Harbourwood Post-acute And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearwater, Florida.
- Location
- 549 Sky Harbor Dr, Clearwater, Florida 33759
- CMS Provider Number
- 106041
- Inspections on file
- 30
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Harbourwood Post-acute And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was subjected to verbal abuse and aggressive handling by a CNA during care, as witnessed by a PCA. The incident was reported to the DON, but the facility's investigation was deemed inconclusive due to the resident's inability to communicate. The staff member who reported the abuse experienced retaliation and a hostile work environment, and the resident was not promptly evaluated by psychiatric services.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Nursing staff failed to recognize and respond to changes in condition, follow physician orders for diagnostic tests, and report abnormal lab results for three residents. One resident experienced a delay in care and hospitalization due to missed diagnostic tests and lack of physician notification. Another resident's elevated troponin was not promptly reported, and a third resident endured prolonged symptoms and delayed intervention, ultimately calling 911 for hospital transfer. Staff interviews revealed gaps in knowledge and inconsistent adherence to facility protocols.
A resident was re-admitted with multiple diagnoses and an active order for Plavix, but the care plan was not updated to reflect current medication orders. The care plan incorrectly included interventions for aspirin and diuretics, which were not prescribed, and staff acknowledged the care plan should have been revised to match the resident's current needs.
A resident with a history of PTSD and anxiety reported being forced to accept care from a CNA described as rough and verbally abusive, resulting in skin tears and bruising. Staff interviews and documentation confirmed the resident's repeated distress and allegations of abuse, particularly involving certain staff, but the care plan lacked specific interventions to address these behaviors. Facility staff were unaware of the resident's trauma history, and there was no evidence of individualized planning or adequate staff training to prevent further incidents.
A resident with a documented history of PTSD and trauma did not have a comprehensive, trauma-informed care plan in place. Despite multiple assessments and documentation of trauma, staff were not informed or trained on the resident's triggers, and the care plan lacked individualized interventions addressing the resident's trauma history. This resulted in staff being unaware of the resident's needs and unable to provide appropriate support.
A resident with Alzheimer's disease was allegedly struck by a CNA, resulting in a scrape on the nose. The witnessing CNA delayed reporting the incident due to fear of retribution. The facility failed to conduct a timely and thorough investigation, and the family was not immediately notified, violating the facility's abuse policy.
The facility failed to inform residents of their rights to accept or decline medical treatments and to formulate an Advance Directive. Several residents reported not being adequately informed during the admission process, and medical records lacked documentation of acknowledgment. The facility's policy on Advance Directives was not effectively implemented.
The facility failed to complete and update PASARR evaluations for residents with mental illness, resulting in missing Level II evaluations for several residents. This included residents with bipolar disorder, major depressive disorder, and PTSD, whose conditions were not accurately reflected in their PASARR documentation. The facility's policy on coordinating assessments with the PASARR program was not effectively implemented, leading to significant gaps in ensuring appropriate care for residents with mental health needs.
The facility failed to provide adequate ADL care, resulting in unmet grooming needs for residents. A resident with severe cognitive impairment was not assisted with facial hair removal despite requests. Two other residents had long, untrimmed fingernails with substances underneath, despite care plans indicating the need for assistance. Staff interviews revealed inconsistencies in providing these services, contrary to facility policy.
A resident with a pre-existing toe wound did not receive prescribed treatment at the facility, despite being cognitively intact and reporting the issue. The facility's staff, including an LPN and RN/UM, were unaware of the wound, and it was not documented in the resident's medical records or skin assessments. The DON acknowledged the oversight, which violated the facility's policy for comprehensive skin evaluations and communication of skin condition changes.
A long-term care facility reported a 25% medication error rate, with errors involving incorrect insulin administration, failure to administer prescribed medications, and improper priming of insulin pens. Residents were affected by these errors, and staff admitted to not following proper procedures.
The facility failed to ensure timely communication of x-ray results to medical providers, leading to delays in notifying them about residents' conditions. Additionally, the facility did not provide adequate nail care, as some residents had overgrown and unclean nails despite staff training. Furthermore, the facility did not adhere to physician orders for wound care, with instances of undocumented or incomplete dressing changes, potentially risking residents' health.
The facility failed to follow infection prevention protocols, including improper PPE use by staff when caring for a resident on contact precautions, inadequate cleaning of medical equipment between uses, and neglecting hand hygiene practices for residents and staff. These actions were contrary to the facility's established infection control policies.
A resident experienced back pain after being repositioned by nursing aides, but the facility failed to notify the resident's representative or inform the resident of the x-ray results. The RN did not communicate the incident or findings to the family or physician, as confirmed by the LPN and DON.
