Luxe At Jupiter Rehabilitation Center (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Jupiter, Florida.
- Location
- 674 Pioneer Road, Jupiter, Florida 33458
- CMS Provider Number
- 106148
- Inspections on file
- 22
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Luxe At Jupiter Rehabilitation Center (the) during CMS and state inspections, most recent first.
Two residents were observed smoking outside the main entrance of a non-smoking campus without supervision, indicating a failure to maintain a smoking policy in accordance with NFPA 101 regulations.
The facility failed to treat residents with dignity during ADLs and did not provide timely care upon request. A resident felt uncomfortable with staff speaking foreign languages during care, while another described staff as rough and disrespectful. A resident's wife reported aides refusing to shave her husband, and another resident found it rude when staff did not speak English. Delays in "diaper" changes and lack of hot water were also reported, with a CNA pouring cold water on a resident, causing her to stop breathing momentarily. The DON was informed, and a nurse expressed discomfort with staff communication practices.
The facility failed to provide sufficient hot water to residents, affecting their ability to maintain personal hygiene. Surveyors found water temperatures below the required range, and residents reported ongoing issues with hot water availability. Despite awareness of the problem, the deficiency persisted, impacting residents' comfort and hygiene.
The facility was found to have insufficient nursing staff, leading to delayed care and multiple complaints from residents and staff. Residents experienced long wait times for assistance with ADLs and call light responses, while staff struggled with high resident acuity and inadequate staffing levels. The facility's staffing practices, based on census rather than acuity, contributed to these issues, impacting the quality of care provided.
A long-term care facility failed to provide palatable and appropriately heated meals to residents, affecting their dining experience. Several residents reported receiving cold or tasteless food, with some meals sitting out in the hallway for extended periods. The Registered Dietician acknowledged the issue, attributing it to potential staffing problems and delays in meal delivery.
The facility failed to provide sufficient hot water to residents, affecting their ability to shower and maintain hygiene. Water temperatures were significantly below the required range, and multiple residents reported issues with cold water. Staff and maintenance were aware of the problem, with faulty check valves and a mixing valve identified as contributing factors. Despite attempts to address the issue, the deficiency persisted, causing discomfort for residents.
The facility failed to treat residents with dignity and provide timely care, as evidenced by multiple complaints. A resident felt uncomfortable with staff speaking foreign languages during care, while another described staff as rough and disrespectful. A resident's wife reported aides refusing to shave her husband properly. Other residents experienced delays in receiving assistance, rude behavior, and inadequate care, including a lack of hot water. The DON was informed of these issues during interviews.
The facility failed to provide adequate grooming care, implement a bowel management program, notify physicians as required, and ensure proper supervision and education following incidents. A resident was left with a dreadlock in their hair, another did not receive necessary bowel management, and a third was left unsupervised, resulting in a fall. Additionally, a resident dependent on tube feedings did not receive proper nutritional care.
The facility failed to provide adequate care for several residents, including not administering necessary medications for bowel irregularity, giving medications outside prescribed parameters, and failing to coordinate transportation for a medical appointment. Additionally, a resident's high blood glucose levels were not reported to a physician as required.
A resident at risk due to medication use and decreased endurance was left unsupervised in her room, resulting in a fall. An Activities staff member, unaware of the resident's needs, left her alone without notifying nursing staff. The care plan lacked specific interventions for supervision, and only the involved staff member received education, highlighting a deficiency in staff training and communication.
A resident with severe malnutrition and dependent on tube feeding did not receive the prescribed amount of Jevity due to a failure to follow the physician's order. The resident was supposed to receive 85 ml/hr, but was administered 80 ml/hr, leading to a shortfall. The nurse did not check the updated order and was not informed of the change during the shift report. The resident also had a dry mouth, which was noted but not adequately managed.
A facility failed to ensure timely changes of a mid-line dressing for a resident, leading to a deficiency in fluid administration. The resident's dressing was observed to be loose and not changed as per policy, which requires changes if damp, loosened, or soiled, and at least every seven days. The resident reported having to request changes, and staff interviews revealed a lack of clarity in policy adherence. The resident had an MDRO infection, highlighting the importance of timely dressing changes.
The facility failed to adhere to physician orders for care and suctioning for two residents. One resident lacked a clear order specifying the LPM or device type, leading to discrepancies in administration. Another resident received 4 liters continuously instead of the prescribed 2 liters as needed for exertion. Staff were unaware of these discrepancies, resulting in improper care administration.
A facility failed to properly assess and document the use of side rails for a resident. Despite the admission assessment indicating no need for side rails, the resident's bed had multiple rails installed without physician orders or further assessments. Interviews with staff revealed confusion over responsibility for bed rail assessments, with conflicting statements from the ADON, Rehab Director, and an LPN.
