Lilac At Bayview, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Augustine, Florida.
- Location
- 161a Marine Street, Saint Augustine, Florida 32084
- CMS Provider Number
- 105816
- Inspections on file
- 23
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lilac At Bayview, The during CMS and state inspections, most recent first.
A resident was admitted with a PASRR Level I indicating depressive disorder and no need for Level II screening, but later developed additional diagnoses of anxiety disorder, psychosis, and brief psychotic disorder. Despite these new findings and a psychiatry referral, the facility did not update the PASRR or initiate a Level II screening as required by policy.
A resident with a G-tube and severe malnutrition continued to receive enteral feeding past the physician-ordered stop time. Nursing staff acknowledged the feeding should have been stopped earlier, but it remained infusing due to inattention to the schedule. The facility could not provide a policy for following physician's orders when requested.
Two residents at nutritional risk did not receive physician-ordered interventions as required. Orders for daily nutritional supplements and documentation of intake were not followed, and a speech therapy referral for weight management was not completed. Staff confirmed the lack of documentation and absence of a system to flag new orders.
Two residents received intravenous antibiotics several hours later than scheduled, resulting in a medication error rate above 5%. Nursing staff admitted to routinely administering medications late, and management confirmed that facility policy requires administration within one hour of the scheduled time. The late administrations were not accompanied by physician notification, as required by policy.
Surveyors found that medications, including prescription and over-the-counter drugs, were left unsecured at the bedsides of three residents. Residents reported keeping and taking these medications on their own, and staff interviews confirmed that no residents were authorized for self-administration or provided with lock boxes. Facility policy requires all medications to be stored in locked compartments, but this was not followed.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents with indwelling devices and on antibiotics, failing to use required PPE such as gloves and gowns during high-contact care activities like IV medication administration and G-tube management, despite physician orders and facility policy. Nursing staff and leadership confirmed that EBP should have been implemented in these situations.
A facility failed to implement a comprehensive care plan for a cognitively impaired resident, resulting in inadequate monitoring and documentation. The resident, involved in an incident with another cognitively impaired resident, was supposed to be monitored every 15 minutes as per physician's orders. However, staff interviews and observations revealed inconsistencies in performing and documenting these checks, and the Director of Nursing could not provide the necessary records. The deficiency was further highlighted by staff passing the resident's room without conducting the required checks.
A facility failed to implement its QAPI plan effectively, leading to an incident where two cognitively impaired residents were found in a compromising situation. The QAPI committee identified a lack of discussion about intimate relations as a root cause, but this was not addressed in the admissions process. Interviews revealed inconsistencies in handling the situation and oversight in addressing RCA findings.
A resident with moderate cognitive impairment was abruptly discharged from a facility due to smoking policy violations, despite being on 1:1 supervision and demonstrating safe smoking practices. The discharge was executed without adequate notice or involvement of the resident's Power of Attorney, leading to a traumatic transfer 203 miles away. The facility's actions were inconsistent with their discharge planning policy, causing distress to the resident and her family.
A resident with moderate cognitive impairment was abruptly discharged from a facility without proper involvement of her or her POA in the discharge planning process. Despite being issued a 30-day notice for violating smoking rules, the facility initiated an emergency discharge just four days later, moving the resident 203 miles away. The resident and her family were not adequately informed or involved in selecting a post-discharge provider, leading to significant emotional distress.
Failure to Initiate Level II PASRR for Resident with New Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with newly identified or possible serious mental disorders was properly reviewed for a Level II Pre-Admission Screening and Resident Review (PASRR). Record review showed that the resident was admitted with a PASRR Level I from the hospital indicating depressive disorder and no need for Level II screening. However, subsequent documentation at the facility included additional diagnoses of anxiety disorder, psychosis, and brief psychotic disorder. The resident's admission summary also noted a history of depression, dementia, and other medical conditions, and a psychiatry referral was made for evaluation and treatment of depression, anxiety, dementia, and psychosis. Despite these new or newly evident psychiatric diagnoses, the facility did not update the Level I PASRR to reflect the changes or initiate a Level II PASRR screening as required. The Director of Nursing confirmed that there was no documentation indicating that the PASRR had been revised or that a Level II screening had been started. Facility policy requires prompt referral for Level II review when a resident exhibits behavioral, psychiatric, or mood-related symptoms suggesting a mental disorder, but this process was not followed in this case.