The facility failed to maintain a safe and homelike environment on the second floor, with issues such as a hole in a bathroom ceiling tile, lifted floor tiles, dusty air conditioner filters, and rusted grab bars in the shower room. These deficiencies were observed during a survey, indicating non-compliance with the facility's policy on providing a clean and comfortable environment.
A resident experienced back pain after being repositioned, leading to an x-ray that showed degenerative changes. The facility failed to notify the ordering practitioner of the results, contrary to policy. Staff interviews revealed the nurse did not inform the resident's family or doctor, only the next shift nurse.
A facility failed to maintain resident dignity by not knocking before entering a resident's room, as observed on three occasions. Staff interviews confirmed the expectation to knock, aligning with the facility's policy on promoting resident dignity. However, this practice was not consistently followed, leading to a deficiency in respecting residents' private spaces.
A resident was unable to participate in her care plan meetings because they were scheduled during her dialysis treatments. Despite being cognitively intact and expressing a desire to be involved, the facility did not adjust the meeting schedule or provide updates, contrary to their policy requiring resident involvement in care planning.
A resident with severe cognitive impairment was observed using the phone in front of the nurse's station, lacking privacy. The resident's room phone had connection issues, and the facility did not provide an alternative private space for calls. The DON stated calls should be private, but the facility lacked a formal privacy policy.
The facility failed to accurately complete MDS assessments for two residents. One resident with hearing loss was not assessed for hearing aid needs, despite an audiological evaluation indicating the necessity. Another resident's discharge status was incorrectly recorded as a hospital discharge instead of home. The MDS Coordinator acknowledged these oversights, and the facility lacks a specific policy for MDS assessments, relying on the RAI as a guide.
A facility failed to create a resident-centered care plan for a resident with PTSD. Although the resident's family was satisfied with the care, the care plan lacked specific focus, goals, or interventions for PTSD. The Social Services Director acknowledged the diagnosis but could not specify triggers or how staff would be informed. The facility's policy requires person-centered care plans with measurable objectives, but this was not met for the resident's PTSD needs.
A resident with moderate-severe hearing loss did not receive necessary audiology services due to the facility's failure to coordinate care. Despite the resident's report of lost hearing aids and a grievance filed, staff did not follow up to ensure replacement aids were provided. The facility's policy mandates the provision of medically-related social services, which was not met in this instance.
A resident on a mechanical soft diet was not provided with meals that met her dietary needs. She struggled with her breakfast containers and was not assisted, and at lunch, she received meat that was too hard to chew. The Dietary Manager confirmed the meal was not prepared according to the resident's dietary requirements, and the Speech Therapist noted the resident's ongoing need for a mechanical soft diet.
Three residents experienced unmet dietary preferences due to the facility's failure to honor their food choices. A resident repeatedly requested ketchup for breakfast but was denied, another received hot cereal instead of cold, and a third was not provided with condiments for tea. Despite being cognitively intact, their requests were often ignored, leading to dissatisfaction.
The facility failed to honor the rooming request of two residents, leading to increased depression and anxiety for one resident. Despite acknowledging the request, staff cited concerns about medication errors and did not document or address the request appropriately.
A resident's grievance regarding her roommate was not promptly addressed by the facility, leading to exacerbated symptoms of depression and anxiety. The facility's grievance policy was not followed, and the concerns were not documented or resolved in a timely manner.