A facility failed to obtain an ordered laboratory result for a medication level for a resident, despite a pharmacist's recommendation and a physician's order. The resident was on a medication requiring careful monitoring due to its impact on chemistry, but the necessary lab result was not found in the resident's record, indicating a lapse in following physician orders and ensuring timely lab services.
The facility failed to honor food preferences for several residents, leading to deficiencies in meeting their nutritional needs. A resident did not receive her preferred chef salad and whole milk consistently, while another was served a regular portion of meat instead of the required double protein portion. Additionally, a resident did not receive her preferred peanut butter and jelly sandwich or dry cereal, and another resident did not receive fortified oatmeal or large meat portions. The facility also failed to provide fortified foods and chocolate milk to a resident as documented. The Certified Dietary Manager and Registered Dietitian acknowledged these discrepancies.
The facility failed to maintain sanitary conditions in food storage and preparation areas, as observed during an inspection. Issues included debris in the microwave, dirty insets, residue on utensil holders, and unlabeled thickened fluids in the fridge. The ice machine had sealant substances and rust, and the nourishment room contained undated and unlabeled food items. Additionally, the kitchen's garbage pail was overflowing during a lunch meal temperature check.
The facility failed to ensure arbitration agreements were properly explained and signed by residents or their representatives. A resident admitted with intact cognition did not recall discussing the agreement due to medication effects, and two other residents confirmed they were not informed or given copies of the agreements. Staff interviews revealed confusion and improper documentation practices regarding arbitration consent.
The facility failed to provide timely assistance with activities of daily living and incontinence care for residents unable to perform these tasks. A resident was found with a wet brief after a four-hour delay in care, while another was unresponsive with soiled clothing and sheets. A third resident reported a four-hour delay in receiving incontinence care from night shift staff.
Two residents in an LTC facility received inadequate wound care, leading to severe deficiencies. One resident was hospitalized with maggots in a pressure wound due to improper management, while another did not receive prescribed treatments for multiple pressure ulcers. The Wound Nurse, lacking prior wound care experience, failed to follow physician orders, contributing to the inadequate care provided.
A resident was found to have live maggots in a wound dressing upon hospital admission, raising concerns about neglect. The facility did not report this as an allegation of neglect, despite policy requirements for immediate reporting of such incidents. The facility conducted an internal review and determined appropriate care was provided, but failed to document the hospital's concerns as a reportable event.
A resident's nebulizer equipment was improperly stored, with a dirty mask found in a grocery store bag. The resident, with a history of COPD, required inhalation treatment for shortness of breath. The staff failed to document changes to the nebulizer tubing and mask, contrary to facility policy.
Two residents with severe cognitive impairments eloped from the facility due to inadequate supervision and ineffective alarm systems. One resident exited through an unlocked front door and was found by police a mile away, while the other exited through a stairwell door and was found at a nearby rehabilitation hospital. Staff failed to respond to alarm systems, and some doors were not properly secured, contributing to the incidents.
A facility failed to provide daily wound care for a resident, leading to complications requiring additional surgery. The resident's surgical wound care was not administered as ordered, resulting in skin flap maceration and bone exposure. Another resident experienced psychological harm due to a delayed response to a dislodged PICC line, with staff failing to document the incident accurately. These deficiencies highlight significant lapses in care and communication within the facility.
A resident experienced psychological harm when her PICC line was dislodged, leading to distress and blood on her clothing and bed. The assigned nurse had left early, leaving another RN to manage the situation, who failed to document the incident. Emergency personnel were called by the resident's family. Staff interviews revealed inconsistencies in handling and documentation, with the ADON documenting the event based on second-hand information.
A resident with cognitive impairment experienced a change in condition, including malaise and poor appetite, leading to a urinalysis that confirmed a UTI. The facility failed to notify the resident's representative about these changes and the subsequent diagnosis. The DON had no response when questioned about the lack of notification.
The facility failed to maintain a safe environment by leaving several Soiled Utility/Holding rooms and a housekeeping area unsecured, with hazardous materials accessible. An emergency exit was found ajar, and oxygen tanks were improperly stored. Additionally, the facility did not provide timely maintenance for resident toilets, with delays in addressing reported issues. Staff interviews revealed a lack of awareness and response to these deficiencies.
A resident's PICC line was dislodged, leading to an incomplete investigation by the facility. The incident involved significant blood loss, and the investigation lacked comprehensive staff interviews and consistent documentation. The RN involved did not document the incident, and staff accounts varied, with a family member calling 911 due to the resident's distress and lack of staff response.
A facility failed to provide sufficient staffing, resulting in delayed care for a resident with a dislodged PICC line. The resident experienced significant distress and bleeding, with no immediate staff response, leading to a family member calling 911. Numerous complaints highlighted ongoing issues with staffing levels and response times, including reports of staff sleeping during night shifts.
