident's choice to be discharged, the facility did not create a discharge care plan, which is a requirement under the comprehensive care plan statute. The MDS Coordinator acknowledged the absence of a discharge care plan for the resident. Additionally, the facility did not ensure the security of urinary drainage bags for two residents. One resident was observed carrying their drainage bag in their hand and placing it on the floor, while another resident had their drainage bag tubing caught on the wheelchair's wheels. These practices increased the risk of urological complications if the bags were unintentionally pulled, leading to potential dislodgement. Staff members, including an LPN and the DON, were aware of these issues but did not consistently address them. The facility's policies and procedures require the development of a comprehensive care plan within seven days of a resident's assessment, which includes measurable objectives and timetables to meet the resident's needs. However, the facility failed to adhere to these policies, resulting in deficiencies related to the lack of a discharge care plan and the improper management of urinary drainage bags.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident # 1 was discharged home. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the MDS Coordinator/Social Service Director/designee of current residents to ensure a discharge care plan is developed within 48 hours of admission/re-admission to be completed by. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: MDS Coordinator/Social Service Director re-educated by the Chief Clinical Reimbursement Officer on the components of this regulation and to ensure residents have a discharge care plan developed within 48 hours of admission/re-admission to be completed by. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: MDS Coordinator/Social Service Director /designee to conduct ongoing quality monitoring through morning clinical meeting to ensure a discharge care plan is developed within 48 hours of admission/re-admission 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Inadequate Healthcare Leads to Risk of Dislodgement
Penalty
Summary
The facility failed to provide adequate and appropriate healthcare to prevent the potential risk of dislodgement for two residents. Resident #7 was observed in the hallway carrying his drainage bag in his hand and at times placing it on the floor, which increased the risk of dislodgement. Staff, including an LPN and the Director of Nursing (DON), acknowledged the risk and attempted to educate the resident about the dangers of having the bag on the floor. Despite these efforts, the resident did not consistently follow instructions, and was observed ambulating unsteadily in the hallway with the bag in his hand. Resident #8 was observed exiting the elevator with the drainage bag on his lap and the tubing on the wheelchair's wheels, which also increased the risk of dislodgement. The resident was later seen returning to his room after playing bingo, with the bag and tubing positioned close to the wheelchair's wheels. The DON was present and acknowledged the concerns, noting that the resident sometimes moved the bag around. Medical records for Resident #8 indicated a diagnosis of prostatic hyperplasia without lower tract symptoms, and care plans focused on managing the resident's condition to prevent complications. Both residents had specific physician's orders and care plans that included regular care and monitoring of their drainage bags. However, the facility's failure to ensure proper positioning and securing of the bags, as well as the residents' non-compliance with instructions, led to the increased risk of dislodgement. The observations and interviews with staff highlighted the deficiency in providing adequate healthcare to prevent potential risks associated with the residents' conditions.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #7: The drainage bag was properly placed on the frame of the bed by the Director of Nursing. Resident #7 did not suffer any adverse effects from the drainage bag being on the floor. Resident #8: Nursing staff to provide a bag when out of bed to mitigate risk of tubing getting caught in the wheelchair wheel spokes and so the resident does not place the drainage bag on his lap. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review by the DON/designee of current residents with an indwelling catheter to ensure drainage bags are secure and not on the floor, and that the drainage bag is covered, to be completed by [date]. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses are re-educated by the DON/designee on the components of this regulation to ensure drainage bags are secure, not on the floor, and that the drainage bag is covered, to be completed by [date]. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; DON/designee to conduct ongoing quality monitoring through visual observation of residents with an indwelling catheter to ensure drainage bags are secure and not on the floor.
Rodent Infestation and Infection Control Failures in LTC Facility
Penalty
Summary
The facility failed to address a rodent infestation in a timely manner, leading to potential health risks for residents. Despite reports from staff and residents about rodent sightings, the administration did not take immediate action to eradicate the pests. Observations revealed that rodents were seen in resident rooms, and food was improperly stored, providing a food source for the pests. The facility's pest control policy was not followed, and there was a lack of coordination with local agencies to address the infestation. Infection control procedures were not properly implemented, as evidenced by the mishandling of a Glucometer during blood glucose monitoring for a resident. The staff member placed the contaminated Glucometer in her pocket, contrary to CDC guidelines, which state that supplies should not be carried in pockets and should be cleaned and disinfected after each use. Additionally, during wound care for another resident, proper hand hygiene and the use of personal protective equipment were not observed, increasing the risk of infection transmission. The facility also failed to maintain a clear separation between soiled and clean laundry areas, leading to potential cross-contamination. Observations in the laundry room showed that staff did not consistently use personal protective equipment, and there was no physical separation between areas for soiled and clean linens. The facility's infection preventionist had not completed the required specialized training, further contributing to the systemic failure in infection prevention and control.