Failure to Protect Resident from Verbal Abuse and Aggressive Handling
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple comorbidities, including dementia, mood disorder, and physical weakness, was subjected to verbal abuse and aggressive handling by a CNA during incontinence care. A Personal Care Attendant (PCA) witnessed the CNA using explicit language, threatening to let the resident fall, and aggressively transferring the resident to a wheelchair, after which the resident was observed shaking. The PCA reported the incident to the Director of Nursing (DON), who instructed the PCA to continue training with another CNA. The PCA also reported feeling retaliated against for reporting the abuse, including being told to limit details in her written statement and experiencing a hostile work environment, with the CNA making threatening remarks such as 'snitches get stitches.' The facility conducted an internal investigation, but the DON and Nursing Home Administrator (NHA) determined the allegation was inconclusive, citing the resident's inability to communicate due to severe cognitive impairment. The resident was not evaluated by psychiatric services until several days after the incident, due to the psychiatric provider's unavailability. The psychiatric and social work assessments found the resident confused and unable to recall the incident, with no immediate signs of distress observed. The CNA involved was suspended and later returned to work before being suspended again for making threatening remarks in the parking lot. Interviews with other staff confirmed awareness of the incident and that abuse and neglect training had been provided. The facility's policy prohibits all forms of abuse and outlines procedures for prevention and reporting. Despite these policies, the incident involving verbal abuse and aggressive handling was substantiated by direct witness testimony and staff interviews, indicating a failure to protect the resident from abuse as required.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Nursing Staff Competency in Recognizing and Responding to Resident Changes in Condition
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in recognizing and responding to changes in condition, following physician orders, and reporting abnormal laboratory results for three residents. For one resident with a history of metabolic encephalopathy, acute renal failure, atrial fibrillation, and chronic kidney disease, multiple physician orders for diagnostic tests, including a chest x-ray and urinalysis, were not completed, and the medical team was not notified of these omissions. Additionally, critical laboratory results for sodium and chloride were not obtained, and again, there was no documentation of physician notification. The resident subsequently experienced a significant change in condition, including altered mental status and hypoxia, leading to hospitalization for acute hypoxic respiratory failure, severe hypernatremia, and acute renal insufficiency. Another resident with heart failure, a cardiac pacemaker, and hypertension had a stat troponin test ordered, which returned an elevated result. The abnormal result was available in the facility’s lab portal, but the medical team was not notified until the advanced registered nurse practitioner reviewed the labs the following day. Facility staff interviews confirmed that nurses are expected to notify the medical team of all test results, especially abnormal ones, and to document this communication, but this did not occur in this instance. A third resident, with a history of major depressive disorder, diabetes, anemia, hypertension, chronic kidney disease, and congestive heart failure, reported feeling unwell and experienced continuous vomiting for several days. Despite repeated complaints and documentation of symptoms, there was a delay in obtaining and acting upon physician orders for diagnostic tests and a change in condition assessment. Laboratory results eventually revealed critically elevated BUN and creatinine levels, but the resident had to call 911 himself to be transferred to the hospital. Staff interviews revealed uncertainty about the process and timeliness for stat labs and diagnostic tests, and the DON confirmed that a change in condition should have been completed earlier.
Failure to Update and Revise Care Plan After Resident Re-Admission
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident following their re-admission. The resident, who had diagnoses including non-ST elevation myocardial infarction, type 2 diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, and dependence on renal dialysis, was discharged and then re-entered the facility. Upon review, the resident's active care plan included interventions for medications such as aspirin and diuretics, which were not currently ordered for the resident. Instead, the resident had an active order for Plavix (Clopidogrel Bisulfate) for blood clot prevention, but this was not accurately reflected in the care plan. There was no order for aspirin or diuretic medications, yet these remained as focuses and interventions in the care plan. Interviews with the LPN and RN responsible for care plans revealed that they did not attend care plan meetings and only reviewed care plans during quarterly MDS assessments. Both staff members acknowledged that the care plan should have been updated to remove the diuretic therapy focus and to accurately reflect the administration of Plavix instead of aspirin. The facility's policy requires the comprehensive care plan to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and to include measurable objectives and timeframes based on the resident's needs as identified in the assessment. This process was not followed for the resident in question.
Failure to Protect Resident from Abuse and Inadequate Intervention for High-Risk Behaviors
Penalty
Summary
The facility failed to protect a resident's right to be free from physical, verbal, and psychological abuse, and did not adequately identify, correct, or intervene in situations where abuse and neglect were more likely to occur. The resident, who had a history of PTSD, adjustment disorder, and anxiety, reported being forced to receive care from a CNA whom he described as rough, verbally abusive, and dismissive of his right to refuse care. The resident sustained skin tears and bruising on his arms, which he attributed to an incident with the CNA. Documentation and interviews confirmed the presence of these injuries, and staff notes indicated the injuries occurred after the staff member grabbed the resident's arms during care. Multiple staff interviews revealed a pattern of the resident expressing distress and making allegations of rough or abusive care, particularly involving male and African American CNAs. Staff acknowledged the resident's history of trauma and his tendency to refuse care or become agitated, but there was a lack of specific interventions in the care plan to address these behaviors or to guide staff responses. The Social Services Director admitted to not following up on reports of the resident's discomfort with certain staff and not referring him to psychiatric services as might have been indicated. The Risk Manager and other staff were unaware of the resident's trauma history and did not review or update the care plan accordingly. The facility's policies required the prevention of abuse and the implementation of individualized interventions for residents with behaviors that might lead to conflict. However, the care plan for the resident only included general interventions and did not specify actions for staff to take when the resident was yelling, refusing care, or expressing distress. Staff interviews indicated that expectations for handling such situations were unclear, and there was no evidence that the facility had ensured staff were trained or prepared to manage the resident's specific needs. This lack of individualized planning and intervention contributed to repeated incidents where the resident felt threatened, was injured, and reported abuse.
