Lakeland Hills Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakeland, Florida.
- Location
- 610 E Bella Vista Dr, Lakeland, Florida 33805
- CMS Provider Number
- 105283
- Inspections on file
- 20
- Latest survey
- April 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lakeland Hills Center during CMS and state inspections, most recent first.
The facility failed to accurately reconcile hospital discharge medications and follow physician orders for several residents, resulting in missed or incorrect medication administration, lack of follow-up on laboratory and outpatient orders, and failure to document or notify physicians as required. These failures led to serious harm, including seizures, falls, hospitalization, and death. Staff interviews confirmed lapses in medication reconciliation, order verification, and adherence to prescribed protocols.
Nursing staff failed to demonstrate competency in medication reconciliation, laboratory follow-up, and adherence to physician orders, affecting multiple residents. Deficiencies included lack of proper training, failure to document or report G-tube malfunctions, unauthorized medication administration, and inadequate follow-up on lab orders. These failures resulted in worsened resident conditions and led to an Immediate Jeopardy determination.
Three residents experienced significant medication errors due to failures in medication reconciliation and administration. One resident with a seizure disorder and G-tube did not receive the correct dose and form of anti-seizure medication, leading to multiple seizures, a fall, and death. Another resident with epilepsy and a feeding tube did not receive all prescribed seizure medications after readmission, resulting in seizure-like activity and hospital transfer. A third resident with diabetes received unauthorized insulin doses from an LPN, contrary to physician orders, and was hospitalized for hyperglycemia. These incidents were linked to failures in communication, documentation, and adherence to medication protocols.
The QAPI committee failed to ensure effective diabetes management for two residents, resulting in nursing staff not following physician orders for insulin administration, lack of required physician notifications for high blood sugar readings, and inadequate documentation of care. These deficiencies were not effectively identified or addressed through the facility's QAPI process.
The facility failed to maintain essential laundry equipment, resulting in a shortage of clean linen for resident care. One of two industrial dryers was non-functional due to a trunnion bearing assembly failure, leading to delays in repairs and communication issues with the vendor. CNAs reported linen shortages and resorted to using the remaining dryer after hours, which was against protocol.
Two residents experienced a deficiency in their shared bathroom, which had a strong odor and improperly sized toilet seat. A CNA used towels to soak up water, concerned for a resident with sight challenges and fall risk. The Maintenance Director was unaware of the issue due to a lack of communication and absence of an electronic work order system, leading to the deficiency.
A resident with hemiplegia and heart failure was unable to reach the call light due to improper implementation of the care plan. Despite being cognitively intact, the resident reported difficulty in accessing the call light, which was observed to be out of reach. The facility's policy mandates that care plans be followed to ensure residents' well-being, which was not done in this instance.
The facility failed to ensure proper food labeling, storage, and sanitation in the kitchen. Observations revealed unlabeled food items, dirty cookware, and improper glove use by staff. Additionally, the facility did not maintain accurate sanitizer logs or calibrate thermometers correctly, leading to multiple deficiencies in food safety and handling practices.
Failure to Reconcile Medications and Follow Physician Orders Resulting in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not accurately reconciling medications, failing to follow up on physician orders for laboratory testing, medical equipment, and outpatient services, and not administering medications as ordered. One resident was readmitted from the hospital with a history of seizures and a G-tube, requiring a specific dose and form of seizure medication. The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of medication. Despite multiple notifications to the physician and pharmacy about the need to change the medication to a solution for G-tube administration, the correct order was not implemented in a timely manner. The resident subsequently experienced multiple seizures, a fall with head trauma, and ultimately died from his injuries. Laboratory orders for seizure medication levels were not completed as ordered, and follow-up on outpatient cardiology appointments and equipment was not performed. Another resident with epilepsy and a feeding tube was readmitted to the facility, but the hospital discharge medication list was not properly reconciled. Several medications, including a seizure medication, were omitted from the facility's orders, and the resident did not receive these medications. The resident experienced seizure-like activity and required transfer to a higher level of care. Staff interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. The facility initiated an investigation after being notified by the resident's family that the resident had not received her seizure medications since her last hospitalization. A third resident with diabetes and epilepsy was not managed according to physician orders for blood sugar testing and insulin administration. An LPN administered large doses of insulin without a physician's order after observing high blood sugar readings, and failed to document the blood sugar readings or notify the physician as required. The resident was subsequently sent to the hospital for hyperglycemia and influenza A. Staff interviews confirmed that the nurse did not follow the prescribed sliding scale insulin orders and acted without proper authorization or documentation.