Failure to Follow Physician's Orders for Enteral Feeding
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders regarding the administration of enteral feeding for a resident with severe protein-calorie malnutrition, dysphagia, and a gastrostomy tube. The physician's order specified that Jevity 1.5 should be administered via G-tube at 40 ml/hr, starting at 2:00 PM and stopping at 10:00 AM daily, with an autoflush every hour for four hours. However, during an observation at 12:10 PM, the enteral feeding was still infusing, contrary to the order to stop at 10:00 AM. Interviews with nursing staff, including an RN, an LPN/Nurse Manager, and the Director of Nursing, confirmed that the feeding should have been stopped at 10:00 AM as per the physician's order. The RN admitted to not paying attention to the time, resulting in the feeding continuing past the ordered stop time. The facility was unable to provide a policy and procedure for following physician's orders when requested during the survey.
Failure to Implement and Document Physician-Ordered Nutritional Interventions
Penalty
Summary
The facility failed to implement physician-ordered nutritional interventions for two residents identified as being at nutritional risk. For one resident with a history of autoimmune gastritis, dysphagia, and significant weight loss, the care plan included a mechanically altered diet and a physician's order for a daily nutritional supplement with documentation of the amount consumed. However, records did not show that the amount of supplement consumed was documented as ordered. Additionally, a physician's order for a speech therapy consult related to weight management was not carried out, and there was no documentation of a referral or evaluation by speech therapy. Interviews with staff confirmed that the orders were not followed, and there was no system in place to flag new physician orders for follow-up. For another resident at risk for altered nutrition due to psychotropic medication use and recent weight loss, a similar physician's order for a daily nutritional supplement with documentation of intake was not followed. Medication and treatment administration records did not include the required documentation of supplement consumption. Staff interviews confirmed the lack of compliance with the physician's orders for both residents.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.45% during the survey period. Specifically, two residents were observed receiving their prescribed intravenous antibiotics significantly later than scheduled. For one resident, Cefepime HCL was ordered to be administered every 12 hours for a urinary tract infection, with a scheduled dose at 9:00 AM. However, the medication was administered at 11:00 AM, two hours late. The nurse responsible acknowledged routinely administering medications late and incorrectly stated the frequency of administration. Another resident was prescribed Daptomycin to be administered intravenously every 24 hours for bacteremia, scheduled at 8:00 AM. The medication was given at 12:10 PM, four hours late. The nurse again admitted to consistently administering medications late. Interviews with nursing management confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time, and any deviation outside this window is considered late. Review of the facility's policy corroborated this standard, and there was no documentation of physician notification for the late administrations.
Unsecured Medications Found in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage of drugs and biologicals in accordance with professional standards. Unsecured medications were found in the rooms of three residents across two hallways. In one instance, two bottles of medication labeled Prevagen and Cerebral were repeatedly observed at the bedside of a resident, who confirmed he had kept and taken these pills daily for months. In another case, a medication cup containing seven unidentified pills was found on a resident's bedside table; the resident stated these were his morning medications, which he delayed taking until after eating. The LPN and Unit Manager both confirmed that medications, including over-the-counter drugs, are not permitted in resident rooms unless the resident has been assessed for self-administration and provided with a lock box, which was not the case here. Additionally, a medication cup with an unidentifiable pink pill was found unsecured on another resident's bedside table. The resident stated that medications were routinely left at the bedside until food was available. Review of this resident's medical record showed no assessment for self-administration of medication. Interviews with nursing staff and the DON confirmed that no residents were authorized to have medications at bedside and that all medications should be administered under direct observation or stored securely. The facility's own policy requires all medications to be stored in locked compartments and not left unattended, which was not followed in these instances.
Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring staff adhered to Enhanced Barrier Precautions (EBP) for two residents who were at increased risk of infection due to the presence of indwelling medical devices and ongoing antibiotic therapy. For one resident with an indwelling urethral catheter and a diagnosis of infection and inflammatory reaction, staff did not use required personal protective equipment (PPE) such as gloves and gowns while administering and discontinuing intravenous antibiotics and flushing a PICC line, despite clear signage and physician orders for EBP. Similarly, another resident with diagnoses including endocarditis and pneumonia, and who had a G-tube and was receiving intravenous antibiotics, did not receive care in accordance with EBP. The registered nurse failed to use PPE while administering IV medications, flushing the IV, and managing the G-tube, contrary to physician orders and facility policy. Interviews with nursing staff and leadership confirmed that PPE should have been used during these high-contact care activities, and the facility's policy required EBP for residents with indwelling devices or wounds.