Failure to Develop and Implement Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to assess, develop, and implement a comprehensive care plan addressing a resident's documented PTSD diagnosis and potential trauma triggers. Despite multiple social services trauma screens and progress notes indicating a history of trauma, PTSD, and specific traumatic experiences, the care plan did not reflect individualized interventions for trauma or identify known triggers. The care plan focused on adjustment issues and claustrophobia but omitted interventions related to the resident's history of sexual abuse and trauma, even though these were documented in the resident's records. Interviews with facility staff, including CNAs, LPNs, the DON, and the psychiatrist, revealed a lack of awareness regarding the resident's PTSD diagnosis and trauma history. Staff members were not informed of the resident's trauma-related needs or trained to identify or respond to potential triggers. The psychiatrist and psychologist were also unaware of the full extent of the resident's trauma history, and the psychologist noted that the resident's fear and refusal of care could be related to unaddressed trauma. The absence of trauma-informed care planning led to staff not being equipped to provide appropriate support or interventions. Documentation reviews showed inconsistencies in the recognition and care planning for PTSD and trauma. The resident's MDS did not list PTSD or trauma-related diagnoses, and trauma screens often left care plan updates blank or marked as not applicable. The facility's policy required trauma-informed, person-centered care planning, but this was not followed in practice for this resident, resulting in a failure to meet the resident's mental and psychosocial needs as identified in assessments.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report and thoroughly investigate an allegation of abuse in a timely manner for a resident diagnosed with Alzheimer's disease and other conditions. The resident was dependent on staff for various activities of daily living. An alleged incident occurred where a CNA reportedly struck the resident, resulting in a scrape on the resident's nose. This incident was not reported immediately by the witnessing CNA due to fear of retribution, and the facility did not conduct a timely investigation. The Director of Nursing (DON) was informed of the alleged abuse by a Licensed Practical Nurse (LPN) who had been contacted by the witnessing CNA. The DON then spoke with the witnessing CNA, who confirmed the allegation but had not reported it earlier due to fear of retribution. The alleged perpetrator, another CNA, denied the abuse and claimed the resident's injury was accidental. The facility's investigation was delayed, and the family of the resident was not notified immediately. The facility's policy requires immediate investigation and reporting of abuse allegations, but this was not followed. The investigation was incomplete, as not all relevant staff were interviewed, and the incident report was not reviewed by the Interdisciplinary Team. The facility's failure to adhere to its policies and procedures for handling abuse allegations led to a deficiency in ensuring the safety and well-being of the resident.
Failure to Inform Residents of Advance Directive Rights
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided written notice of their rights to accept or decline medical and surgical treatments and to formulate an Advance Directive. This deficiency was identified for ten residents out of forty-eight sampled. The survey revealed that several residents were not adequately informed about their rights concerning Advance Directives during the admission process. For instance, Resident #167, who was admitted for short-term rehabilitation, expressed uncertainty about what an Advance Directive entailed and stated that staff did not explain it in detail. The medical record showed no documentation indicating that the resident was provided with this information, despite an electronic signature from a staff member. Similarly, Resident #1, who had been at the facility for about a month, did not recall staff going over Advance Directives with her, although she was aware of what they were. The medical record indicated that the resident did not sign the authorization for treatment, and there was no documentation to show that she was informed about her rights to decline medical services. The Social Service Director confirmed that the signature page did not reveal that the resident was provided with or fully understood her Advance Directive rights. Other residents, such as Resident #15, who had been at the facility for many years, and Resident #168, who was admitted for rehabilitation, also reported not being informed about their Advance Directive rights. The medical records for these residents lacked evidence of acknowledgment or documentation that they were provided with information about their rights to formulate an Advance Directive or to accept/refuse medical or surgical treatment. The facility's policy on Residents' Rights Regarding Treatment and Advanced Directive was not effectively implemented, as evidenced by the lack of documentation and resident acknowledgment in the medical records.
Deficiencies in PASARR Process for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) process was completed accurately and updated for residents with new or existing mental illness diagnoses. Specifically, five residents were identified as having deficiencies in their PASARR documentation. For instance, Resident #51, who was admitted with bipolar disorder and major depressive disorder, had a Level I PASRR that did not trigger a Level II evaluation, and no Level II PASARR was found in their records. Similarly, Resident #66, with diagnoses including major depressive disorder and alcohol abuse, also lacked a Level II PASARR despite the presence of mental illness indicators. Resident #75, who was observed screaming for help on multiple occasions, had a Level I PASRR that did not reflect the need for a Level II evaluation despite having bipolar disorder and major depressive disorder. Resident #57, with multiple mental health diagnoses including PTSD and major depressive disorder, had a Level I PASRR that failed to mark these conditions, resulting in no Level II evaluation being conducted. Additionally, Resident #69's PASARR process was incomplete due to an administrative closure caused by an incomplete referral packet, and attempts to rectify this with KePRO were unsuccessful. The facility's policy on coordinating assessments with the PASARR program was not effectively implemented, as evidenced by the lack of appropriate Level II evaluations for residents with serious mental disorders. The Social Services Director confirmed the absence of Level II PASARRs for some residents, indicating a failure in tracking and referring residents for necessary evaluations. This deficiency highlights a significant gap in ensuring that residents with mental health needs receive appropriate assessments and care in accordance with Medicaid rules.