Failure to Address Rodent Infestation and Infection Control Deficiencies
Penalty
Summary
The facility's Administrator failed to address a rodent infestation in a timely manner, despite being aware of the issue for several months. The Administrator did not follow up on reported rodent sightings, failed to ensure the designated Infection Preventionist had completed specialized training, and did not coordinate effectively with other department heads or contact local agencies regarding the infestation. The facility's pest control policies were not followed, and the Administrator relied on in-house maintenance rather than engaging a pest control company, despite multiple complaints from staff and residents. Resident #9, who is cognitively intact, reported seeing rodents in her room and noted that housekeeping services were lacking on weekends. The resident pointed out unused traps in her room and expressed dissatisfaction with the pest control measures in place. The Director of Nursing (DON) was aware of the rodent issue and had communicated it to the Administrator, who chose to handle it internally rather than seeking external pest control services. The DON did not document the sightings or notify the Health Department, expecting the Administrator to resolve the issue. Staff members, including a Registered Nurse and the former Maintenance Director, reported multiple rodent sightings, particularly on the second floor. The Administrator was informed of these sightings but did not take effective action to address the problem. The facility's failure to implement an effective pest control program resulted in the determination of Immediate Jeopardy, with the potential to spread diseases to residents. The lack of a pest control log and inadequate communication between the Administrator and the pest control technician further exacerbated the situation.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility's administrative staff failed to implement and maintain an effective pest control program, resulting in a rodent infestation that was not addressed in a timely manner. The facility's policy required coordination between the Administrator and the Maintenance Department to arrange pest control services monthly or as needed, and staff were supposed to report sightings of live pests. However, the facility did not follow its own policy, as evidenced by the lack of documentation in the pest control log and the failure to educate staff members appropriately. This deficiency had the potential to affect 111 residents in the 120-bed capacity facility. Resident #9, who was cognitively intact and able to communicate, reported that housekeeping services were not provided on Saturdays, leading to a dirty environment. She observed pests, roaches, and mice/rodents in the facility, particularly in her room near the air-conditioning area. Despite her requests for appropriate traps, the pest control measures in place were ineffective. During an interview, a Surveyor observed a rodent running in the hallway toward Resident #9's room, confirming the resident's reports of rodent activity. Interviews with various staff members, including the Administrator, Director of Nursing, and Maintenance staff, revealed a lack of awareness and communication regarding the rodent sightings. Although some staff members reported seeing rodents or hearing about sightings from residents, these reports were not documented in the pest control log. The pest control technician, who visited the facility regularly, was not informed of specific areas needing treatment and relied on verbal reports from staff. This systemic failure to ensure effective pest control and infection control interventions resulted in the determination of Immediate Jeopardy.
Failure to Follow Tube Feeding Orders and Nutritional Assessment
Penalty
Summary
The facility failed to adhere to the physician's orders for tube feeding administration, complete a nutritional assessment, and identify a severe weight loss for a resident with a feeding tube. The resident, who was admitted with diagnoses including seizures, dementia, hypertension, and protein-calorie malnutrition, had a PEG tube placed due to high aspiration risk and poor oral intake. Despite the physician's orders for a specific bolus feeding schedule, the facility did not consistently administer the feedings on time, leading to significant delays and missed feedings. The clinical dietitian did not complete the initial nutritional assessment within the required timeframe, and no admission weight was recorded for the resident. Interviews with staff revealed a lack of communication and coordination regarding the resident's feeding schedule and weight monitoring. The resident experienced a severe weight loss of 17% within a month, which was not identified or addressed by the facility. Observations confirmed that the resident was often without the prescribed tube feeding, and staff were unclear about the feeding orders and schedule. The facility's policies on nutrition and weight management were not followed, contributing to the deficiency. The lack of timely nutritional assessment and failure to adhere to feeding schedules resulted in inadequate care for the resident, highlighting significant lapses in the facility's processes and communication among staff.
