Gulf Coast Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Cape Coral, Florida.
- Location
- 1333 Santa Barbara Blvd, Cape Coral, Florida 33991
- CMS Provider Number
- 105672
- Inspections on file
- 26
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Gulf Coast Village during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food service sanitation, including a visibly soiled ice machine with black biofilm, improper storage of the ice scooper, and kitchen staff working without hair restraints. Cleaning logs for the ice machine were outdated and lacked recent documentation, and staff could not verify that required cleaning had occurred.
A resident with moderate cognitive impairment and incontinence was subjected to verbal and mental abuse by a CNA from a staffing agency, who became upset and yelled at the resident after episodes of diarrhea, causing the resident to feel humiliated and cry. Staff observations and interviews confirmed the resident's emotional distress, and the CNA's behavior was inconsistent with facility policy on abuse.
A resident with severe cognitive impairment and dependence on staff for ADLs was found with excessively long, untrimmed fingernails containing debris. Despite facility policy and care plans requiring nail care on shower days, there was no documentation or evidence that this grooming task was performed over a 30-day period. Staff interviews confirmed a lack of clarity and follow-through regarding responsibility for nail care.
A resident's family member reported symptoms and requested lab work due to a history of hypokalemia. An APRN received a text from staff and issued a stat order for CBC and CMP, but the order was not documented or carried out, and no lab work was performed. The resident later experienced an acute change in condition and was transferred to the hospital after cardiac arrest. The DON confirmed the order was missed and there was no policy for handling texted orders.
The facility failed to ensure dietary staff were trained to test the sanitizing solution in the low-temperature dishwasher, risking foodborne illnesses. The high-temp dishwasher was converted to low-temp, but staff were unaware of testing requirements, and test strips were expired. Additionally, food storage was unsanitary, with insects and improper storage observed. The contracted company serviced the dishwasher, but it had not been tested since April due to lack of staff knowledge.
The facility failed to address grievances from resident council meetings, with no documentation or follow-up on complaints about staffing and call light response times. Residents and families reported long wait times for assistance, particularly on weekends and night shifts, with one resident left in soiled conditions due to staffing shortages. The facility's grievance resolution process was not followed, as confirmed by staff interviews.
The facility failed to provide ongoing resident-centered activities in the TCU, as required by its policy. Two residents reported a lack of suitable activities and engagement, with one expressing a desire for group activities and another noting the absence of an activity director. Observations confirmed the absence of organized activities and staff, and interviews with staff and family members supported these findings.
A facility failed to update the Level I PASRR for a resident with severe mental health issues, using an outdated PASRR from 2018 that did not reflect the resident's current diagnoses of Psychotic Disorder with delusions and Schizoaffective Disorder. The resident required regular clinical evaluations due to multiple psychiatric conditions, but the PASRR was not updated to ensure appropriate specialized treatments.
A resident identified as a high fall risk was administered multiple psychotropic medications, leading to seven falls within a short period. Despite a care plan intervention for a drug regimen review, no documentation of such a review was found. Staff interviews confirmed the lack of documentation and the resident's multiple falls.
A facility failed to justify the continued use of an indwelling urinary catheter for a resident admitted from a hospital. Despite the facility's policy requiring assessment for catheter removal, there was no documentation of such an assessment or a urology referral. The resident, with a diagnosis of neurogenic bladder, reported never needing a catheter before. Staff interviews revealed no voiding trial or consultation was conducted, although the catheter was eventually removed successfully.
A facility failed to obtain physician's orders for the care and management of a PICC line for a resident receiving IV antibiotics. The resident's PICC dressing was heavily soiled and had not been changed since the date marked on it. Staff confirmed the absence of physician's orders, and the DON acknowledged the issue was identified during admission but not addressed.
The facility failed to secure medications as required, with five pills and a Lidoderm patch left unattended on a resident's bedside table, and four large pharmacy medication bags left unattended at the nurses' desk, accessible to staff, residents, and visitors.
The facility did not submit required staffing data to the CMS PBJ system for the third quarter of 2024, resulting in deficiencies such as a one-star rating, low weekend staffing, no RN hours, and lack of 24-hour licensed nursing staff coverage. Despite having supportive documentation, the data upload was unsuccessful, and the Administrator could not explain the issue.