Deficiencies in ADL Care: Facial Hair and Nail Maintenance
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for several residents, specifically in the areas of facial hair removal and fingernail maintenance. One resident was observed with white facial hair on her chin and expressed a desire to remove it herself if provided with a razor or tweezers. Despite her requests and her family member's discussions with staff, the facial hair was not addressed. The resident had a severe cognitive impairment and required supervision or assistance with bathing, indicating a need for staff intervention in her grooming. Two other residents were found with long, untrimmed fingernails that had yellow and brown substances underneath. One resident, who had intact cognition, repeatedly requested nail trimming from CNAs and nurses, but his requests were not fulfilled. His care plan indicated a need for assistance with personal hygiene, including nail care on bath days. The other resident, dependent on staff for care, also had long fingernails with substances underneath, despite having a care plan that included grooming assistance. Interviews with staff, including CNAs and the Director of Nursing, revealed inconsistencies in the provision of nail care and facial hair removal. While some staff stated they offered these services during showers, others indicated that podiatry was responsible for nail care. The facility's policy required staff to maintain residents' grooming and personal hygiene, but the observed deficiencies indicated a failure to adhere to these guidelines, resulting in unmet grooming needs for the residents involved.
Failure to Provide Wound Care for Resident's Toe Wound
Penalty
Summary
The facility failed to provide appropriate wound care for a resident who had a pre-existing toe wound upon admission. The resident, who was cognitively intact, reported that a podiatrist had prescribed an antibiotic cream for the toe wound, but she had not received the treatment at the facility. Despite being followed for other pressure ulcers on her coccyx and heel, the resident's toe wound was not documented or treated by the facility staff, as confirmed by the absence of related notes in her medical records and skin assessments. Observations and interviews revealed that the nursing staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse/Unit Manager (RN/UM), were unaware of the resident's toe wound. The Director of Nursing (DON) acknowledged that the nursing staff should have conducted a comprehensive head-to-toe assessment, which would have included the toe wound. The facility's policy required full body skin evaluations upon admission and weekly thereafter, but this was not adhered to in the case of the resident's toe wound. The lack of communication and documentation regarding the resident's toe wound was further highlighted by the absence of progress notes or prescriptions from the resident's recent podiatry visit. The facility's policy also required nursing assistants to report any changes in skin condition to the resident's nurse, but this did not occur for the toe wound. The failure to document and treat the resident's toe wound represents a deficiency in the facility's wound care management and communication processes.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 25% based on observations of 28 medication administration opportunities. Errors were identified in the administration of medications to four residents. For Resident #15, a registered nurse administered 30 units of Fiasp FlexTouch insulin subcutaneously when the resident was not eating, contrary to the prescribed order of 15 units in the morning and 15 units with meals. For Resident #93, a licensed practical nurse (LPN) failed to administer Cholecalciferol, Eliquis, and Fluticasone Nasal Spray as documented, despite initialing the medication administration record to indicate they were given. Additionally, the LPN did not use the proper technique of priming insulin pens before administering Victoza and Insulin Glargine to Resident #4, admitting a lack of knowledge about the priming requirement. Furthermore, Staff R, another LPN, documented the administration of Ipratropium-Albuterol Solution to Resident #68, which the resident reported not receiving for over 24 hours. The facility's policies on medication administration and injection procedures were not adhered to, contributing to these errors.
