Inn At Freedom Village, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Bradenton, Florida.
- Location
- 6410 21st Ave W, Bradenton, Florida 34209
- CMS Provider Number
- 105655
- Inspections on file
- 19
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Inn At Freedom Village, The during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, dementia with behavioral disturbance, and a history of combative behavior during care did not have a care plan addressing dementia-related behaviors. During incontinence care, the resident became combative, grabbing and attempting to hit CNAs. One CNA placed a pillow over the resident’s arms and leaned on it to hold the arms down while continuing care, contrary to facility training and dementia care policy, which direct staff to use redirection, step away, and notify the nurse rather than using restraint-like measures. Another CNA was initially unsure whether to report the incident, delaying immediate notification to nursing staff.
A resident with Parkinsonism, anxiety disorder, and dementia had a hospital discharge order and facility physician order for clonazepam 0.5 mg PO q24h PRN for anxiety, but the drug was not available in the facility for several days after admission. During this time, CNAs and an RN documented the resident as agitated, hitting staff, combative with care, and smearing BM, while an RN noted there was an order for clonazepam but no prescription on file and contacted the pharmacy and physician. The contracted pharmacy later confirmed it did not receive an electronic prescription for clonazepam until several days after admission, and the medication was not delivered until the following day, despite facility policy requiring proper handling and documentation of controlled substances.
The facility failed to maintain safe operating conditions in two kitchen freezers, with significant ice build-up and condensation observed. Despite work orders being created, the issues persisted due to malfunctioning equipment and inadequate follow-up. The large walk-in freezer had a faulty door handle, contributing to ice accumulation, while the small walk-in freezer continued to have ice build-up despite maintenance efforts.
The facility failed to ensure accurate PASRR documentation for four residents, leading to deficiencies in identifying mental disorders or intellectual disabilities. Residents with diagnoses such as dementia, major depressive disorder, and bipolar disorder did not have their conditions accurately marked on PASRRs, and necessary Level II evaluations were not completed. Interviews revealed a lack of systematic processes to update PASRRs when new diagnoses or medications were added.
The facility failed to provide hand hygiene to residents in the dining room before meals, as observed during a lunch meal. Staff were seen assisting residents with seating and serving beverages but did not offer hand hygiene. Interviews with staff and residents revealed inconsistencies in the practice, with some staff unaware of the requirement and residents reporting infrequent hand hygiene offers. The Infection Preventionist acknowledged the expectation for hand hygiene but doubted its consistent implementation, despite the facility's policy emphasizing its importance.
The facility failed to protect residents' PHI by leaving nursing shift report forms unattended on medication carts in Wing A and Wing C. These forms, containing sensitive information, were observed on carts assigned to an RN and an LPN. Despite a policy requiring PHI to be safeguarded, the forms were left accessible, risking unauthorized access.
The facility failed to report elopement incidents involving two residents within the required timeframe. Both residents, with impaired cognition and requiring assistance with daily activities, were found in the parking lot. Initially not considered at risk for elopement, evaluations after the incidents determined they were at risk. The facility's policy mandates reporting such incidents, but the Nursing Home Administrator and Director of Nursing did not consider them reportable under abuse or neglect guidelines.
A resident with multiple diagnoses, including metabolic encephalopathy, was found with undated dressings on their feet, contrary to physician orders and facility protocols. Despite treatment records indicating care was provided, the dressings were not dated, as confirmed by staff interviews and facility policies.
A facility failed to maintain a medication error rate below 5%, with three errors observed out of 28 opportunities, resulting in a 10.71% error rate. Errors included incorrect dosage of Vitamin D25 administered by an RN and late administration of Ascorbic Acid and Metformin Hydrochloride to two residents. The facility's policy requires medications to be administered within one hour of the scheduled time and checked three times for accuracy, which was not adhered to.
A resident was found with unsecured medications on their bedside furniture, including Tylenol, nasal spray, and medicated powder, without a physician order for self-administration. The facility's policies on medication storage and self-administration were not followed, as revealed by staff interviews.
The facility failed to report abnormal lab results to the physician for two residents with chronic conditions. Despite receiving electronic reports of abnormal CBC and urinalysis results, the nursing staff did not review or communicate these findings to the physician, contrary to the facility's policy requiring direct communication for immediate notification.