A resident with a full code status was found unresponsive without a pulse or respiration. Despite the resident's clear wishes for life-saving measures, CPR was not initiated promptly. Three LPNs on duty delayed calling EMS and starting CPR for 51 minutes while searching for a non-existent DNR order. This delay in confirming code status and initiating CPR led to a critical lapse in providing timely medical intervention, resulting in the resident being pronounced dead by EMS. The incident highlighted a breakdown in communication and process among the staff, leading to a failure to follow established policies and procedures regarding advance directives.
Facility staff delayed CPR for an unresponsive resident without a pulse or respirations for 51 minutes while searching for a non-existent DNR order. Despite the facility's policy requiring immediate CPR in the absence of a DNR order, staff, including RNs and LPNs, experienced confusion and communication breakdowns. Surveillance footage revealed delays and uncertainty in determining the resident's code status. The incident highlighted deficiencies in staff training, communication, and adherence to emergency protocols.
Nursing staff faced challenges in initiating CPR for a resident in cardiac and respiratory arrest due to confusion over the resident's code status. Three staff members, including two RNs and one LPN, delayed CPR and EMS notification for 51 minutes while searching for a non-existent Do Not Resuscitate (DNR) order. The delay occurred as RN Staff A, who found the resident unresponsive, struggled to locate the DNR order and drew her own conclusion. LPN Staff B identified the resident as full code and initiated CPR, while RN Staff C assisted but had not participated in code blue drills.
A facility's administration did not ensure staff were adequately trained and knowledgeable in policies regarding residents' rights to advance directives, including CPR. A resident with full code status was found unresponsive, and CPR was delayed by 51 minutes due to communication breakdown and lack of clear protocols. The resident's code status was known but not documented in the baseline care plan, leading to confusion. The RN Staff Educator and DON acknowledged gaps in staff competency verification and documentation, contributing to the delay in initiating life-saving measures.
Sanitation Deficiencies in Food Service Operations
Penalty
Summary
Surveyors observed multiple lapses in food service sanitation, including a visibly soiled ice machine with black biofilm and crust-like debris on both the interior and exterior surfaces. The ice scooper was repeatedly found lying unholstered, first on the ice machine and later on the edge of a table next to the machine. Photographic evidence was obtained for these observations. The Certified Dietary Manager (CDM) confirmed that facility policy required monthly cleaning and sanitizing of the ice machine, but cleaning logs provided only covered earlier months and lacked documentation for recent cleaning. The Lead Chef acknowledged that the logs were outdated and attributed missing signatures to new staff, but could not provide evidence that cleaning had occurred as required. Additionally, during tray line preparation, three kitchen staff members were observed without proper hair restraints, with one being redirected to put on a hairnet only after being noticed. These observations were verified by the CDM. The facility's failure to maintain sanitary conditions in food service areas, as evidenced by the state of the ice machine, improper storage of the ice scooper, and lack of hair restraints, constituted a deficiency in compliance with professional standards for food safety.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
A resident with moderate cognitive impairment, frequent incontinence, and a need for assistance with personal care experienced verbal and mental abuse from a Certified Nursing Assistant (CNA) assigned through a staffing agency. The resident reported that the CNA became upset and yelled at her after she had episodes of diarrhea, and also gave her dirty looks while providing care. The resident expressed feelings of humiliation and mortification as a result of the CNA's behavior, and was observed crying by staff. The incident was documented in the resident's progress notes, and the resident stated she could not stop crying after the event. Interviews with staff confirmed the resident's emotional distress, with one LPN noting that the resident's reaction was different from her usual tearfulness. The CNA involved denied yelling but acknowledged telling the resident to wait while she attended to another patient. The facility's policy defines mental abuse as including humiliation and demeaning statements, which aligns with the resident's account of the incident. The events leading to the deficiency were directly related to the CNA's inappropriate response and attitude toward the resident during a vulnerable moment.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary grooming care for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had a diagnosis of unspecified dementia and was assessed as having severely impaired cognition, required partial to moderate assistance with personal hygiene. Observations revealed that the resident's fingernails were excessively long, curled inward, and had a brown substance underneath. Despite the facility's policy requiring staff to clean and trim nails on shower days, there was no documentation that this task had been completed for the resident over a 30-day period. The CNA Kardex specified that nail care should occur on designated shower days, but CNA documentation did not show that the task was performed. Interviews with staff confirmed the lack of clarity regarding responsibility for nail care and the absence of documentation. The resident expressed that no one had come to cut her nails and was unable to recall the last time they were trimmed. Staff members, including a CNA, RN, and the Activities Director, acknowledged that the resident's nails were too long and that nail trimming was not being performed as required. The Administrator also confirmed that, according to the Kardex, the task should have been completed by nursing assistants.