Deficiencies in Communication, Nail Care, and Wound Management
Penalty
Summary
The facility failed to ensure effective communication of x-ray results to medical providers, residents, and their representatives, as evidenced by the deficiency related to F-tag 552. The Director of Nursing (DON) acknowledged that the Assistant Director of Nursing (ADON) was responsible for auditing x-ray and lab results to confirm that notifications were made. However, there were instances where the ADON was unavailable, and the Unit Manager (UM) did not fulfill this responsibility, leading to delays in notifying medical providers about x-ray results. For instance, Resident #37's x-ray results, which indicated mild pulmonary vascular congestion, were not communicated to the medical provider until two days after the results were available. The facility also failed to provide adequate nail care for residents, as highlighted by the deficiency related to F-tag 677. Despite education and in-service training provided to staff regarding nail care, observations revealed that some residents had overgrown and unclean nails. For example, Resident #56 expressed difficulty in picking up a spoon due to the length of his fingernails, and Resident #55 had yellowing nails with a dry gray and yellow substance beneath them. These observations indicated a lack of adherence to the facility's policy of providing nail care on shower days and documenting it accordingly. Additionally, the facility did not adhere to physician orders for wound care, as evidenced by the deficiency related to F-tag 686. Observations showed that Resident #39 did not have a dressing on his coccyx wound, despite physician orders for daily dressing changes. The DON confirmed that the nurse responsible for Resident #40's care documented that wound care was performed, but later admitted to not having time to do it. This lack of compliance with wound care protocols could potentially lead to negative outcomes such as infection or worsening of pressure ulcers.
Infection Control Deficiencies in PPE Use and Equipment Cleaning
Penalty
Summary
The facility failed to adhere to professional standards for infection prevention and control, as evidenced by multiple observations of staff not following proper protocols. Staff U, a CNA, was observed entering and exiting Resident #27's room without wearing the required PPE, despite the resident being on contact precautions for an infection. Additionally, Staff P, an RN, and Staff U provided direct care to the resident without PPE. Interviews with staff revealed a lack of compliance with expected PPE use, as outlined by the facility's policies. Further deficiencies were noted in the cleaning and disinfection of medical equipment. Staff J, an LPN, was observed placing used medical equipment, such as a blood pressure cuff and stethoscope, on top of a medication cart without cleaning them between uses. This practice was contrary to the facility's infection control policy, which requires cleaning and disinfection of equipment between resident uses. Staff P, an RN, confirmed that blood pressure cuffs should be cleaned between patient use. The facility also failed to ensure proper hand hygiene practices. During meal delivery, staff did not offer or assist residents #104 and #85 with hand hygiene before meals. Additionally, Staff J, LPN, did not perform hand hygiene after removing gloves and before donning new ones during medication administration for Resident #93. The facility's infection prevention and control program policy mandates hand hygiene in accordance with established procedures, which was not followed in these instances.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the resident representative about a change in condition for a resident who experienced back pain after being repositioned by nursing aides. The resident, who has moderate cognitive impairment and a history of Type 2 Diabetes Mellitus with diabetic neuropathy, reported feeling a sharp pain in her back and legs following the incident. Although an x-ray was conducted, the resident was not informed of the results, and the resident's healthcare surrogate was not notified of the incident or the x-ray findings. Interviews with staff revealed that the RN who was informed of the resident's complaint did not notify the resident's family or the physician about the incident or the x-ray results. The LPN/Unit Manager confirmed that the x-ray report was received during the first shift, and the nurse should have communicated the findings to the doctor and the resident's representative. The DON acknowledged that the nurse should have followed the protocol for notifying the physician and the resident's representative about the x-ray findings.
Deficiencies in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment on the second floor, as observed during a survey. In one room, a hole was found in the ceiling tile of the bathroom, and a section of the bathroom floor tile was lifted, posing potential safety hazards. Additionally, three residents were observed sitting in wheelchairs near grab rails with separated sections and sharp gaps, which could potentially cause injuries. In another room, a portable air conditioner unit was found with a thick layer of grey dust coating the filter and particles inside the exhaust hose. This unit had been in the resident's room since their admission. Furthermore, the second-floor shower room had grab bars with reddish-brown flaky coating, and a shower gurney with a blue foam pad had a significant tear, which was confirmed to be used by multiple residents. The facility's policy on maintaining a safe and homelike environment was reviewed, revealing that it includes ensuring a clean and comfortable environment, allowing residents to use personal belongings, and maintaining sanitary conditions. However, the observations made during the survey indicated that these policies were not adequately implemented, leading to the deficiencies noted in the report.
Failure to Notify Practitioner of X-ray Results
Penalty
Summary
The facility failed to notify the ordering practitioner of radiology results for a resident who experienced back pain after being repositioned by nursing aides. The resident, who has a history of Type 2 diabetes mellitus with diabetic neuropathy and coronary angioplasty, reported sharp pain in her back and legs following the incident. An x-ray was ordered, and the results indicated moderate disc space narrowing and degenerative changes, but there was no documentation that the ordering practitioner was informed of these findings. Additionally, no follow-up x-ray was ordered. Interviews with facility staff revealed that the nurse on duty did not notify the resident's family or the doctor about the x-ray results, only passing the information to the nurse on the next shift. The facility's policy requires that diagnostic test results be communicated to the ordering physician within 24 hours, but this protocol was not followed. The Director of Nurses acknowledged the oversight and indicated that education would be provided to prevent future occurrences.