Food Safety Deficiencies in Kitchen and Food Service
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, distribution, and service, potentially affecting 107 residents. During an initial kitchen observation, several issues were noted, including heavily soiled and stained kitchen utility carts, cracked and stained kitchen floors and walls, and a heavily soiled dry/canned food storage area. Staff personal items were improperly stored on clean food storage shelving, and a chemical test revealed extremely high concentrations of Quaternary Chemical in cleaning cloth buckets. The walk-in refrigerator had a build-up of a black mold-like substance around the gasket area, which was torn and needed replacement. Additionally, the refrigerator's food storage shelves were soiled and rust-laden, and the cooling fan unit was dripping condensation into a pan, posing a risk of food contamination. Other equipment, such as a commercial can opener and aluminum sheet pans, were found to be rust-laden and soiled, with a build-up of black mold-like matter. Further observations revealed numerous small flying insects in the dish room and food preparation areas, and rust-laden racks where clean food preparation equipment was stored. During a breakfast meal observation, it was noted that cold foods were not held at the regulatory temperature of 41 degrees Fahrenheit or below. Specifically, individual portions of milk and orange juice were found to be at 62 and 60 degrees Fahrenheit, respectively, due to being placed on residents' trays too early. These findings indicate a failure to adhere to professional standards for food service safety, potentially compromising the safety and quality of food served to residents.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP) had completed the required specialized training. The job description for the IP position mandates certification in Infection Control within the first 90 days of employment. However, the Director of Nursing (DON), who was assigned as the IP, had not completed the necessary training modules or obtained the certification. The DON was unaware of his assignment as the IP until informed by the Administrator two months prior to the survey. Interviews revealed that both the DON and the Assistant Director of Nursing (ADON) were given access to the infection preventionist training modules, but only the ADON completed the training and obtained certification. Despite this, the ADON did not sign the agreement to be the IP, as the DON was handling infection control duties. The DON acknowledged the lack of a designated IP and expressed efforts to hire one, but the deficiency remained unaddressed at the time of the survey.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment, as observed during a survey conducted over several days. The surveyors noted significant cleanliness and maintenance issues across various areas, including residential rooms, dining areas, hallways, and an elevator. The elevator was found to have heavily soiled floors and walls, with exposed sharp plastic near the handrails, and the metal handrail was worn down to the bare metal. The second-floor nurses' station and bathroom were heavily soiled, with dirt and dust buildup, and the dining room had soiled cleaning equipment stored inappropriately. Numerous residential rooms were found in disrepair, with issues such as cracked floor tiles, leaking ceilings, and offensive odors, particularly urine. Several rooms had missing or damaged furniture, such as wardrobe doors and over-bed tables, and heavily stained and worn portable commode seats. The hallways were also noted to be heavily soiled with black stains and offensive odors, and the fire door had large areas of peeling paint. Additionally, the linen and soiled utility rooms were heavily soiled, with mold-like matter observed in the utility room. Residents were directly affected by these deficiencies, with some complaining about the conditions, such as a resident waiting for a window replacement and another reporting roach sightings. Wheelchairs and Geri chairs used by residents were also in poor condition, with missing or worn armrests. On the third floor, issues included a leaking shower handle, insufficient bathroom lighting, and residents complaining about roach sightings and inadequate bed sizes. These observations indicate a widespread failure in maintaining the facility's environment, impacting the residents' quality of life.
Failure to Ensure Privacy in Resident Phone Use
Penalty
Summary
The facility failed to provide reasonable access to and privacy in the use of communication methods for residents. Observations on the second floor revealed that six residents were using the facility telephone located at the nurses' station desk without any staff intervention to ensure privacy. These residents' conversations could be overheard by numerous staff and other residents in the area. Additionally, outside calls were being routed to the nurses' station, where residents were brought to speak aloud in a non-private setting. This lack of privacy was further evidenced when a resident was observed using the phone speaker to discuss sensitive financial information with a banking institution, which was clearly audible to those nearby. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness regarding the need for private phone conversations for residents. Although the Corporate Maintenance Director indicated that two private cordless phones were available for residents' use, one was found uncharged and without a charging connection. Continuous observations noted that residents continued to use the nurses' station phone without staff intervention, including a resident who used the phone speaker to discuss personal medical conditions with a physician and church. This ongoing issue highlights the facility's failure to ensure residents' privacy during phone calls.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information in a prominent place accessible to residents and visitors. During an initial tour of the facility on the second floor, it was observed that the nurse staffing data posted was outdated, showing the date 08/23/24, while the observation took place on 08/26/24. No other nurse staffing data was found posted elsewhere in the facility. An interview with a Registered Nurse revealed that there was no comprehensive nursing staffing data available, and she was only aware of the staffing assignments for her specific floor, which were noted on a whiteboard.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to administer medications in a timely manner for Resident #70, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Bipolar II Disorder, and Anxiety Disorder. The resident's medication administration records from 08/15/24 to 08/26/24 showed that medications were consistently given more than one hour late, with 57 instances of medications being administered 2 to 6 hours late. During an interview, the resident expressed that the nurses frequently administered medications late and often forgot to provide all medications due at the same time, particularly the protein supplement needed for wound healing. For Resident #52, the facility failed to ensure medications were administered as ordered. The resident, who had diagnoses including Encephalopathy and Parkinson's Disease, had a physician's order for Clonazepam discontinued on 08/07/24. However, the medication was still signed out and documented as administered from 08/09/24 to 08/15/24, despite the discontinuation. This discrepancy was confirmed during a medication cart review and acknowledged by the Assistant Director of Nursing. Additionally, the facility failed to maintain accurate drug records and reconcile controlled drugs for Residents #16, #42, and #54. Resident #16 received an incorrect dosage of Clonazepam on 08/28/24, while Resident #42's medication administration did not match the physician's orders on several occasions. Resident #54 was not administered Clonazepam as per the prescribed schedule on specific dates. These inconsistencies in medication administration and record-keeping were identified through reviews of the Medication Administration Records and Medication Monitoring/Control Records.