Longwood Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Longwood, Florida.
- Location
- 1520 S Grant St, Longwood, Florida 32750
- CMS Provider Number
- 105377
- Inspections on file
- 24
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Longwood Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s scheduled morning medications, including Aspirin, Flomax, Losartan, MiraLAX, and Oxybutynin, were found in a medication cup and a clear plastic cup with liquid left unattended on the bedside table several hours after the documented administration time. The resident, who was alert, reported that the nurse had left these 9:00 AM medications at the bedside. The assigned LPN stated she did not usually leave medications at the bedside but acknowledged leaving the liquid stool softener there, and the MAR showed the medications as given, conflicting with the surveyor’s observation. The DON later confirmed the medications at the bedside were the resident’s scheduled morning doses, contrary to facility policy requiring staff to administer medications, observe consumption, and document refusals.
A resident with severe cognitive impairment and multiple health issues had a Do Not Resuscitate Order (DNRO) signed by his wife, but the facility failed to update the electronic medical record (EMR) to reflect this change. When the resident was found unresponsive, an LPN initiated CPR without verifying the code status, leading to unwanted life-saving measures. The Assistant Director of Nursing (ADON) was responsible for updating the EMR but did not do so, resulting in the resident receiving CPR against his wishes.
A resident with severe cognitive impairment and a documented DNR order was subjected to unwanted CPR due to a failure by nursing staff to verify his code status. The EMR contained conflicting information, listing the resident as Full Code, which led to the initiation of resuscitation efforts contrary to the resident's wishes. The discrepancy arose because the ADON did not update the EMR after a care plan meeting where the DNR was signed. This oversight resulted in the resident being transferred to the hospital and intubated against his wife's wishes.
The facility failed to ensure that licensed nurses had the necessary skills and competencies to provide care and services according to the plans of care for all residents. Issues included improper IV site documentation, medication administration errors, inadequate infection control practices, and failure to follow physician orders. The DON and ADON acknowledged the deficiencies and the lack of regular competency reviews.
The facility failed to ensure care plan meetings were attended by residents and/or their representatives, and the required members of the interdisciplinary team (IDT) for two residents. One resident and his mother were not invited to most care plan meetings, and another resident did not recall receiving invitations. The facility's MDS Coordinator confirmed that care plan meetings were behind schedule and not always attended by the required IDT members.
A resident with multiple diagnoses, including Multiple Sclerosis, did not receive necessary therapy services or adaptive utensils to aid in self-feeding, despite having a care plan in place and concerns raised by the resident's mother. The facility failed to follow its policy requiring referrals to therapy services for residents needing assistance with feeding.
The facility failed to provide adequate ADL care for dependent residents, including shaving and nail care. One resident had dirty, long fingernails for months, another had unkempt facial hair and dirty nails despite expressing a desire for grooming, and a third had excessive facial hair and had not been shaved for three months. Staff acknowledged the issues but did not take appropriate action.
The facility failed to provide proper IV catheter care for two residents. One resident's PICC dressing was not changed for 8 days, and another resident's Midline dressing was not changed for 17 days, contrary to nursing standards and facility policy.
The facility failed to provide timely acquisition and proper administration of physician-ordered medication for three residents. One resident received Midodrine HCl despite high SBP readings, another did not receive prescribed Artificial Tears Ointment, and a third missed doses of Clindamycin Phosphate 1% gel due to insufficient supply and delayed reordering.
A resident with a history of traumatic subdural hemorrhage, seizures, and carpal tunnel syndrome did not receive a prescribed eye ointment for 34 days, despite 13 nurses documenting its administration. The order was never filled by the pharmacy, leading to false documentation and a deficiency in the facility's medical record accuracy.
The facility failed to perform proper hand hygiene and change gloves during wound care for a resident with an infected wound. Additionally, a nurse did not disinfect a glucometer between uses, improperly disposed of a lancet, and did not perform hand hygiene after removing gloves or before preparing medications.
The facility failed to replace a broken bed in a timely manner, causing a resident to sleep in an upright position over the weekend. Additionally, the facility did not maintain cleanliness and proper storage of resident care items in a shared bathroom, leading to concerns about infection control and environmental cleanliness.