Failure to Maintain Resident Dignity by Not Knocking Before Entering
Penalty
Summary
The facility failed to ensure the dignity of residents by not protecting and valuing their private space, as evidenced by staff members entering a resident's room without knocking or being invited. This deficiency was observed on three separate occasions, where a staff member in black scrubs entered the room of Resident #29 without knocking or receiving an invitation. These observations were made over the course of three consecutive days. Interviews with staff members, including CNAs and the Director of Nursing, revealed that the facility's policy required staff to knock before entering a resident's room to maintain dignity and respect. Despite this policy, the observations indicated a failure to adhere to these standards. The facility's policy on promoting and maintaining resident dignity emphasized the importance of respecting residents' living spaces and personal possessions, yet this was not consistently practiced by the staff.
Resident Excluded from Care Plan Meetings Due to Scheduling Conflict
Penalty
Summary
The facility failed to provide Resident #44 the opportunity to participate in her care planning meetings. Observations and interviews revealed that Resident #44, who is cognitively intact with a BIMS score of 15, expressed a desire to be involved in her care plan meetings. However, these meetings were consistently scheduled during her dialysis treatments, preventing her from attending. Despite her expressed interest, staff did not adjust the meeting schedule or provide alternative means for her participation. Interviews with staff, including the MDS Coordinator, LPN/Unit Manager, and Social Service Director, confirmed that care plan meetings for second-floor residents, including Resident #44, were held on Wednesdays, coinciding with her dialysis schedule. The staff acknowledged that they did not follow up with Resident #44 to update her on the meetings or involve her in the planning process. The facility's policy requires the inclusion of residents and their representatives in care planning to the extent practicable, but this was not adhered to in the case of Resident #44.
Failure to Provide Privacy for Resident Phone Calls
Penalty
Summary
The facility failed to ensure personal privacy for a resident by not providing a private space for phone use. During an observation, a resident with severe cognitive impairment was seen using the phone in front of the nurse's station, which did not offer privacy. The resident did not have a phone in her room due to connection issues, and the facility did not provide an alternative private space for phone calls, as confirmed by the Director of Nursing. Interviews with the Resident Council Secretary and the Unit Manager revealed that it was common for residents to use the phone at the nurse's station, and there was a belief that conversations were not overheard. However, the Director of Nursing stated that calls should be transferred to the resident's room or conducted in a private office. The facility was unable to provide a policy on privacy when requested, indicating a lack of formal guidelines to ensure residents' privacy during phone calls.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to accurately complete resident assessments for two residents, leading to deficiencies in their care. Resident #77, who has moderate-severe hearing loss, was not accurately assessed in the MDS to reflect her need for hearing aids. Despite reporting the loss of her hearing aids and the need for replacements, the MDS assessment inaccurately indicated that she had adequate hearing and did not use hearing aids. This oversight occurred even after an audiological evaluation confirmed her hearing loss and the need for amplification. The MDS Coordinator acknowledged that the assessment should have been updated following the audiologist's evaluation, but it was not. Resident #113's discharge status was inaccurately recorded in the MDS assessment. Although the resident was discharged home, the MDS inaccurately documented the discharge status as being to a short-term general hospital. This error was identified by the MDS Coordinator, who admitted it was an oversight. The facility does not have a specific policy for MDS assessments, relying instead on the Resident Assessment Instrument (RAI) as a guide, which may have contributed to the oversight.
Failure to Develop PTSD-Specific Care Plan
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). Despite the resident's family member expressing satisfaction with the care provided, the care plan lacked specific focus, goals, or interventions related to the resident's PTSD. The Social Services Director acknowledged the diagnosis and mentioned that the resident was care planned for potential mood state issues related to PTSD and depression. However, she could not specify any triggers for the resident's PTSD or how staff would be informed of these triggers. The Director of Nursing and Regional Nurse confirmed that residents with PTSD should be care planned and evaluated by social services and psych services. The facility's policy on comprehensive care plans mandates the development of a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs. The policy also emphasizes the importance of culturally competent and trauma-informed services. Despite these guidelines, the facility did not ensure that the resident's care plan addressed the specific needs related to PTSD.