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to adequately monitor behaviors for residents on psychotropic medications, as evidenced by the lack of proper documentation and monitoring for four residents. Resident #76, who was readmitted with diagnoses including Major Depressive Disorder and Anxiety Disorder, had an order for Risperdal with specific monitoring instructions. However, the behavior monitoring records for August 2024 only showed check marks without the required 'Y' or 'N' documentation, indicating a failure to properly observe and record the resident's condition. Similarly, Resident #306, diagnosed with Dementia and Depression, had an order to monitor for side effects of antipsychotic medication. The behavior monitoring records for this resident also lacked the necessary 'Y' or 'N' documentation, with only check marks present. This indicates that the facility did not follow the prescribed monitoring protocol, failing to ensure that the resident's behaviors and potential side effects were adequately observed and documented. Resident #307, with diagnoses including Bipolar Disorder and Paranoid Schizophrenia, and Resident #56, with Alzheimer's and Anxiety Disorder, also experienced similar deficiencies in behavior monitoring. For Resident #307, the records from mid-August 2024 showed only check marks without the required documentation. For Resident #56, the Treatment Administration Record indicated 'N' for observed behaviors without further documentation in the progress notes, as required. Interviews with staff revealed misunderstandings about the documentation process, contributing to the failure to properly monitor and document resident behaviors.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage of medications and biologicals, as evidenced by several observations and interviews. A bottle of Dakin's solution was found in an unlocked clean utility closet on the third floor, which was intended for a resident who no longer resides in the facility. The Director of Nursing (DON) acknowledged that the bottle should not have been in the closet. Additionally, Resident #28 was observed with two tubes of Cortisone cream on her bed, despite having no physician's order for the cream and no evaluation for self-administration of medication. The DON confirmed that no residents were authorized to self-administer medications, indicating a lapse in adherence to the facility's policy on medication storage and self-administration. Further deficiencies were noted with the handling of wound treatment carts. On two separate occasions, wound treatment carts were left unlocked and unattended. One cart was observed at the third-floor nursing station containing various medications and scissors, with the responsible wound care nurse not present. Staff ZZ, an RN, acknowledged the cart should have been locked. Another incident involved Staff XX, an LPN, who left a wound care cart unlocked in the hallway while attending to a resident's wound care. Staff XX admitted to not having keys to the cart, which led her to leave it open, contrary to the facility's policy requiring locked compartments for medications. These incidents highlight the facility's failure to comply with its own policies regarding the secure storage of medications and biologicals. The lack of secure storage poses potential risks to residents, especially those with cognitive impairments, as evidenced by Resident #28's moderate cognitive impairment and unauthorized access to medication. The facility's policies clearly state that all drugs and biologicals must be stored in locked compartments, yet these observations indicate a significant oversight in maintaining these standards.
Deficiency in Meeting Residents' Dietary Needs
Penalty
Summary
The facility failed to provide 107 out of 111 residents with a nourishing, palatable, well-balanced diet that met their dietary needs and preferences. During a breakfast meal observation, it was noted that residents were served a 4-ounce serving of a light-colored pink liquid instead of the preferred orange juice. The approved menu indicated a 6-ounce portion of Vitamin C juice should be served. Upon investigation, it was found that the juice served was a watered-down tropical punch mix, not following the mixing directions, and providing significantly less nutritional value than required. The Certified Dietary Manager confirmed that orange juice had not been available for two days, and no other citrus juices were available. A list showed that 43 residents requested orange juice, while others requested different juices. Additionally, during another breakfast meal observation, the facility did not prepare enough sausage links for residents on a regular consistency diet, resulting in some residents receiving only one link or none at all. The approved menu required two sausage links per serving. Furthermore, the facility failed to provide fresh bananas as per the approved menu, and no nutritional substitute was planned or served. Interviews with dietary staff revealed that bananas were not regularly available, contributing to the deficiency in meeting residents' dietary needs.
Failure to Follow Approved Menus for Resident Meals
Penalty
Summary
The facility failed to prepare in advance and follow the approved menu for 107 of the facility's 111 residents. During the review of the approved menu for the lunch meal, it was noted that the facility served a 2-ounce portion of homemade chili instead of the required 6-ounce portion, substituted canned pineapple for watermelon cubes, and served pureed regular bread instead of pureed cornbread to residents on pureed diets. An interview with the facility cook revealed that she did not review the approved menu and was unaware of the specific dietary requirements, including the need for watermelon and pureed cornbread. For the breakfast meal, the facility did not provide bananas as required by the approved menu and prepared an insufficient number of sausage links, resulting in some residents receiving only one link or none at all. The facility cook admitted that bananas were never purchased or served according to the menu, and there was an inadequate supply of sausage links. The facility's diet census indicated that there were 71 residents on regular diets, 10 on pureed diets, and 20 on mechanical soft diets, highlighting the widespread impact of these deficiencies.
Failure to Follow Standardized Recipe for Turkey Patty Melt
Penalty
Summary
The facility failed to prepare foods using standardized recipes, impacting the nutritive value, flavor, appearance, and overall appeal of meals served to 107 of the facility's 111 residents. During a review of the approved menu for a lunch meal, it was noted that the Turkey Burger Patty Melt was to be served to residents on Regular, Mechanical Altered, and No Concentrated Sweets Diets. However, the preparation did not follow the standardized recipe, which included specific ingredients and cooking instructions to ensure the meal was appetizing and nutritious. Observations during the lunch meal revealed that the Turkey Patty Melt was prepared and served incorrectly. The turkey burgers appeared white and uncooked, deviating from the recipe's requirement for browning. The sandwiches were made with white bread and American cheese instead of the specified Swiss cheese and sauteed onions, and they were not cooked until golden brown. An interview with a staff member revealed a lack of awareness and use of the standardized recipe, contributing to the deficiency in meal preparation.