Failure to Document and Implement Stat Physician Order Received via Text
Penalty
Summary
A deficiency occurred when a physician's order for stat laboratory work, given in response to a family member's concern about a resident's symptoms and medical history of hypokalemia, was not documented, signed, dated, or implemented. The resident's son reported his father was cold, shaky, and not feeling well, and requested lab work to check potassium levels. Although a nurse texted the Advanced Practice Registered Nurse (APRN) with this information and received an order for a stat CBC with differential and a CMP, there was no documentation in the resident's chart of the physician notification, the order, or any lab work being performed on that day. The APRN later confirmed the order was given via text, but could not identify which nurse sent the message, and the order was never carried out. Subsequent review of the resident's medical record revealed no progress notes or documentation of the change in condition or the physician's order on the date in question. The resident later experienced an acute change in condition, including altered mental status and diarrhea, and was emergently transferred to the hospital after a cardiac arrest. The Director of Nursing (DON) confirmed the absence of documentation and implementation of the stat order, noting that the nurse involved was an agency nurse who no longer worked at the facility. The facility did not have a policy or procedure in place for handling medication orders received via text.
Deficiency in Dishwasher Sanitization and Food Storage Practices
Penalty
Summary
The facility failed to ensure that dietary staff operating the low-temperature dishwasher were adequately trained and competent in testing the sanitizing solution, which is crucial for preventing foodborne illnesses among residents consuming an oral diet. The high-temperature dishwasher had been converted to a low-temperature one due to malfunction, requiring the use of a sanitizer. However, dietary staff, including Dietary Aide Staff C, were not aware of the need to test the sanitizer, nor did they know where the test strips were kept. The Certified Dietary Manager (CDM) and the Executive Chef were unaware of the requirement for daily monitoring/testing of the sanitizer, and the test strips available were expired. Additionally, the facility failed to store food in a sanitary manner. During an inspection, a small flying insect was observed on a bucket of chicken bouillon, and food items were stored on the floor, contrary to the facility's food storage policy. The walk-in refrigerator and freezer were found to have black bio growth around the bottom of the freezer entry door and the refrigerator ceiling. These observations were verified by the CDM, who acknowledged the presence of the insect and the improper storage of food items. The facility's contracted company had been servicing the dishwasher, which was in chemical sanitation mode due to a back-ordered booster heater. The chemical line was found severed, causing sanitizer to be pumped onto the floor, but it was repaired during a service call. The contracted company representative stated that the dishwasher should be tested monthly, but it had not been tested since the booster went out in April, as no one at the facility knew it was required. The facility had not documented any monitoring of the sanitizer level, and the Executive Chef admitted to not having started training the kitchen staff on testing the sanitizer level.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to promptly address grievances expressed during resident council meetings, as evidenced by a lack of documentation and follow-up on complaints regarding staffing and call light response times. The facility's policy requires grievances to be filed verbally or in writing and resolved promptly, with non-emergency concerns addressed within seven days. However, grievances voiced during resident council meetings in July, August, September, and October 2024 were not documented in the Grievance Log, and there was no evidence of resolutions to these complaints. The grievances included insufficient staff to assist residents after meals and delayed response to call lights, particularly on weekends and night shifts. Interviews with residents and their families corroborated these issues, with reports of long wait times for call light responses and inadequate staffing on weekends. One resident reported waiting up to two hours for assistance at night, despite having a history of falls with fractures. Another resident's son reported that his mother, who is incontinent and has dementia, was left in soiled conditions for over an hour due to staffing shortages. The Social Worker and Administrator confirmed that grievances from resident council meetings were not being logged or tracked, indicating a breakdown in the facility's grievance resolution process.