A resident who required one-to-one supervision due to multiple falls was left unattended by a CNA, resulting in a fall and minor injury. The incident was not reported immediately as required by facility policy, leading to a delay in addressing the neglect.
A resident with a high risk for falls experienced an unwitnessed fall with minor injury when the assigned CNA left her post before being relieved. Despite being instructed to stay until the end of her shift, the CNA left, resulting in the resident being unsupervised and subsequently falling and injuring her nose. The DON confirmed that the resident was supposed to be under constant supervision due to her impulsive behavior and poor safety awareness.
A facility failed to administer medications as ordered for a resident with multiple health issues, resulting in a 6% medication error rate. The RN omitted scheduled doses of Fluticasone Propionate nasal spray and Spiriva Respimat inhaler, despite the resident's moderate cognitive impairment and questioning about the missing medications. The RN later acknowledged the omission but claimed to have administered the medications later.
An RN left a medication cart unattended with a Gabapentin pill on top, partially covered by a towel, for about 10 to 15 minutes. The Assistant DON confirmed this was against the facility's policy, which requires medications to be secured in locked compartments or under direct observation.
A resident with Multiple Sclerosis and mild protein-calorie malnutrition did not receive meals that met his dietary requirements and preferences. Despite needing finger foods, he often received inappropriate items and was repeatedly served chicken, which he disliked. The facility's staff did not assist him in setting up his meals, and the Certified Dietary Manager acknowledged the errors in meal provision.
The facility failed to ensure that services furnished by an outside agency were properly arranged, as there was no contract or written agreement with the dialysis center for a resident dependent on dialysis. Despite regular communication and nursing assessments, the facility lacked formal documentation of the arrangement.
The facility failed to post required nurse staffing information daily and did not retain the postings for a minimum of 18 months. The nurse staffing information was not updated over the weekend, and the Staffing Coordinator could not provide forms for January 2023. The facility's policy mandates daily posting and 18-month retention, which was not followed.
Unattended Scheduled Medications Left at Bedside
Penalty
Summary
Surveyors identified a deficiency in medication administration when a resident’s physician-ordered 9:00 AM medications were found unattended at the bedside several hours later. At 12:27 PM, a medication cup containing four pills (a yellow tablet, a pink tablet, a white tablet, and a pink and gray capsule) and a six-ounce clear plastic cup with clear liquid and a spoon were observed on the resident’s bedside table next to the lunch tray. The resident, who was alert to person, place, and time, stated these were his 9:00 AM medications and that the clear liquid was his MiraLAX, both of which he reported had been left at the bedside by the nurse. Review of the resident’s physician orders showed scheduled 9:00 AM doses of Aspirin 81 mg, Flomax 0.4 mg, Losartan 25 mg, MiraLAX 17 g, and Oxybutynin 10 mg. The assigned LPN stated she did not know where the medications at the bedside came from and said they were not present when she administered the 9:00 AM medications, although she acknowledged leaving the resident’s 9:00 AM liquid stool softener (MiraLAX) at the bedside in a clear plastic cup. The facility’s MAR documented that the resident’s 9:00 AM medications had been given by the LPN at 9:00 AM, which conflicted with the surveyor’s observation of the medications still present in the cup at 12:27 PM. The DON later confirmed, after speaking with the physician and verifying the medications, that the four pills and the clear liquid were indeed the resident’s scheduled 9:00 AM medications that remained on the bedside table three and a half hours after the scheduled administration time. Facility policy on Medication Administration required that medications be administered by licensed staff as ordered and that staff observe resident consumption of medication and report and document refusals, which did not occur in this instance.