Repeated Deficiencies in Environment, Pharmacy, QAPI, and Pest Control
Penalty
Summary
The facility failed to implement effective plans of action to correct identified quality deficiencies in several areas, including maintaining a safe, clean, comfortable, and homelike environment, pharmacy services and procedures, quality assurance and performance improvement activities, and pest control. These deficiencies were identified during a recertification survey and a complaint survey, indicating repeated issues in these areas. The deficiencies have the potential to affect 111 residents residing in the facility at the time of the survey. The facility's policy and procedures outline a comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on various indicators of care outcomes and quality of life. However, the facility's failure to demonstrate effective implementation of corrective actions suggests a lack of adherence to these procedures. The QAPI program is designed to be an ongoing review of care and services, involving leadership and input from staff, residents, and families, but the repeated deficiencies indicate that the program's intended systematic approach to identifying and addressing underlying causes of problems was not effectively utilized.
Inaccurate Medication Classification in MDS Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for residents during the Minimum Data Set (MDS) observation period, affecting three residents. Resident #48, who was admitted with conditions including cardiac arrhythmia and dementia, had discrepancies in the MDS documentation regarding medication classification. The MDS indicated the resident was receiving an anticoagulant but not an antiplatelet, despite physician orders for both aspirin (an antiplatelet) and Eliquis (an anticoagulant). Similarly, Resident #100, admitted with cerebral infarction and hemiplegia, was documented in the MDS as receiving an anticoagulant, although physician orders only included antiplatelet medications, aspirin and clopidogrel, with no anticoagulant prescribed. Resident #59, with a history of heart disease and atrial fibrillation, was also inaccurately documented in the MDS as receiving an anticoagulant, while physician orders only included antiplatelet medications. The MDS Coordinator misclassified these medications, as confirmed by the facility's Consultant Pharmacist, who clarified the correct classification of aspirin and clopidogrel as antiplatelets, not anticoagulants.
Staffing Shortages Affect Resident Supervision and Care
Penalty
Summary
The facility failed to ensure minimum nursing staff was provided daily to meet the needs of residents, affecting the safety and well-being of the residents. A review of the facility's State Minimum Nursing Staffing records from June to August revealed that on specific dates, the daily average for nursing staff was below the required minimum of 1.0. The administrator, responsible for completing the Nurse Staffing Calculations, acknowledged the shortfall and attributed it to nurses punching in late. Additionally, there was confusion regarding the inclusion of food/nutrition service staff hours in the direct care staff calculations, which the Director of Nursing (DON) agreed to revise. Observations and interviews highlighted the impact of staffing shortages on resident supervision. On one occasion, a Certified Nursing Assistant (CNA) was observed monitoring residents on the smoking patio from inside the facility, rather than being present outside with them. The CNA explained that typically two staff members are present, but due to being short-staffed, she was alone that day. Another staff member expressed feeling that the facility was short-staffed, although they managed to work together to complete their tasks.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that residents had a functioning call light system to request assistance from staff, affecting five residents. The facility's policy requires that call lights be answered promptly and any malfunctions reported to maintenance or relevant staff. However, several residents reported that their call lights were not working, and staff were aware of these issues but did not resolve them. Resident #6, who is cognitively intact and requires assistance with personal care, reported being left soaking wet in bed due to a non-functioning call light. Resident #9, also cognitively intact, stated that her call light had been malfunctioning for over six months, and despite having manual call bells, staff could not hear them. Resident #19, who uses a wheelchair and requires supervision for toilet transfers, reported that his call light had not worked for over a month. Maintenance staff acknowledged the issue but indicated they were not equipped to fix it. Observations confirmed that the call light system in Resident #19's bathroom did not function, as no auditory signal was heard at the nurses' station. Resident #83 demonstrated that their call light did not activate any notification at the nurses' station, and no staff responded to the call light during the observation period. Similarly, Resident #88's call light did not trigger any notification, and no staff responded when it was activated. Interviews with staff revealed that the call light system had been malfunctioning for an extended period, with one CNA stating that the issue had persisted for the entire six months of her employment. The facility administrator acknowledged that repairs were underway but indicated that the issue could not be resolved immediately due to the need for specific parts. This ongoing deficiency in the call light system compromised the residents' ability to communicate their needs effectively to the staff.