Lack of Resident-Centered Activities in TCU
Penalty
Summary
The facility failed to implement an ongoing resident-centered activities program to meet the needs of residents in the Transitional Care Unit (TCU). The facility's policy, revised in October 2022, stated that it would provide a program to support residents' choice of activities, including daily activities and events, and encourage participation from residents and families. However, observations and interviews revealed that the facility did not adhere to this policy, as there were no organized activities or activity staff present in the TCU during the survey period. Resident #250, who had intact cognition and expressed a strong interest in group activities, reading, and religious activities, reported that there were no activities available in the TCU. The resident participated in therapy sessions in the morning but stated that there was nothing to do for the rest of the day. The resident was unaware of the available games and puzzles and felt discouraged from accessing them due to staff behavior. Similarly, Resident #251 expressed dissatisfaction with the lack of activities, stating that there were no activities that suited her interests and that she was unaware of any activity director or outdoor activities. Interviews with staff and family members corroborated the residents' experiences. A family member noted the absence of activities and the unavailability of BINGO in the TCU, despite requests to the Unit Manager. The Life Enrichment Volunteer Coordinator mentioned that the TCU had its own activity calendar, but residents were not informed or engaged in these activities. The Activity Assistant stated that the TCU was rehabilitation-focused, implying that therapy was considered the primary activity for residents, which did not align with the residents' needs and preferences.
Failure to Update PASRR for Resident with Severe Mental Health Issues
Penalty
Summary
The facility failed to complete an accurate Level I Preadmission Screening and Resident Review (PASRR) for a resident with a diagnosis of severe mental health issues requiring treatment. The resident was transferred from another skilled nursing facility with a PASRR dated from 2018, which did not reflect the resident's current diagnoses of Psychotic Disorder with delusions and Schizoaffective Disorder. These diagnoses were made in 2018 and 2020, respectively, but were not updated in the PASRR documentation. The resident's clinical record indicated that they were admitted with significant psychiatric conditions, including a recent diagnosis of Major Depressive Disorder. The psychiatric progress note highlighted the need for regular clinical evaluations due to the resident's multiple psychiatric conditions. During an interview, the Minimum Data Set (MDS) Coordinator confirmed that the PASRR from the previous facility was outdated and did not accurately represent the resident's current mental health status, which could potentially prevent the resident from receiving appropriate specialized treatments.
Failure to Conduct Drug Regimen Review Leads to Multiple Falls
Penalty
Summary
The facility failed to conduct a drug regimen review for a resident receiving psychotropic medications who sustained multiple falls. The resident, admitted with diagnoses including pleural effusion, generalized muscle weakness, and a left rib fracture, was identified as a high fall risk. Despite this, the resident was administered multiple medications, including Xanax, Alprazolam, Zolpidem Tartrate, Lorazepam, and Oxycodone, which have potential side effects of increased falls, dizziness, and weakness. A drug interaction warning was triggered for the combination of these medications, indicating the risk of additive central nervous system depression. The resident experienced seven falls within a short period, with incidents occurring during attempts to transfer unassisted or while changing positions. Despite the addition of a medication regimen review to the care plan, there was no documentation that this review was conducted. Interviews with staff confirmed the lack of documentation and the multiple falls sustained by the resident. The facility's failure to implement the care plan intervention for a drug regimen review contributed to the resident's repeated falls.
Failure to Justify Continued Use of Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide justification for the continued use of an indwelling urinary catheter for a resident who was admitted with the catheter from an acute care hospital. The facility's policy requires an assessment for the removal of the catheter unless clinically necessary, but there was no documentation of such an assessment or a urology referral in the resident's clinical record. The resident, who had a diagnosis of neurogenic bladder and intact cognition, reported that she had never needed a catheter before her recent hospital admission and that it was removed once at the hospital due to a urinary tract infection. Interviews with facility staff revealed that the resident had failed a voiding trial at the hospital, but no subsequent voiding trial or urology consultation was conducted at the facility. The catheter was eventually removed, and the resident was able to void successfully. The Director of Nursing did not provide additional information regarding the use of the catheter for this resident, indicating a lack of proper documentation and assessment for the necessity of the catheter's continued use.