Failure to Honor Advance Directive Leads to Unwanted CPR
Penalty
Summary
The facility failed to honor a resident's advance directive, specifically a Do Not Resuscitate Order (DNRO), resulting in the resident receiving unwanted cardiopulmonary resuscitation (CPR). The incident involved a male resident with severe cognitive impairment and multiple health issues, including dementia and chronic kidney disease. Despite the resident's wife signing a DNRO form, the facility did not update the electronic medical record (EMR) to reflect the change in code status from Full Code to DNR. On the night of the incident, the resident was found unresponsive in his wheelchair. A Licensed Practical Nurse (LPN) initiated CPR without verifying the resident's code status in the EMR or the Code Status Binder. Emergency Medical Services (EMS) continued CPR upon arrival and transported the resident to the hospital, where he was intubated and later passed away after life support was withdrawn at the wife's request. The failure to update the EMR and verify the code status led to the administration of life-saving measures against the resident's explicit wishes. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) was responsible for updating the EMR but failed to do so due to being busy with other tasks. The Director of Nursing (DON) and other staff members were aware of the DNRO but did not ensure the EMR was updated. The incident highlighted a breakdown in communication and procedure adherence, resulting in the resident's advance directive not being honored.
Removal Plan
- A medical record audit was completed for current residents to ensure DNR forms were present in the electronic medical record for residents with DNR orders.
- Current licensed nurses were educated on resident's rights regarding treatment and Advanced Directives by the Director of Nursing/delegate.
- 40 out of 41 total licensed nurses received education; 98% of nurses: 10 out of 41 nurses completed the education, 24% of nurses, an additional 29 of 41 nurses completed their education, 71% of nurses. An additional 1 of 41 nurses completed the education, 2%. 1 remaining licensed nurse to receive education upon return from leave and prior to working next shift.
- New hire nurses at the facility will receive the above education during orientation and prior to working an assignment.
- Current licensed nurses participated in mock code drills: 18 out of 41 total Licensed Nurses participated in mock code drills; 44% of nurses: 11 out of 41 nurses participated in mock code drills, 27% of nurses. 7 out of 41 nurses participated in mock code drills, 17%. 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift.
- New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment.
- Residents and/or responsible parties for current residents residing in facility were interviewed by Social Services/Delegate to validate current physician orders for code status reflect resident and/or responsible party's current wishes for code status. Code status updated, if applicable based on interviews conducted.
- Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting completed with Medical Director, Administrator, and additional Interdisciplinary team (IDT) members on the adherence to CPR policy and policy and procedure for Resident Rights Regarding Treatment and Advance Directives and a review of the root cause analysis was completed.
- As part of the ongoing Quality Assurance Assessment (QAA) process, an ad hoc QAPI was conducted that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on the Advance Directives process, code process and results of audits. No discrepancies or concerns were noted related to Advanced Directive code status standards and guidelines.
Failure to Verify DNR Status Leads to Unwanted CPR
Penalty
Summary
Licensed nurses at the facility failed to adhere to the policy and procedure for Cardiopulmonary Resuscitation (CPR) by not verifying the resuscitation or code status of a resident in an emergency situation. The incident involved a resident who was found unresponsive in his wheelchair at the nurse's station. Without verifying the resident's code status in the medical record, a licensed nurse initiated CPR. This action was contrary to the resident's documented wishes and a physician's order for Do Not Resuscitate (DNR). The resident, an elderly male with severe cognitive impairment and multiple medical conditions, had a documented DNR order signed by his wife and attending physician. Despite this, the electronic medical record (EMR) contained a conflicting physician order indicating Full Code status. The discrepancy arose because the Assistant Director of Nursing (ADON) failed to update the EMR with the correct DNR status after a care plan meeting where the resident's wife signed the DNR order. Consequently, when the resident was found unresponsive, the staff relied on the outdated EMR information, leading to the initiation of unwanted resuscitation efforts. The failure to verify the resident's code status before initiating CPR resulted in the resident undergoing aggressive resuscitation efforts, which were against his and his family's wishes. The incident highlighted a breakdown in communication and procedure adherence among the nursing staff, as multiple staff members assumed the code status had been verified by others. This oversight placed the resident at risk for unwanted medical intervention and prolonged suffering, ultimately leading to his transfer to the hospital where he was intubated against his wife's wishes.
Removal Plan
- Current licensed nurses were educated on facility's CPR policy and on procedure for performing a code to include confirmation of resident code status prior to initiating CPR. Post test and code procedure competencies completed to validate comprehension.