Failure to Address Grievances Related to Non-Functional Call Lights
Penalty
Summary
The facility failed to properly address and resolve grievances related to non-functional call lights for four residents. Resident #6 reported being left soaking wet in bed due to a non-working call light, which staff were aware of but had not fixed. Resident #9 experienced a similar issue, with her call light not functioning for over six months despite maintenance attempts to repair it. She was provided with manual call bells, which staff claimed they could not hear, leaving her without an effective means to request assistance. Resident #19 also faced issues with a non-functional call light for over a month, forcing him to wheel himself out of his room to get staff attention. Maintenance staff acknowledged the problem but indicated they were not equipped to fix it. Resident #206's call light was non-functional during her stay, and despite her son's concerns, the issue was not resolved. A manual bell was provided as a temporary solution, but the call light remained unfixed until her discharge. The facility's grievance log from August 2023 to August 2024 did not document any complaints regarding the call lights from these residents. Interviews with staff revealed inconsistencies in the grievance process, with some staff not filling out grievance forms and others documenting issues in progress notes instead. The Assistant Director of Nursing and Director of Nursing acknowledged the lack of proper grievance documentation, and the Social Services Director, responsible for maintaining the grievance log, confirmed the absence of relevant entries.
Incomplete Documentation of Resident Leaving AMA
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who left against medical advice (AMA). The resident, who had been readmitted to the facility, left AMA without proper documentation of family notification. The resident's Minimum Data Set (MDS) indicated a cognitive response with a Brief Interview of Mental Status (BIMS) score of 15 on one occasion and 14 on another, suggesting some level of cognitive awareness. However, there was no documentation in the nursing notes indicating that the family was informed about the resident's decision to leave AMA. The Assistant Director of Nursing admitted during an interview that she personally notified the family but failed to document the conversation. The resident's emergency contact, who is a family member, confirmed being informed about the resident leaving AMA but expressed concerns about the resident's mental capacity to make such a decision. The emergency contact mentioned that the resident had a history of going off medication and wanting to leave, which had occurred in the past. Despite the verbal notification, the lack of documentation in the medical records constitutes a deficiency in maintaining complete and accurate records.
Loose Handrails on 3rd Floor
Penalty
Summary
The facility failed to ensure that handrails were securely affixed to the walls on the 3rd floor, as observed during an initial tour conducted on August 26, 2024, between 9:45 AM and 11:00 AM. The handrails were found to be loose in several locations, including next to specific rooms, near the 3rd floor elevator close to the nursing station, and across from other rooms. Photographic evidence was obtained to document these deficiencies. During an interview on August 30, 2024, at 1:00 PM, the Administrator acknowledged the issue with the loose handrails on the 3rd floor. She mentioned that a similar problem had occurred on the 2nd floor, where the handrails had been secured to the wall.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, leading to potential safety risks. Resident #88, who had a slight cognitive impairment, fell while attempting to go to the bathroom without assistance because the call light was not within reach. Observations confirmed that the call light cord was consistently found on the floor, out of reach. Resident #88 expressed concern about not being able to call for help in the event of another fall. Staff confirmed the call light system's function but did not address the accessibility issue. Resident #11, who was cognitively intact but dependent on staff for toileting hygiene, was unable to reach the call light due to it being wrapped around the bed rail and out of reach. Resident #15, who was rarely understood and also dependent on staff, indicated through gestures that the call light was inaccessible. Resident #306, with cognitive impairment and a history of falling, was found with the call light behind the bed on the floor, unable to call for assistance. These observations highlight a consistent issue with call light accessibility for residents with varying levels of cognitive and physical impairments.
Deficiencies in Comprehensive Care Plans for Medications and Advance Directives
Penalty
Summary
The facility failed to implement comprehensive care plans for antipsychotic medications for three residents and an advance directive for one resident. Resident #56, who was admitted with Alzheimer's, Anemia, and Anxiety Disorder, was prescribed Seroquel for psychosis. However, there was no care plan developed to address the use of this antipsychotic medication. The Assistant Director of Nursing acknowledged the absence of a care plan and mentioned that the staff member responsible for care plans was not yet working full-time. Resident #94, admitted with Anxiety Disorder, Type 2 Diabetes Mellitus, and Altered Mental Status, had a severely impaired cognitive status. Despite having physician's orders for insulin and clonazepam, there was no comprehensive care plan documented except for an entry on advanced directives. The Assistant Director of Nursing confirmed the lack of a care plan and noted that only an interdisciplinary care plan conference record was available. Resident #306, diagnosed with Dementia and Depression, was prescribed Olanzapine for a psychotic disorder. The care plan did not include any entry for antipsychotic medications, despite the physician's orders requiring close observation for side effects. Additionally, Resident #100, with a cognitive response score indicating full cognitive ability, had no care plan addressing advanced directives, even though the physician's orders indicated a full code status. The Social Service Director acknowledged the oversight and entered the care plan during the surveyor's visit.
Failure to Revise Smoking Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for smoking was revised by the interdisciplinary team after each assessment for a resident who was sampled for smoking. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Nicotine Dependence, had a care plan that was not reviewed or revised since its target date. The care plan included objectives such as educating the resident on the facility's smoking policy and designated smoking areas, assessing smoking safety, and encouraging cessation. Interviews revealed that the Medical Records Personnel misunderstood the Interdisciplinary Care Plan Conference Records as the care plans, indicating a lack of clarity in documentation processes. Additionally, the Assistant Director of Nursing and the Director of Nursing acknowledged that the paper care plans had not been revised and there were no electronic care plans for the resident, except for the advanced directive care plan. This oversight in updating the care plan after each assessment led to the deficiency identified by the surveyors.