Failure to Provide Competent Dementia Care and Appropriate Response to Combative Behavior
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were competent to provide appropriate care and services to a resident with dementia-related behaviors. The resident was admitted for short-term rehabilitation with diagnoses including Parkinsonism, anxiety disorder, and unspecified dementia with behavioral disturbance, and had a Minimum Data Set indicating moderate cognitive impairment. Review of the resident’s care plan showed no plan of care addressing behaviors related to dementia. A nursing progress note documented that the resident was combative with care and had smeared bowel movement on himself and the bed. During a night shift, a CNA (Staff H) attempted to provide incontinence care to the resident, who was covered in feces. The resident had previously grabbed Staff H’s wrist during care, so she requested assistance from another CNA (Staff G). While assisting, the resident grabbed Staff G’s hands and bent her fingers and then attempted to hit Staff H when they rolled him. In response, Staff H placed a pillow over the resident’s arms, leaned her right arm on the pillow to hold his arms down, and told him he was not going to be combative while she continued to clean him with her left hand. Staff H reported holding the resident in this manner for about 30 seconds until they were able to dress him and transfer him to a chair. Staff G reported being unsure about what she had witnessed and initially did not think she needed to report the event immediately, intending instead to ask the DON the next morning. Another CNA (Staff I) advised that the incident needed to be reported to a nurse, and the other CNA reported it. The nurse manager (Staff B) was notified and learned that Staff H had used a pillow to lean on the resident to prevent him from striking staff, which was not consistent with the facility’s training that CNAs should notify the nurse, step away, and reattempt care if redirection is unsuccessful when a resident is combative. Review of the facility’s dementia care policy indicated that restraints should not be used unless safety is an issue and only according to policy, with staff instructed to check with a supervisor before using restraints. The lack of a behavior-focused care plan and the use of a pillow to physically restrict the resident’s movement during care formed the basis of the deficiency.
Failure to Obtain and Provide Ordered Controlled Medication for Resident With Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that a prescribed controlled medication, clonazepam 0.5 mg, was available for a resident with Parkinsonism, anxiety disorder, and non-Alzheimer’s dementia with behavioral disturbance. The resident was admitted with a hospital discharge order for clonazepam 0.5 mg PO daily PRN for anxiety, and the facility’s physician orders dated 02/14/2026 reflected clonazepam 0.5 mg every 24 hours PRN for anxiousness related to anxiety disorder for 14 days. The resident’s MDS showed moderate cognitive impairment (BIMS score of 9) and active diagnoses of non-Alzheimer’s dementia and anxiety disorder. Despite these orders, the contracted pharmacy confirmed that no prescription for clonazepam was received before 02/20/2026, and the medication was not delivered to the facility until 02/21/2026. During this period without the ordered clonazepam available, documentation showed behavioral issues. A CNA note from 02/17/2026 at 02:00 a.m. described the resident as agitated and hitting staff, which triggered an alert on the facility’s EMR dashboard and was discussed in the morning clinical meeting. On 02/20/2026 at 03:33 a.m., an RN documented that the resident was combative with care, had smeared bowel movement on himself and the bed, and that although there was an order for clonazepam 0.5 mg PRN, there was “no script”; the pharmacy was called and the primary physician was made aware. A psychiatric ARNP visit on 02/20/2026 noted the resident was being followed for psychotropic medication management due to dementia with inappropriate behavior and resistance to ADL care at night, and the plan was to continue clonazepam 0.5 mg PO every 24 hours PRN for 14 days as currently prescribed. The facility’s own policy required compliance with all laws and requirements related to handling and documentation of controlled substances, yet the ordered controlled medication was not obtained and available for use until several days after admission.