- 39 of 41 total licensed nurses received education; 95% of nurses: 10 out of 41 nurses completed the education, 24% of nurses, an additional 29 of 41 nurses completed their education, 71% of nurses.
- 2 remaining licensed nurse to receive education upon return from leave and prior to working next shift.
- New hire nurses at the facility will receive the above education during orientation and prior to working an assignment.
- Current licensed nurses participated in Mock Code Drills: 18 of 41 total licensed nurses participated in mock code drills; 44% of nurses 11 out of 41 nurses participated in mock code drills, 27% of nurses, 7 out of 41 nurses participated in mock code drills, 17%.
- 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift.
- New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment.
- Ad Hoc QAPI completed with Medical Director, Administrator, Director of Nursing and additional IDT members on the adherence to CPR policy and checking the residents code status prior to initiating CPR.
Nursing Competency Deficiencies
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary skills and competencies to provide care and services according to the plans of care for all residents. During the Recertification survey, it was found that an admission nurse did not identify and document a resident's IV site, and none of the assigned nurses assessed the site or questioned the lack of physician orders. Additionally, another resident's IV dressing was not changed according to physician orders. The Director of Nursing (DON) confirmed that the nurses did not follow the facility's protocols. Furthermore, a nurse left medication unattended on top of the medication cart and did not follow proper infection control practices, such as disposing of a used sharp, performing hand hygiene, and disinfecting a blood glucose meter. The Assistant Director of Nursing (ADON) acknowledged that the nurse had only a brief orientation without competency checks and minimal knowledge of the policies and procedures reviewed with her. The B Wing Unit Manager (UM) confirmed that all nurses assigned to a resident failed to acquire an ordered eye ointment, and 13 nurses inaccurately documented the administration of the medication, which was never in the facility. Additionally, another resident did not receive a prescribed skin ointment for several days because the nurses did not contact the pharmacy for timely delivery. The ADON confirmed that nurses were to administer all medications as ordered by the physician and document administration at the time it occurred. Infection control concerns were also identified during wound care observation, where a nurse did not change her gloves or perform hand hygiene throughout the procedure. The ADON acknowledged that several nurses administered multiple doses of a blood pressure medication outside of the physician-ordered parameter, indicating a lack of careful reading or comprehension of the order. The DON acknowledged that direct care nurses and nursing management failed to identify a resident's declining ability to feed himself and initiate a therapy referral in a timely manner. Concerns related to personal hygiene tasks, including nail care and shaving, were also noted. The ADON, who was also the Staff Development Coordinator, confirmed that the facility did not conduct an annual skills fair or review competencies at regular intervals to ensure all nurses possessed or maintained the necessary skills. The Corporate Director of Education acknowledged that the nursing competency for glucose meter disinfection was incorrect and that the company planned to move towards standardized competencies with a requirement for all nurses to perform return demonstrations. The DON confirmed that there was no evidence of utilizing the Competency Based Orientation packet or preceptor checklists to verify the competencies of newly hired and current staff nurses.
Failure to Ensure Resident and IDT Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure care plan meetings were attended by residents and/or their representatives, and the required members of the interdisciplinary team (IDT) for two residents. Resident #8, a male with multiple diagnoses including Multiple Sclerosis and depression, was admitted in December 2022. Despite his cognitive intactness and expressed preference for family involvement, neither he nor his mother were invited to or attended most care plan meetings. The facility's records showed that out of five scheduled meetings, only one was attended by his mother, and none were attended by a Certified Nursing Assistant (CNA). Additionally, there was no documentation indicating that the resident received invitations or that the meetings were rescheduled when necessary. Resident #24, a female with diagnoses including diffuse large cell lymphoma and stroke, also experienced similar issues. She did not recall receiving invitations to care plan meetings, and her medical record lacked documentation of an Admission care plan meeting. A quarterly meeting was attended by the resident and only two IDT members, missing other essential team members. The facility's MDS Coordinator confirmed that care plan meetings were behind schedule and not always attended by the required IDT members. The Director of Nursing acknowledged that the expectation was for residents and/or their representatives and all required IDT members to participate in care plan meetings. The facility's policy indicated that care plans should be developed and reviewed by an IDT, incorporating the resident's preferences. However, the facility failed to adhere to this policy, resulting in inadequate involvement of residents and their representatives in care planning processes.