Failure to Obtain Physician's Orders for PICC Line Care
Penalty
Summary
The facility failed to obtain physician's orders upon admission for the care and management of a peripherally inserted central catheter (PICC) for a resident receiving intravenous antibiotics. The facility's policy required sterile dressing changes for central vascular access devices upon admission unless the dressing was clean, dry, and intact. However, the clinical record for the resident showed no documentation of a physician's order for the care, including dressing changes of the PICC. During an observation, the resident was found with a heavily soiled PICC dressing that had not been changed since the date marked on it. Interviews with the resident and staff confirmed the lack of physician's orders for the PICC line care. The Director of Nursing verified the issue and acknowledged it was identified during the admission assessment, but no corrective action was taken at that time.
Unsecured Medications Found in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in locked compartments, as required by their policy. During an observation, five unidentified pills and a sealed Lidoderm patch were found unsecured and unattended on a resident's bedside table while the resident was not present in the room. A registered nurse confirmed that these medications were left unattended, acknowledging that they should not have been left on the bedside table. Additionally, four large plastic pharmacy medication bags were observed left unattended at the B wing nurses' desk. These bags, which contained medications delivered by the pharmacy, were easily accessible to staff, residents, and visitors passing by. The Regional Nurse Consultant verified the unattended status of these bags and confirmed their contents.
Failure to Submit Staffing Data to CMS PBJ System
Penalty
Summary
The facility failed to submit the required staffing data to the Center for Medicare/Medicaid (CMS) Payroll-Based Journal (PBJ) system for the Fiscal Year Quarter three of 2024, covering the period from April 1 to June 30. A review of the facility's Staffing Data Report for this period revealed deficiencies in several areas, including a one-star rating, excessively low weekend staffing, no Registered Nurse (RN) hours, and a failure to maintain licensed nursing staff coverage 24 hours a day. Although the facility provided supportive documentation verifying the required staffing and nursing hours for the third quarter, the data was not successfully uploaded to the PBJ system. During an interview, the Administrator explained that the Corporate Office had sent a digital file containing the staffing information for the third quarter, which staff at the facility attempted to upload. However, the upload was unsuccessful, and the Administrator could not explain the reason for the failure. The staff is currently working on preparing the staffing file for the fourth quarter.
Failure to Honor Advance Directives for Full Code Status
Penalty
Summary
The facility failed to honor the advance directives for full code status for Resident #1, who was found unresponsive without a pulse or respiration on [DATE] at 5:19 a.m. Despite having a full code status, CPR was not initiated promptly. Three Licensed Nurses on duty did not call Emergency Medical Services (EMS) or initiate CPR for 51 minutes while attempting to locate a non-existent Do Not Resuscitate Order. The delay in initiating CPR for Resident #1, who had expressed the wish to receive life-saving measures in the event of cardiac or respiratory arrest, resulted in the resident being pronounced dead by EMS. The clinical staff's failure to promptly confirm code status and initiate CPR for Resident #1, as per the facility's policy and procedure on Advance Directives and CPR, led to a delay in providing life-saving measures. Despite the resident's clear full code status, there was confusion among the staff in locating a DNR form, which was not present. This confusion and delay in decision-making regarding CPR led to a critical lapse in honoring the resident's advance directives and right to receive appropriate medical intervention in a timely manner. The investigation into the incident revealed that there was a breakdown in communication and process among the staff involved in responding to Resident #1's medical emergency. The failure to promptly initiate CPR, despite the resident's full code status and expressed wishes for life-saving measures, highlights a significant deficiency in ensuring that staff follow established policies and procedures to honor advance directives. This deficiency placed Resident #1 at risk and resulted in a violation of the resident's right to receive timely and appropriate medical treatment as per their expressed wishes.