Failure to Maintain Safe Operating Condition of Kitchen Freezers
Penalty
Summary
The facility failed to maintain food service equipment in a safe operating condition, specifically in two kitchen freezers. During a kitchen tour, significant ice build-up and condensation were observed in both the large walk-in freezer and the small walk-in freezer located inside the refrigerator. The large walk-in freezer had ice accumulation on the floor, ceiling, and racks, with icicles forming, while the small walk-in freezer had ice build-up on the blower unit and racks. The Director of Dining Services acknowledged that the door handle of the large walk-in freezer was malfunctioning, preventing it from sealing properly and contributing to the ice build-up. Despite work orders being created to address these issues, the problems persisted. The work orders for the small walk-in freezer were marked as completed, but the ice build-up continued, indicating that the underlying issues were not resolved. The Maintenance Director and the Nursing Home Administrator were involved in addressing the work orders, but the issues remained unresolved. The CDM later discovered that the vendor was waiting for parts to repair the large walk-in freezer, but there was a lack of timely follow-up and documentation regarding the delay. This lack of effective maintenance and follow-up led to the continued unsafe condition of the kitchen freezers.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Level I Preadmission Screening and Resident Review (PASRR) for four residents, leading to deficiencies in the identification and documentation of mental disorders or intellectual disabilities. Resident #1 was admitted with diagnoses including unspecified dementia, major depressive disorder, and panic disorder, yet the PASRR did not mark panic disorder or indicate the need for a Level II evaluation. The resident was on medications for anxiety and depression, and the care plan noted impaired cognitive function and the use of psychotropic medications. Resident #6 was admitted with diagnoses such as unspecified dementia, bipolar disorder, and major depressive disorder, but the PASRR left the section for mental illness blank. The resident was prescribed an antidepressant, and the care plan included interventions for depression. Similarly, Resident #30 had diagnoses including major depressive disorder and schizoaffective disorder, but the PASRR did not mark mental illness, and no Level II evaluation was completed. The resident had severe cognitive impairment and was on antipsychotic medication. Resident #24 was admitted with multiple diagnoses, including major depressive disorder and bipolar disorder, but the PASRR did not reflect these mental health conditions, nor was a Level II evaluation conducted. Interviews with facility staff revealed a lack of a systematic process to update PASRRs when new diagnoses or medications were added, contributing to the oversight. The facility's policy required screening for mental disorders and referral for Level II evaluation if indicated, but this was not consistently followed.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to ensure that hand hygiene was offered to residents in the dining room prior to meals during an observation on July 15, 2024. During the lunch meal observation, it was noted that no hand hygiene was provided to the sixteen residents present in the dining room. Staff were observed assisting residents with seating and providing beverages and condiments, but did not offer any form of hand hygiene before serving the meal. Interviews with staff members revealed inconsistencies in the practice of offering hand hygiene, with some staff stating they provide hand hygiene in other contexts but not specifically before meals in the dining room. Interviews with residents confirmed the lack of consistent hand hygiene practices before meals. One resident reported that hand hygiene was only offered occasionally, and another resident stated that staff did not ask if they wanted to wash their hands before eating. The Infection Preventionist acknowledged the expectation for hand hygiene before meals and noted that staff had been educated on this practice, but expressed doubt that it was being consistently implemented. The facility's policy on hand hygiene, revised in August 2019, emphasizes its importance in preventing infection, yet the observations and interviews indicate a failure to adhere to this policy.
Failure to Protect Resident Health Information
Penalty
Summary
The facility failed to ensure the privacy of residents' personal health information (PHI) by leaving nursing shift report forms unattended on medication carts in the hallways of Wing A and Wing C. On multiple occasions, these forms were observed on top of medication carts assigned to a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), containing sensitive information such as room numbers, scheduled skin checks, residents' names, mobility devices, blood sugar checks, and additional health details like diet, oxygen use, and urinary catheter information. Photographic evidence was obtained to document these observations. An interview with the Assistant Director of Nursing (ADON) revealed that nursing staff are expected to cover or turn over their nursing report forms to prevent the disclosure of PHI. The facility's policy, effective since August 1, 2020, outlines the need to safeguard PHI by ensuring documents are not easily accessible to unauthorized staff or visitors. Despite this policy, the observed incidents indicate a failure to adhere to these guidelines, resulting in the potential for unauthorized access to residents' confidential health information.