Failure to Provide Necessary Therapy and Adaptive Equipment for Self-Feeding
Penalty
Summary
The facility failed to provide timely and appropriate treatment and services to maintain and/or improve the ability to perform activities of daily living (ADLs) related to eating for a resident. The resident, a male with multiple diagnoses including Multiple Sclerosis and muscle weakness, was admitted to the facility and required partial to moderate assistance for eating. Despite having a care plan in place to monitor and refer for therapy if a decline in ADLs was noted, the resident did not receive the necessary therapy services or adaptive utensils to aid in self-feeding. The resident's mother had raised concerns during a care plan meeting, but no follow-up actions were taken by the facility to address these concerns, and the resident did not receive the recommended therapy or adaptive spoon. The facility's policy required referrals to therapy services for residents needing assistance with feeding, but this was not adhered to in the resident's case. The Director of Rehabilitation confirmed that no therapy referral was received after the care plan meeting, and the Director of Nursing acknowledged that the facility should have helped the resident continue feeding himself. The facility's failure to provide the necessary therapy services and adaptive equipment resulted in a deficiency in maintaining the resident's ability to perform ADLs related to eating.
Inadequate ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for dependent residents, specifically related to shaving and nail care. Resident #83, a cognitively intact male with a history of stroke and muscle weakness, had dirty and excessively long fingernails. Despite being dependent on staff for personal hygiene, his nails had not been trimmed or cleaned for two to three months. The Assistant Director of Nursing (ADON) confirmed the resident's nails were dirty and too long, and the resident expressed a desire for nail care that had not been provided. Weekly skin evaluations did not document the condition of his fingernails, and there was only one recorded refusal of a bath in the past 30 days. Resident #77, a male with moderate cognitive impairment and end-stage heart failure, had long, unkempt facial hair and dirty, jagged fingernails. Despite his need for substantial assistance with personal hygiene, he had not been shaved or had his nails trimmed. The resident expressed a desire to be shaved and have a haircut, but these needs were not met. His assigned nurse and CNA acknowledged the resident's poor hygiene but did not take action to address it. The Unit Manager confirmed the resident's ADL care was inadequate and stated that baths and nail care should be provided at least twice weekly. Resident #73, a cognitively intact male with a history of traumatic brain injury and seizures, had excessive facial hair and had not been shaved for approximately three months since transferring to a different unit. The resident expressed a preference for a neatly trimmed goatee and moustache but had not received the necessary grooming. The Unit Manager and Director of Nursing (DON) confirmed that nurses and CNAs were responsible for ensuring residents' personal hygiene and that refusals of care should be documented and reported. The facility's policy required staff to provide ADL care, including bathing and grooming, for residents unable to perform these activities themselves.
Failure to Ensure Proper IV Catheter Care
Penalty
Summary
The facility failed to ensure proper care and services for intravenous (IV) catheters according to standards of practice for two residents. Resident #90 had a peripherally inserted central line catheter (PICC) with a semi-permeable dressing dated 3/31/24. Despite a physician's order to observe the catheter site every shift and change the dressing weekly, the dressing had not been changed for 8 days. The Assistant Director of Nursing stated that PICC dressings were changed on Wednesdays, and since the resident was readmitted on a Friday, the dressing was not due to be changed until the following Wednesday. This practice did not align with the Infusion Nurses Society's guidelines, which specify that transparent semipermeable dressings should be changed every 5-7 days. Additionally, there was an incorrect physician order identifying the type of IV as a Midline instead of a PICC, which could have contributed to the oversight in care. Resident #108 had a Midline IV catheter with a dressing dated 3/22/24. The dressing had not been changed in 17 days, although it should have been changed every 7 days per nursing standards of practice. The assigned LPN confirmed the lack of orders for dressing changes or flushes for the Midline IV since the resident's readmission. The B-wing Unit Manager and the Director of Nursing both acknowledged that the dressing should have been changed weekly. The facility's policy also indicated that PICC and Midline dressings should be changed weekly or more frequently if soiled, but there were no standing orders to address these types of IVs, requiring nurses to contact the physician for specific orders.