Failure to Provide Supervised Feeding for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good nutrition for a resident who was unable to eat without staff assistance. During an observation, it was noted that the resident, who was cognitively impaired and diagnosed with dysphagia, was left unsupervised with a lunch tray placed within reach. The resident was seen using her hands to scoop large portions of pureed food into her mouth, leading to coughing and regurgitation. The Director of Nursing (DON) was called to the room and confirmed the resident's need for maximum assistance with eating and honey-thick liquids, as per her care plan and physician orders. The resident's clinical record indicated a diagnosis of hemiplegia and dysphagia, with orders for a pureed diet and honey-thick liquids. The Minimum Data Set (MDS) documented that the resident required maximum assistance with eating, yet the nutritional assessment inaccurately noted independent feeding. The assigned CNA was unaware of who placed the tray in front of the resident, as she was assigned to the dining room at the time. This lack of supervision and adherence to the care plan resulted in the resident being at risk during mealtime.
Inadequate Supervision and Safety Hazards in Smoking and Laundry Areas
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, as evidenced by inadequate supervision of a resident who smokes, improper disposal of cigarette butts and trash, and failure to maintain dryer lint cleanliness. Specifically, Resident #59, who has a history of Chronic Obstructive Pulmonary Disease and requires supervision while smoking, was observed smoking on the patio without direct supervision. The staff member responsible for supervision was inside the facility and unable to see all residents on the patio, citing short staffing as the reason for inadequate supervision. Additionally, the smoking patio was found to have multiple cigarette butts scattered on the floor and paper trash mixed with cigarette butts in a designated bin, which was acknowledged by staff as needing to be emptied. Furthermore, the laundry area showed a lack of documentation for lint removal at scheduled times, and an observation revealed a significant accumulation of lint in one of the dryers, indicating that the lint removal process was not being followed as required.
Medication Administration Error with High-Risk Medication
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically for high-risk medications. During a medication administration observation, a registered nurse (RN) was preparing morning medications for a resident diagnosed with Hemiplegia, Type 2 Diabetes Mellitus, and Hypertension. The resident, who was cognitively intact, had a physician's order for Labetalol HCL 100mg tablet, with a prescribed dose of 1.5 tablets (150 mg) to be given every 12 hours for hypertension. However, the RN prepared only one tablet of Labetalol 100 mg, which was an incorrect dose. The surveyor intervened before the incorrect dose was administered, prompting the RN to review the medication orders. Upon review, the RN acknowledged the error and corrected the dose to the prescribed 150 mg by preparing one and a half tablets. This incident highlights a lapse in the medication administration process, where the RN did not initially verify the correct dose as per the facility's policy and the medication administration record.
Failure to Provide Appropriate Food Consistency for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs, specifically for residents requiring thickened liquids and pureed diets. During an observation, a resident with cognitive impairment and a diagnosis of dysphagia was found with a lunch tray containing non-thickened water and was eating pureed food with bare hands, leading to coughing and regurgitation. The resident required honey-thick liquids and maximum assistance with eating, as documented in their care plan and physician orders. However, the resident was left unsupervised with inappropriate food and liquid consistency, indicating a lack of adherence to the prescribed dietary requirements. Additionally, during a review of the breakfast meal preparation, it was observed that regular consistency grits and scrambled eggs were being served to residents on a pureed diet. The breakfast cook admitted to not reviewing the approved menu, which led to the improper preparation of meals for residents with dysphagia. The facility's policy and procedure for thickened liquids were not followed, as evidenced by the presence of non-thickened liquids at the resident's bedside and the failure to provide the appropriate food consistency, posing a risk of choking or aspiration for residents with specific dietary needs.