Failure to Ensure Nursing Staff Competency and Adherence to Physician Orders
Penalty
Summary
Licensed nursing staff failed to demonstrate knowledge and competency in several critical areas of resident care, affecting six out of ten sampled residents. Deficiencies included failure to accurately reconcile medications upon admission, failure to follow up on laboratory orders, administration of medication without a physician's order, failure to report and document gastrostomy tube (G-tube) malfunctions, practicing outside the nursing scope of responsibility, failure to follow physician orders for blood sugar testing, and failure to implement hospice consultation orders. These failures resulted in worsened conditions for residents and created the likelihood of serious injury or death, leading to a determination of Immediate Jeopardy. For one resident with a history of seizures and a G-tube, there were multiple failures in medication reconciliation and laboratory follow-up. Orders for seizure medication levels were entered as completed, but no lab results were found in the medical record. Interviews revealed that nurses lacked access to the lab portal, had not received formal training on the lab process or the admission process, and often relied on informal guidance from coworkers. The DON confirmed that the process for lab follow-up was not followed, and that staff were not supposed to reconcile medications or enter orders without physician communication. Additionally, the emergency drug kit did not contain necessary anti-seizure medications, and some nurses lacked access to the electronic medication dispensing system. In another case, staff failed to report and document a G-tube malfunction for a resident with multiple complex diagnoses. Nurses cut the G-tube without physician orders or documentation, and there was no facility policy on G-tube care. Staff interviews confirmed that cutting the tube was done without proper notification or documentation, and that education on this issue was lacking. In a separate incident, an LPN administered insulin to a resident with diabetes without a physician's order and failed to document blood sugar readings or the amount of insulin given. These actions were only discovered during shift handoff, and the resident required transfer to the emergency room for further care.
Failure to Prevent Significant Medication Errors and Ensure Accurate Medication Reconciliation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the areas of medication reconciliation upon admission and the administration of physician-ordered medications. In one case, a resident with a history of seizures and a gastrostomy tube was readmitted from the hospital with orders for a specific dose and form of seizure medication (Levetiracetam/Keppra). The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of the medication. Documentation showed confusion and delays in changing the medication from tablet to solution for G-tube administration, and there was a lack of clear communication and documentation regarding dose changes. The resident subsequently experienced multiple seizures, a fall with head trauma, and was transferred to a higher level of care, where he later died. Additionally, physician-ordered laboratory tests for seizure medication levels were not implemented as ordered, with no results found in the medical record. Another resident, also with a history of seizures and a feeding tube, was readmitted with hospital discharge orders for multiple medications, including two anti-seizure drugs and other critical medications. The facility failed to obtain and reconcile the correct hospital discharge medication list, resulting in the omission of key medications, including a prescribed seizure medication. The resident did not receive the ordered anti-seizure medication, and there were multiple missed doses of another seizure medication due to unavailability. The resident subsequently experienced seizure-like activity and required transfer to a higher level of care. Interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. A third resident with diabetes and epilepsy was affected by improper medication administration when an LPN administered two large doses of insulin without a physician's order, contrary to the resident's sliding scale insulin protocol, which required physician notification for high blood sugar readings. The nurse did not document the blood sugar readings or the insulin administration and failed to notify the physician as required. The resident was later sent to the hospital for hyperglycemia and influenza A. Interviews confirmed that the nurse acted outside the scope of practice and did not follow established protocols for medication administration and physician notification.