Failure to Provide Timely and Proper Medication Administration
Penalty
Summary
The facility failed to provide timely acquisition and proper administration of physician-ordered medication for three residents. Resident #77, who had a physician order for Midodrine HCl to be held if systolic blood pressure (SBP) was greater than 120 mm/Hg, received the medication multiple times despite having SBP readings above the specified limit. This error was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the risk of administering the medication under these conditions. Resident #73 had a physician order for Artificial Tears Ointment to be administered at bedtime for eye irritation. However, the medication was never acquired, and nurses substituted it with a different eye drop without a physician's order. The resident continued to experience symptoms, and the B Wing Unit Manager (UM) confirmed that the facility did not stock the prescribed ointment and that the nurses should have contacted the pharmacy and the physician when the medication was not available. Resident #98 had a physician order for Clindamycin Phosphate 1% gel to be applied three times daily for a rash. The medication was not available over the weekend, and the resident missed several doses. The B Wing UM and other nursing staff confirmed the medication was not reordered in time, and the small tube initially provided was insufficient to cover the treatment period. The Evening Shift Nursing Supervisor noted that the medication was almost empty and not available over the weekend, leading to missed doses documented inaccurately by the nursing staff.
Failure to Administer Prescribed Medication and False Documentation
Penalty
Summary
The facility failed to ensure the medical record accurately reflected the administration of a prescribed eye ointment over a 34-day period for a resident. The resident, a male with a history of traumatic subdural hemorrhage, seizures, and carpal tunnel syndrome, was prescribed Artificial Tears Ointment to be administered at bedtime for eye irritation. Despite the Medication Administration Record (MAR) being initialed by 13 nurses over this period, the resident reported not receiving the medication and continued to experience persistent, itchy, and watery eyes. Upon investigation, it was discovered that the order for the eye ointment was never filled by the pharmacy, and there was no evidence that Central Supply had ordered it. This discrepancy indicated that multiple nurses documented the administration of a medication that was never actually provided to the resident. The Unit Manager (UM) and the Director of Nursing (DON) confirmed the findings, acknowledging the significant issue of false documentation. The facility's policy on medical record documentation emphasized the importance of accurate representation of the resident's experiences and explicitly stated that false information should not be documented. The failure to administer the prescribed medication and the subsequent false documentation by the nursing staff led to the deficiency identified in the report.
Infection Control Deficiencies
Penalty
Summary
The facility failed to perform proper hand hygiene and change gloves during wound care for a resident with an infected wound on the left foot. The wound nurse did not change gloves or perform hand hygiene between removing the dirty dressing and cleaning the wound, which is against the facility's policy and CDC guidelines. The Assistant Director of Nursing (ADON) expressed concern when informed of this break in infection control practices. Additionally, a registered nurse (RN) failed to disinfect a glucometer according to the manufacturer's instructions and facility policy. The RN used the glucometer for multiple residents without cleaning it between uses and disposed of a used lancet improperly by rolling it inside her gloves and placing it in the trash instead of a designated sharps container. The RN also did not perform hand hygiene after removing gloves or before preparing medications. The facility's policies for hand hygiene, glucometer disinfection, and medication administration were not followed, leading to potential cross-contamination and infection risks. The ADON confirmed the expectations for proper infection control practices, including the use of hand sanitizer or washing hands with soap and water after removing gloves and before medication administration.