Failure to Follow Prescribed Diet Orders for Resident
Penalty
Summary
The facility failed to adhere to the prescribed diet orders for a resident with Type 2 Diabetes and Iron Deficiency, as observed during a survey. The resident, who was cognitively intact, was supposed to receive a diet with no concentrated sweets, no added salt, double portions, and fortified foods as per the physician's orders. However, during observations, it was noted that the resident's breakfast and lunch trays did not include double portions or fortified foods as ordered. The breakfast tray included oatmeal, eggs, a muffin, and juice, while the lunch tray had regular portions of roast pork, spinach, potatoes, bread, and juice, none of which were fortified or doubled as required. Interviews with the Dining Manager revealed that the facility had a system in place for providing fortified foods and double portions, which involved communication slips from the Clinical Dietitian to the kitchen staff and updates in the electronic system. Despite this system, the resident was not included in the list of those receiving fortified meals, indicating a lapse in communication or oversight. The Dietary Manager was unaware of the resident's specific dietary orders, which contributed to the failure to provide the prescribed diet, highlighting a deficiency in the facility's dietary management processes.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment, specifically Divided Plates, to five residents who required them for self-feeding during meals. Observations during lunch and breakfast meals revealed that the meal tray tickets for these residents indicated the need for Divided Plates, yet the plates were not provided. Interviews with dietary staff and the Certified Dietary Manager revealed a lack of awareness regarding the need for such adaptive equipment, and it was noted that only one Divided Plate was available in the kitchen serving area. Further investigation through clinical record reviews and interviews with the Director of Skilled Therapy confirmed that these residents had been assessed by occupational therapists and had physician orders for Divided Plates to facilitate self-feeding. Despite this, the facility did not provide the necessary equipment, and the Director of Skilled Therapy was unaware of the current physician orders. The residents involved had documented needs for adaptive equipment to assist with feeding, as indicated by therapy assessments and physician orders dating back several years.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during an inspection of the outside garbage/refuse area. A large body of stagnant water was found between the garbage dumpster and the cardboard recycling dumpster, measuring approximately 10-12 feet wide and 12 inches deep at the center. This area contained stagnant algae and what appeared to be medical waste, including medication bottles, inhaler tubes, disposable gloves, masks, gowns, and other unidentifiable waste. Additionally, the area was littered with various pieces of garbage and trash. Behind the dumpster and along the walkway to the rear of the building, similar medical waste and trash were observed. Four large tires filled with stagnant water were also noted next to the dumpsters, posing a potential source of insect and rodent activity. The facility administrator acknowledged awareness of the situation and its potential for infection control and pest issues.
Deficiencies in Vaccination Documentation and Offerings
Penalty
Summary
The facility failed to offer and document influenza and pneumococcal vaccinations for several residents, leading to deficiencies in immunization records. Resident #72 was admitted to the facility, but there was no documentation of influenza and pneumococcal immunizations in either the electronic medical records or the paper chart. Additionally, there was no record of consent or refusal for these vaccines since the resident's admission. The Assistant Director of Nursing (ADON) confirmed the absence of immunization documentation during an interview. For Resident #89, the Director of Nursing (DON) and Infection Preventionist (IP) reported offering the influenza vaccine, but the resident's father refused it over the phone. However, no signed consent or documentation of refusal was found in the resident's electronic medical record. Furthermore, the DON/IP was uncertain about the resident's eligibility for the pneumonia vaccine. Similarly, Resident #210's records lacked documentation of influenza and pneumococcal vaccines, and no refusal consents were on file. The DON/IP stated that the admission nurse is responsible for documenting prior vaccinations and offering vaccines to residents without them, but this process was not followed for Resident #210.
Deficiency in Providing Adequate Closet Space and Privacy
Penalty
Summary
The facility failed to provide individual closet space with privacy doors for five residents out of a sample of 43. During a facility tour, it was observed that several residents either did not have a closet or had a closet without a privacy door. Specifically, one resident was sharing his closet with others on the floor, and his roommate did not have a closet at all. Another resident had a closet without a door, while his roommate had a closet with a door. Similar issues were noted in other rooms, where some residents had closets without doors, and one resident did not have a closet at all. Interviews with staff revealed a lack of awareness and consistency regarding the closet situation. A registered nurse deferred the issue to the maintenance department, while a certified nursing assistant initially claimed that every resident had their own closet, which would be divided if shared. However, she later acknowledged the absence of closet doors in certain rooms and the lack of a closet for one resident, justifying it by stating that the resident only wore gowns and had no belongings. This inconsistency in staff responses highlights the facility's failure to ensure adequate and private closet space for all residents.
Failure to Conduct Timely CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that performance reviews for Certified Nursing Assistants (CNAs) were completed at least every 12 months. During a survey, the Director of Nursing (DON) was unable to provide performance review evaluations for five CNAs with hire dates ranging from November 2020 to August 2023. The DON explained that the inability to provide these evaluations was due to a recent transition of ownership, and Human Resources informed him that the information was not available from the previous owner.
Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
The facility failed to prevent the neglect of a resident who was documented as an elopement risk. The resident, who had a history of exit-seeking behavior and wandering, was not adequately supervised and managed to leave the facility undetected. The resident exited through an unlocked laundry room door, which staff had failed to latch properly. This incident occurred in a facility located in a high-traffic area, posing significant risks to the resident's safety. The resident, who had severe cognitive impairment due to Alzheimer's Disease and other related conditions, was last seen by a CNA between 7:00 PM and 7:30 PM. The CNA had taken the resident to the second floor to prepare for bed but left the resident unsupervised afterward. The resident was later found missing when a nurse attempted to administer medication between 8:00 PM and 8:30 PM. Despite efforts to locate the resident within the facility, including searching all floors and rooms, the resident could not be found, prompting the staff to notify the RN Supervisor and eventually the police. The resident was located by local law enforcement at approximately 2:30 AM at a county dump site, 1.5 miles from the facility. The security guard at the dump site found the resident confused and contacted the police, who had been searching the area. The resident was returned to the facility without injuries and was subsequently sent to the hospital for evaluation. The facility's failure to ensure proper supervision and secure exits directly contributed to this incident of neglect.
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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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