Failure to Implement Effective QAPI Plan for Diabetes Management
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to implement an effective Performance Improvement Plan (PIP) for diabetes management, as evidenced by multiple incidents involving two residents with diabetes. In one case, a resident with Type 2 Diabetes Mellitus, legal blindness, epilepsy, and acute kidney failure was admitted and later discharged to an acute care hospital after experiencing uncontrolled hyperglycemia. Nursing staff failed to follow physician orders for insulin administration, with one LPN administering two separate 20-unit doses of insulin without a physician's order and without documenting the blood sugar readings or the insulin given. The nurse also failed to notify the physician as required when the blood sugar was above the specified threshold, and there was no documentation of these actions in the resident's medical record. Another resident with Type 2 Diabetes Mellitus and other complications had physician orders specifying that the physician should be notified if blood sugar exceeded a certain level. Despite multiple documented instances of blood sugar readings above this threshold, there was no evidence that the physician was notified as ordered. The medication administration records showed repeated high blood sugar readings and insulin administration, but the required notifications to the physician were not documented. The facility's QAPI policy outlines a process for tracking, measuring, and correcting performance issues, including the use of the Plan-Do-Study-Act (PDSA) cycle and regular reporting to the QA&A Compliance Committee. However, the events described demonstrate that the QAPI process was not effectively implemented or monitored in relation to diabetes management, as evidenced by the lack of adherence to physician orders, failure to document critical care actions, and absence of systematic follow-up on identified deficiencies.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to ensure that essential laundry equipment was in safe operating condition, specifically one of the two industrial dryers, which impacted the availability of clean linen for resident care. On the morning of January 14, 2025, a Certified Nursing Assistant (CNA) reported a shortage of linen, stating that she was unable to complete resident care due to the lack of towels, flat sheets, chuck pads, and washcloths. Another CNA confirmed that one of the dryers was not working, leading to competition among staff for available linens. The Laundry Aide confirmed that one of the dryers had been non-functional since the previous month, and the Housekeeping/Laundry Supervisor acknowledged that the dryer had been down for about three weeks, attributing the delay to the need for parts and technician availability. The Maintenance Director stated that the dryer had stopped working some time ago due to a failure in the trunnion bearing assembly, which caused the drum to lock up. Despite placing a service call to the vendor, there was a delay in diagnosing the problem and ordering the necessary parts. The Maintenance Director noted that two technicians visited the facility to diagnose the issue, confirming the initial diagnosis, but there was a lack of communication regarding the ordering of parts. A package containing the part arrived without paperwork, and the Maintenance Director was attempting to arrange for technicians to install the parts. This situation led to CNAs using the remaining functional dryer after hours to meet linen needs, which was against protocol and further slowed laundry production.
Failure to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for two residents, resulting in a deficiency. Observations revealed that the shared bathroom of two residents had a strong ammonia and urine odor, with wet towels placed around the base of the toilet. The toilet seat was improperly sized, being two inches shorter than the commode base. Staff A, a CNA, acknowledged the use of towels to soak up water, expressing concern for Resident #7, who has sight challenges and is at risk for falls. Resident #7, who has a history of hemiplegia, muscle weakness, and blindness, confirmed her ability to use the bathroom independently. Resident #8, who is cognitively intact, reported the persistent odor and expressed discomfort. Interviews with the Housekeeping/Laundry Supervisor and the Maintenance Director revealed lapses in communication and maintenance procedures. The Housekeeping/Laundry Supervisor stated that bathrooms should be cleaned daily and issues reported to the Maintenance Director, who was unaware of the bathroom's condition due to the absence of an electronic work order system. The Maintenance Director confirmed the toilet's instability and the incorrect toilet seat size, acknowledging that he had not been informed of the issue. The lack of communication and proper maintenance reporting contributed to the deficiency, as the Maintenance Director was not aware of the problem and therefore could not address it.
Failure to Implement Care Plan for Resident with Mobility Issues
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, weakness, and heart failure. The resident, who was cognitively intact, reported being unable to move her left arm and reach the call light, which was observed to be out of her reach. Despite the care plan specifying that the call bell should be within reach and that the resident required assistance for bed mobility, these interventions were not properly implemented. During an observation, the call light was found hanging on the left side of the bed, inaccessible to the resident. The Maintenance Director acknowledged the issue and suggested obtaining a clip to position the call light better. The facility's policy requires that each resident receives necessary care and services according to their comprehensive assessment and care plan, which was not adhered to in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food and beverages were labeled and stored correctly, as observed during a kitchen tour. Three containers of red juice in the walk-in cooler were found without labels or dates, and two plates of food covered in plastic wrap were also unlabeled. Additionally, a box of frozen broccoli and a box of frozen pepperoni were found open to the air in the freezer. The Certified Dietary Manager (CDM) acknowledged these issues and stated that staff were expected to label and date all foods and beverages. The facility also did not maintain cleanliness and proper sanitation in the kitchen. A drying rack had an unknown black residue, and a pot and pan on the drying rack were found dirty with a greasy white substance and flaky reddish-brown spots. The three-compartment sink used for washing, rinsing, and sanitizing was not properly logged for sanitizer solution checks, with missing entries for multiple dates. The CDM and Senior Registered Dietitian (Sr RD) confirmed these observations and stated that logs should be filled out. Furthermore, staff did not adhere to proper glove use and thermometer calibration procedures. Staff A used the same gloves for multiple tasks, including handling food, writing in a logbook, and stirring food, without changing them. Additionally, Staff A's method of calibrating a digital thermometer was incorrect, as it involved running it under hot water instead of using an ice bath or boiling water method. Staff B was observed placing lids on bowls without wearing gloves initially. The Sr RD confirmed that gloves should be worn when handling ready-to-eat food and should be changed when soiled or ripped.
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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