Failure to Replace Broken Bed and Maintain Cleanliness
Penalty
Summary
The facility failed to replace a broken bed in a timely manner, compromising the comfort and safety of a resident. The resident, who had multiple medical conditions including diffuse large cell lymphoma and stroke, reported that the remote control for her bed stopped working over the weekend, forcing her to sleep in an upright position. Despite the resident's discomfort and the efforts of CNAs to assist her, the bed was not replaced until Monday morning. The Maintenance Director confirmed that no staff contacted him over the weekend, and the Director of Nursing acknowledged that the situation was mishandled, as functional beds were available in the facility. Additionally, the facility failed to maintain cleanliness and proper storage of resident care items in a shared bathroom. Observations revealed that multiple unlabeled and dirty items, including bath basins, a bed pan, and a urinal, were improperly stored in the bathroom. The Evening Shift LPN Nursing Supervisor and the Director of Nursing both confirmed that these items should have been labeled and stored in plastic bags to prevent infection and maintain a clean environment. The facility's policy on maintaining a safe and homelike environment was not followed, leading to concerns about infection control and environmental cleanliness. The facility's policy and procedure for a safe and homelike environment, which includes ensuring sanitary conditions and prompt maintenance, were not adhered to. Staff failed to report the broken bed to maintenance over the weekend and did not properly store or label resident care items in the shared bathroom. These deficiencies highlight lapses in both maintenance and infection control protocols, directly impacting the residents' comfort and safety.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to report an alleged violation of neglect for a resident who was cognitively intact and required one-to-one supervision due to multiple falls. On the night in question, the resident was found walking alone in the hallway with a bloody nose, having fallen because the assigned sitter left before being relieved. The sitter, a CNA, had informed the shift supervisor that she wanted to leave early, but was instructed to stay until the end of her shift. Despite this, the CNA left the resident unattended, leading to the fall and minor injury. The shift supervisor reported the incident to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) the following morning via a messaging service. However, the DON did not receive an audible notification and was unaware of the situation until three days later. The facility's policy requires that allegations or suspicions of neglect be reported immediately and within 24 hours, but this protocol was not followed in this case. The resident's medical record and care plan indicated a high risk for falls, necessitating constant supervision. Despite this, the CNA left her post, and the supervisor did not ensure immediate coverage. The DON acknowledged that the CNA's actions could be considered neglect and that the incident should have been reported promptly. The facility's failure to adhere to its own policies and procedures resulted in a delay in reporting the neglect, which was only addressed after the DON became aware of the situation days later.
Failure to Provide Adequate Supervision Resulting in Resident Fall
Penalty
Summary
The facility failed to provide appropriate supervision to prevent a fall with minor injury for a resident who was at high risk for falls. The resident, who had diagnoses including schizoaffective disorder, anxiety disorder, muscle weakness, lack of coordination, and repeated falls, was supposed to have one-to-one supervision every shift. Despite this, the resident experienced an unwitnessed fall with minor injury when the assigned Certified Nursing Assistant (CNA) left her post before being relieved by another staff member. The CNA had informed the 3 PM to 11 PM Supervisor that she wanted to leave early, but the supervisor instructed her to stay until the end of her shift. The CNA left anyway, resulting in the resident being unsupervised and subsequently falling and injuring her nose. The Director of Nursing (DON) confirmed that the resident was supposed to be under constant supervision due to her impulsive behavior and poor safety awareness. The incident log and medical records revealed that the resident had a history of falls, including a witnessed fall on 2/11/24, a witnessed fall on 3/09/24, and the unwitnessed fall on 4/05/24. The facility's policy on accidents and supervision, revised on 10/18/22, stated that supervision is an intervention to mitigate accident risk and should be based on the individual resident's assessed needs. The DON acknowledged that the one-to-one sitter should not have left the resident unsupervised, as the expectation was for the sitter to remain with the resident until properly relieved by another staff member. This failure to adhere to the supervision policy directly led to the resident's fall and minor injury.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident, resulting in a medication error rate of 6%. Specifically, a registered nurse (RN) omitted the scheduled 9:00 AM doses of Fluticasone Propionate nasal spray and Spiriva Respimat inhaler for a resident with a history of encephalopathy, pulmonary embolism, COPD, and COVID-19. The resident, who had moderate cognitive impairment, questioned the RN about the missing medications, but the RN incorrectly assured him that all medications had been administered. During a medication reconciliation, it was confirmed that the RN did not administer the inhaler and nasal spray as required. The B Wing Unit Manager later discussed the issue with the RN, who acknowledged the omission but claimed to have returned to administer the medications later that morning. The Assistant Director of Nursing expressed confusion over why the RN did not administer all scheduled medications at the bedside, as per the facility's policy and procedure for medication administration, which mandates that medications be administered as ordered by the physician and in accordance with professional standards of practice.