Failure to Coordinate Audiology Services for Resident
Penalty
Summary
The facility failed to coordinate audiology services for a resident, leading to a deficiency. The resident, who was cognitively intact and had been admitted to the facility with hearing aids, reported that two sets of her hearing aids were lost by the facility. Despite expressing her desire for replacement hearing aids, no arrangements were made by the facility to address her needs. The resident's audiology assessment indicated moderate-severe hearing loss in one ear and mild-severe in the other, highlighting the necessity for hearing aids. Interviews with staff revealed a lack of follow-up and coordination in providing the resident with necessary audiology services. The Licensed Practical Nurse/Unit Manager did not review the audiologist's notes because the resident was not on her unit at the time. The Social Service Director admitted to not following up with the audiology services to ensure the resident received her hearing aids, despite the resident filing a grievance regarding the missing aids. The Nursing Home Administrator acknowledged the facility's responsibility to coordinate services for obtaining hearing aids but stated that the facility is not responsible for replacing them. The facility's policy requires the provision of medically-related social services, including arranging for adaptive equipment, which was not fulfilled in this case.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a resident with therapeutic food that met her nutritional needs. On two separate occasions, the resident was observed struggling with her meals. During breakfast, she had difficulty opening her food containers and was not offered assistance or provided with hand hygiene. At lunch, she was seen spitting out her meat, stating it was too hard to chew and not in accordance with her mechanical soft diet. The resident's care plan indicated she was on a mechanical soft diet due to her difficulty with chewing, and her physician's order confirmed this dietary requirement. Interviews with facility staff revealed lapses in the dietary management process. The Dietary Manager admitted that she was not present during the preparation of the resident's meal and acknowledged that the meat provided was not mechanically altered as required. The Speech Therapist confirmed that the resident had been evaluated for chewing difficulties and had requested to remain on a mechanical soft diet. The facility's policy mandates that dietary and nursing staff provide therapeutic diets as prescribed, but this was not adhered to in the case of the resident, leading to the deficiency.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food choices for three residents, leading to dissatisfaction and unmet dietary preferences. Resident #1, who was admitted for short-term rehabilitation, repeatedly requested ketchup for her breakfast eggs but was consistently denied. Despite her cognitive intactness and multiple requests to various staff members, her meal ticket was never updated to include ketchup, and staff often failed to return with the condiment, leaving her meals cold and her requests unmet. Resident #167 also experienced issues with meal preferences, specifically with receiving hot cereal instead of her preferred cold cereal, despite her meal ticket indicating her preference. She frequently did not receive the right condiments for her coffee, such as creamer, and her requests to staff were often ignored or unfulfilled. The Certified Dietary Manager confirmed that the resident was mistakenly served hot cereal and acknowledged the error in meal preparation and delivery. Resident #19 faced similar issues with his tea, as he was not provided with creamer or sugar, which he routinely requested. Despite being cognitively intact and having been at the facility for two months, his requests were often ignored, and he was left with cold tea that he did not want to drink. The Certified Dietary Manager confirmed that the kitchen was never out of condiments and that staff should have been able to fulfill these requests. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of a specific policy for resident food choices, which contributed to the ongoing issues.
Failure to Honor Rooming Request
Penalty
Summary
The facility failed to honor the right of two residents to share a room, despite their requests and documented psychological distress due to separation. Resident #1 expressed a desire to room with Resident #2, her family member, to alleviate feelings of depression and anxiety. The facility's Social Service Director (SSD) and a Licensed Practical Nurse (LPN) acknowledged the request but cited concerns about potential medication errors and the possibility of Resident #1 attempting to assist the bed-bound Resident #2. However, these concerns were not documented in the residents' clinical charts, and the request for rooming together was not formally recorded or addressed. Resident #1's clinical chart and psychological notes indicated that her symptoms of depression and anxiety were exacerbated by being separated from Resident #2. Despite daily visits, the lack of rooming together continued to affect her mental health. The SSD and LPN admitted to having discussions about the rooming request but failed to document these conversations or take appropriate action to honor the residents' rights. This oversight led to the deficiency noted in the report.
Failure to Address Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure a prompt effort to resolve a grievance regarding a roommate for one of the residents. The resident, who was admitted to the facility on an unspecified date, expressed dissatisfaction with her current roommate and desired to room with a family member who also resided in the facility. The resident reported that her current roommate's behavior, such as turning up the television volume and increasing the room temperature, exacerbated her symptoms of depression and anxiety. Despite these complaints, there was no documentation of the grievance in the facility's grievance log, and the concerns were not addressed promptly by the staff. The resident's psychology encounter notes from February indicated that her symptoms of depression and anxiety were worsened by her living situation and the discord with her roommate. The Licensed Practical Nurse (LPN) Unit Manager acknowledged the issues between the resident and her roommate but had not reviewed the psychology notes that documented the resident's concerns. The facility's grievance policy required staff to record grievances and take steps to resolve them promptly, but this procedure was not followed in this case, leading to the deficiency.
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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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