Failure to Timely Report Elopement Incidents
Penalty
Summary
The facility failed to report an alleged violation of abuse/neglect within the required timeframe concerning the elopement of two residents. Resident #43, who was admitted with diagnoses including atrial fibrillation, hypertension, and dementia, was found in the parking lot. The resident had a Brief Interview Status (BIMS) score of 00, indicating severely impaired cognition, and required assistance with activities of daily living. Initially, the resident was not considered at risk for elopement, but after the incident, an evaluation determined the resident was at risk. Similarly, Resident #281, with diagnoses including congestive heart failure, prostate cancer, and dementia, was also found in the parking lot. This resident had a BIMS score of 8, indicating moderately impaired cognition, and required substantial assistance with daily activities. Like Resident #43, Resident #281 was not initially considered at risk for elopement, but an evaluation after the incident determined the resident was at risk. The Nursing Home Administrator and Director of Nursing reviewed the elopement events and stated that elopements are not considered abuse or neglect, thus not reportable under Day 1 and Day 5 abuse and neglect reporting. However, the facility's policy requires all reports of resident abuse, neglect, exploitation, or theft to be reported to local, state, and federal agencies and thoroughly investigated. The facility submitted Adverse Incident Forms for both residents after the incidents, but not within the required timeframe.
Failure to Date Dressings for Resident
Penalty
Summary
The facility failed to provide nursing care according to standards by not properly dating skin care dressings for a resident. Resident #59, who was admitted with diagnoses including metabolic encephalopathy and rhabdomyolysis, was observed on two occasions with undated dressings on their feet. The resident reported that the dressings had not been changed for a couple of days, although the Treatment Administration Record indicated treatment was provided on specific dates. This discrepancy highlights a failure to adhere to the physician's orders for wound care, which required dressing changes on specific days. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that the facility's protocol required dressings to be dated and initialed after application. The facility's policies and procedures for wound care and dressings also mandated labeling with the date, time, and initials. Despite these guidelines, the dressings for Resident #59 were not dated, indicating a lapse in following established procedures for wound care management.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations, interviews, and record reviews. During the survey, 28 medication administration opportunities were observed, resulting in three errors involving three residents. This led to a medication error rate of 10.71%. Specifically, Staff E, RN, administered an incorrect dosage of Vitamin D25 (Cholecalciferol) to a resident, providing 1000 units instead of the ordered 3000 units. Additionally, two residents did not receive their scheduled medications on time, with one resident's Ascorbic Acid and another's Metformin Hydrochloride being administered late, despite the MAR being initialed as if they were given on time. The facility's policy on medication administration, revised in April 2019, requires medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time. The policy also mandates that the individual administering the medication checks the label three times to ensure the right resident, medication, dosage, and time. However, these protocols were not followed, as evidenced by the late administration of medications and incorrect dosage given, contributing to the high medication error rate observed during the survey.
Failure to Secure Medications for a Resident
Penalty
Summary
The facility failed to store medications safely and securely for one resident, as observed during a survey. Unsecured medications, including Tylenol, nasal spray, and medicated powder, were found on the bedside furniture of a resident who was cognitively intact. The resident reported taking Tylenol occasionally and informing the nurse when he did so. However, there was no physician order for self-administration of medications for this resident, nor was there an active care plan indicating that self-administration was permitted. Interviews with facility staff revealed a lack of adherence to the facility's policies regarding medication storage and self-administration. A Licensed Practical Nurse stated that medications found at the bedside should be taken and reported to a supervisor. The Director of Nursing indicated that medications should be stored in a lock box if found at the bedside and that an assessment should be conducted for self-administration. The facility's policies require that unauthorized medications at the bedside be returned to the nurse in charge and stored securely, which was not followed in this instance.
Failure to Report Laboratory Results to Physician
Penalty
Summary
The facility failed to ensure that laboratory results were reported to the provider and physician orders were followed up on for two residents. Resident #333, who was admitted with diagnoses including urinary tract infection, depression, and chronic kidney disease, had abnormal laboratory results for a CBC and urinalysis reported electronically to the facility. However, the staff did not review these lab reports, and the abnormal results were not communicated to the physician for review. Similarly, Resident #336, admitted with chronic kidney disease, Type 2 Diabetes Mellitus, and depression, also had abnormal CBC results reported electronically. These results were not reviewed by the nursing staff, nor were they reported to the physician. The Assistant Director of Nursing confirmed that the facility's process for reporting laboratory test results was not followed, as the nursing staff failed to notify the physician when the lab results were received. The facility's policy requires direct voice communication with the physician for results requiring immediate notification, which was not adhered to in these cases.
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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