Failure to Implement Comprehensive Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan to ensure the medical, physical, and psychosocial needs of a cognitively impaired resident were met, resulting in a deficiency. The incident involved a female resident with severe cognitive impairment who was found in bed with a male resident, also severely cognitively impaired. Both residents were placed on 1:1 supervision following the incident, but the care plan was not updated to reflect the physician's order for every 15-minute monitoring checks. The facility's documentation and monitoring practices were inadequate, as evidenced by the lack of 15-minute monitoring logs for the resident after a certain date. Interviews with staff revealed inconsistencies in the understanding and execution of the monitoring requirements. A Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) both indicated that they were not consistently performing or documenting the required checks, and the Director of Nursing (DON) was unable to produce the necessary documentation when requested. Observations further highlighted the deficiency, as staff were seen passing by the resident's room without conducting the required checks. The room's layout, with a curtain obscuring the view, compounded the issue, as it allowed for the possibility of unmonitored activity. Despite claims from staff that checks were being performed, the lack of documentation and direct observation indicated otherwise, leading to the conclusion that the facility failed to adequately implement the care plan and ensure the resident's safety.
Failure to Implement QAPI Plan and Address Resident Intimacy
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) plan effectively, particularly in using data for Root Cause Analysis (RCA) to prevent future adverse events. This deficiency was highlighted by an incident involving two residents with severe cognitive impairments who were found in a compromising situation. The facility's investigation revealed that the residents were allegedly engaged in sexual intercourse, with one resident having a BIMS score indicating severe cognitive impairment and the other initially assessed as cognitively intact but later found to have severe impairment as well. The incident occurred when a CNA discovered the two residents in bed together, leading to immediate 1:1 supervision for both. Despite the facility's response to the incident, the QAPI committee's RCA identified a lack of discussion about intimate relations as a root cause, which was not addressed in the admissions process. The facility's failure to incorporate this into their QAPI plan and educate residents on intimate relations contributed to the deficiency. Interviews with staff and the Regional Director of Operations (RDO) revealed inconsistencies in the facility's handling of the situation and the QAPI committee's oversight in addressing the RCA findings. The RDO acknowledged the need for resident education on intimate relations but admitted that no changes were made to the admissions process. The facility's policies on abuse prevention and QAPI were not effectively implemented, leading to a failure in preventing and addressing the incident adequately.
Abrupt Discharge Due to Smoking Policy Violation
Penalty
Summary
The facility failed to provide sufficient preparation and orientation for a safe and orderly discharge of a resident, leading to a traumatic and abrupt transfer. The resident, who had a history of non-compliance with the smoking policy, was initially given a 30-day notice for discharge due to smoking violations. However, this notice was rescinded, and the resident was informed of an immediate discharge due to endangering other residents by smoking near a resident on oxygen. Despite being placed on 1:1 supervision and demonstrating safe smoking practices thereafter, the resident was abruptly discharged to a facility 203 miles away, causing distress to both the resident and her family. The resident, who had moderate cognitive impairment and was mostly independent in daily activities, was discharged without adequate notice or involvement in the discharge planning process. The facility's actions were inconsistent with their discharge planning policy, which emphasizes resident participation and preparation for discharge. The resident's son, who was the Power of Attorney, was not adequately informed or involved in the discharge decision, and the resident was transferred without the opportunity to say goodbye to her husband, who was also a resident at the facility. Interviews with the resident, her family, and facility staff revealed a lack of communication and coordination in the discharge process. The facility's administrator and Director of Nursing cited safety concerns as the reason for the immediate discharge, but the resident's family and the Long-Term Care Ombudsman were not adequately informed or consulted. The facility's failure to adhere to its own discharge planning policy and the abrupt nature of the discharge caused significant trauma to the resident and her family.
Failure to Involve Resident and Family in Discharge Planning
Penalty
Summary
The facility failed to involve a resident and her representative in the discharge planning process, leading to an abrupt and traumatic discharge. The resident, who had moderate cognitive impairment and was her own responsible party, was issued a 30-day notice of discharge for violating smoking rules. Despite this, the facility initiated an emergency discharge just four days later, without providing the resident or her Power of Attorney (POA) with adequate information or options for alternative discharge locations. The resident was moved to a facility 203 miles away, causing distress to her and her family. The facility's actions were inconsistent with their discharge planning policy, which emphasizes involving residents and their representatives in selecting post-discharge providers. The resident's son, who was also her POA, was not informed of the discharge until after it had occurred, and the resident was not given the opportunity to say goodbye to her husband. The facility's staff, including the Administrator and Director of Nursing (DON), failed to ensure that the resident's preferences and needs were considered in the discharge process. Interviews with the resident, her husband, and her son revealed that the discharge was handled in a manner that was perceived as abrupt and insensitive. The resident's husband described the experience as traumatic, and the son expressed frustration with the facility's lack of communication and disregard for the family's wishes. The facility's failure to adhere to its own policies and procedures resulted in a deficiency in the discharge planning process, causing significant emotional distress to the resident and her family.
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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