Unsecured Medication on Unattended Cart
Penalty
Summary
The facility failed to keep medication under direct observation when not secured in a locked compartment, as observed on one of the two medication carts on the B Wing. On 4/08/24 at 1:59 PM, an RN left her medication cart unattended at the nurses' station and entered a resident's room to perform a blood glucose check. Upon returning at 2:04 PM, a medication cup containing a Gabapentin pill was found on top of the cart, partially covered by a towel. The RN admitted to pulling the medication earlier in the shift but did not administer it because the resident was not in her room. Instead of securing the pill in the cart's drawer, she left it on top of the cart, unattended for about 10 to 15 minutes. The Assistant Director of Nursing confirmed that it was unacceptable for the RN to leave a pill in a cup on top of an unattended medication cart. The facility's policy, revised on 5/04/22, mandates that all drugs be stored in locked compartments and that medications must be under the direct observation of the person administering them or locked in the medication storage area/cart. The RN's actions were in direct violation of this policy, leaving the medication accessible to anyone in the vicinity of the nurses' station.
Failure to Meet Resident's Dietary Requirements and Preferences
Penalty
Summary
The facility failed to provide meals that met the dietary requirements and preferences of a resident, leading to a deficiency. The resident, a male with Multiple Sclerosis and mild protein-calorie malnutrition, required a regular diet with finger foods. Despite this, he frequently received inappropriate food items such as oatmeal, rice, and corn, which he could not easily pick up with his fingers. Additionally, the resident repeatedly received chicken for both lunch and dinner, which he disliked, and the staff did not assist him in opening containers or setting up his meals, further complicating his ability to eat independently. The resident's care plan included providing and serving the diet as ordered, monitoring meal intake, and having the Registered Dietitian (RD) evaluate and make recommendations as needed. However, the facility did not adhere to these interventions. The resident's mother confirmed that although finger foods were noted on every meal slip, the resident often received inappropriate items. The Certified Dietary Manager (CDM) acknowledged the errors and confirmed that the food provided did not reflect the menu options on the meal slip. Further observations revealed that the resident continued to receive meals that did not meet his preferences or dietary requirements. The CDM admitted that the meal tracking software incorrectly categorized certain foods as finger foods and was unaware that the resident was not consuming the House Shakes provided as supplements. The facility's policy on Resident Food Preferences was not effectively implemented, leading to the resident's nutritional needs not being met adequately.
Lack of Contract for Dialysis Services
Penalty
Summary
The facility failed to ensure that services furnished to a resident by an outside agency were properly arranged. Specifically, the facility did not have a contract or written agreement with the dialysis center to provide hemodialysis services for a resident who depended on dialysis. This deficiency was identified during a review of the care provided to a resident with multiple diagnoses, including chronic kidney disease stage 4 and dependence on dialysis. The resident was observed to have a clean and dry dialysis fistula site and reported attending dialysis sessions regularly. Despite the regular communication between the dialysis center and the facility, and the completion of nursing assessments upon the resident's return from dialysis, the facility was unable to provide documentation of a formal arrangement or contract with the dialysis center. The Director of Nursing confirmed that no such agreement existed, highlighting a lapse in ensuring that necessary services were formally arranged and documented for the resident's care.
Failure to Post and Retain Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information daily and did not retain the postings for a minimum of 18 months. On 4/08/24, the nurse staffing information posted in the lobby was dated 4/04/24, indicating it was not updated over the weekend. The Staffing Coordinator, responsible for creating and posting the nurse staffing form, confirmed she did not work over the weekend and the Weekend Nursing Supervisor was supposed to update the information. Additionally, the Staffing Coordinator could not provide nurse staffing forms for January 2023, as she only assumed her role in October 2023 and was informed of the 18-month retention requirement shortly after. The facility's policy, revised on 11/28/22, mandates daily posting and 18-month retention of nurse staffing information, which was not adhered to in this instance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