Delayed CPR Initiation Due to Miscommunication and Policy Misunderstanding
Penalty
Summary
The facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1, who was found unresponsive, without a pulse or respirations. Despite the absence of a Do Not Resuscitate (DNR) Order, CPR was delayed for 51 minutes while staff attempted to locate a non-existent DNR order. Resident #1, who had Chronic Obstructive Pulmonary Disease with acute exacerbation and generalized muscle weakness, was pronounced dead by Emergency Medical Services (EMS). The facility's policy clearly outlined the importance of prompt initiation of CPR for residents requiring emergency care, especially in the absence of a DNR order. The investigation revealed that the facility staff, including Registered Nurses (RN) and Licensed Practical Nurses (LPN), were involved in the delay of initiating CPR for Resident #1. Despite efforts to locate a DNR order, including checking the Electronic Medical Record (EMR) and hard chart, no such order was found. The staff's actions, as captured in the surveillance video, showed a series of delays and confusion in determining the resident's code status and initiating CPR promptly. The failure to follow established protocols for residents without a DNR order led to a critical delay in providing life-saving measures for Resident #1. During interviews and incident investigations, it was evident that there was a breakdown in communication and understanding among the staff regarding the process for initiating CPR in the absence of a DNR order. Despite the facility's clear policy on CPR initiation and code status determination, there were discrepancies in staff responses and actions when faced with an unresponsive resident. The delay in administering CPR to Resident #1 highlighted a critical deficiency in staff training, communication, and adherence to established protocols for emergency situations.
Delayed CPR Initiation Due to Miscommunication on Code Status
Penalty
Summary
The facility failed to ensure nursing staff had the appropriate competencies to immediately initiate lifesaving measures, including CPR, when residents with full code status experienced cardiac or respiratory arrest. In a specific incident on [DATE] at 5:19 a.m., Resident #1 was found in cardiac and respiratory arrest, but three nursing staff members (two Registered Nurses and one Licensed Practical Nurse) delayed the initiation of CPR and calling for Emergency Medical Services (EMS) for 51 minutes while attempting to locate a non-existent Do Not Resuscitate Order. This delay in providing immediate lifesaving measures resulted in Resident #1 being pronounced deceased by EMS. The investigation revealed that the nursing staff involved, including RN Staff A, LPN Staff B, and RN Staff C, faced challenges in determining the appropriate course of action when Resident #1 was found unresponsive. RN Staff A, who found Resident #1 unresponsive, struggled to locate a DNR order and ultimately drew her own conclusion, leading to a delay in initiating CPR. LPN Staff B, who responded to the call for help, also faced difficulties in locating the DNR order but correctly identified Resident #1 as a full code and initiated CPR. RN Staff C, who was busy with another resident, assisted with CPR but did not recall participating in any code blue drills.
Deficiency in Staff Training and Documentation of Advance Directives
Penalty
Summary
The facility's Administration failed to ensure staff were adequately trained and knowledgeable in policies and procedures regarding residents' rights to advance directives, including the right to receive CPR in the event of cardiac or respiratory arrest. This deficiency was highlighted when Resident #1, who was a full code, was found unresponsive without pulse or respiration. Despite the resident's full code status being known to the Social Services Department, it was not documented in the baseline care plan. The clinical staff on duty did not initiate CPR until 51 minutes after Resident #1 was found unresponsive, ultimately resulting in the resident's death. The investigation revealed that the delay in initiating CPR was due to a breakdown in communication and a lack of clear protocols for staff to follow in such situations. The RN Staff Educator mentioned a process breakdown where staff were unsure of what to do in the absence of a yellow DNR form. The Director of Nursing acknowledged that while nurses were CPR certified, there was a lack of documentation and verification of their competency in responding appropriately to residents found unresponsive. The Social Worker confirmed that Resident #1's advance directives and code status were not documented in the baseline care plan, leading to confusion among staff during the critical event. The deficiency in ensuring staff were trained and knowledgeable in honoring residents' advance directives, specifically regarding CPR procedures, created a situation where Resident #1's expressed wishes as a full code were not promptly honored. The failure to have clear documentation and protocols in place for such scenarios led to a delay in initiating life-saving measures, ultimately resulting in the resident's death. The lack of a systematic approach to ensuring staff competency and adherence to advance directives put residents at risk of not receiving appropriate and timely care in emergency situations.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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