Two residents expressed dissatisfaction with meal options due to the facility's failure to accommodate their food preferences. One resident was not informed about available tuna sandwiches, while another did not receive a menu or alternate meal options upon admission. The Kitchen Manager admitted to not obtaining preferences or providing necessary information to the residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents requiring them, as per their infection control policy. Residents with wounds or indwelling devices did not have EBP signage on their doors, and staff did not consistently use gowns during care. Observations and interviews confirmed the lack of adherence to EBP protocols, indicating a deficiency in the facility's infection control program.
A resident reported that a CNA was mean and pulled on her arms during care, causing pain. The grievance was filed the same day but was not reported to the abuse hotline until two days later, violating the facility's policy requiring immediate reporting of abuse allegations.
A resident's urinary catheter was not secured, causing tension on the tubing, and the same water was used for bathing and catheter care, violating infection control practices. The resident also had a small skin injury and a soiled dressing that were not properly addressed.
The clinical staff failed to assess a resident after an injury, did not report all pertinent information to the provider, and did not complete an incident report or investigation. The resident, admitted for rehabilitation and assessed as high risk for falls, sustained a wrist fracture. Despite the resident's report of a fall, the incident was not documented, and no post-fall assessment was completed. Interviews revealed a lack of communication and documentation among staff.
Non-Compliance with Smoking Policy
Penalty
Summary
The facility failed to maintain its smoking policy in accordance with NFPA 101 regulations. On April 7, 2025, at approximately 3:30 PM, two residents were observed smoking just outside the main entrance of the facility. This observation was made despite the facility being designated as a non-smoking campus and lacking a designated smoking area. The residents were found to have personal possession of cigarettes and lighters and were smoking without any supervision from the facility staff. An interview with the Administrator confirmed these findings. The absence of a smoking policy and the lack of supervision for residents who were smoking indicate a failure to comply with the NFPA 101 standards, which require specific provisions for smoking regulations, including the prohibition of smoking in certain areas and the provision of noncombustible ashtrays and metal containers for ash disposal in permitted smoking areas.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The 2 residents observed smoking just outside the main entrance were educated on safe smoking practices, removed from front patio and smoking materials were secured by staff. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Facility audit completed of current residents who smoke to ensure assessments completed and smoking contracts signed acknowledging facility policies and safe smoking practices. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 the facility implemented a smoking policy and a designated smoking area adopting smoking regulations as outlined in K741, for current residents identified as smoking residents; required. Newly admitted residents shall be informed that they will be admitted under the non-smoking campus policy and regulations. On 4.22.25 Administrator completed education with current staff on safe smoking practices, storage of smoking materials and designated smoking area. Newly Hired staff will be educated on safe smoking practices, storage of smoking materials and designated smoking area during new hire orientation by the Assistant Director of Nursing as part of the systematic changes. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Maintenance Director/designee will conduct random audits of the smoking area as well as all areas of the facility premises to ensure compliance with the smoking policy 2 times a week for 4 weeks, every week for a month and then monthly. Findings will be shared with the Quality Assurance and Improvement Committee until committee determines substantial compliance has been met.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity during activities of daily living (ADLs) care and failed to provide care upon request for several residents. Resident #254 reported feeling uncomfortable when staff spoke in foreign languages during care, which she could not understand. Resident #251 described the staff as rough, pushy, and disrespectful, noting that they did not greet him or work well together. Resident #256's wife expressed concerns about the refusal of aides to shave him, despite her providing a razor, and noted that the aide did not perform the task well. Resident #55 found it rude when staff did not speak English while providing care, and Resident #83 reported that staff had a nasty attitude and argued while caring for her. Resident #250 experienced delays in receiving assistance for a "diaper" change, with aides showing an attitude and not responding promptly to her requests. She also mentioned filing a complaint without receiving feedback on the resolution. Resident #23 highlighted issues with the lack of hot water in her bathroom and recounted an incident where a CNA poured cold water on her, causing her to stop breathing momentarily. The Director of Nursing was informed of these concerns, and Staff E, a nurse, expressed discomfort with staff communicating in a foreign language in front of residents. These incidents reflect a pattern of inadequate care and communication, leading to residents feeling disrespected and neglected in their care needs.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 residents #254, 251, 256, 55, 83, and 23 were assessed by licensed nurse, no concerns identified related to alleged deficient practice. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #256 discharged on 4.8.25 and is no longer residing in the facility. Resident #250 discharged on 4.2.25 and is no longer residing in the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 the Director of Social Services completed a quality review of current residents to ensure that residents rights are honored with emphasis treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. Any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.17.25 Ad Hoc Resident council meeting held to review survey results and plans being implemented for correction of alleged deficient deficiencies. On 4.22.25 the Director of Nursing completed education with current staff on the components of F550 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee. Newly hired staff will be educated on the components of F550 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents 2 times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F550 residents' rights are honored with emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Facility Fails to Provide Adequate Hot Water to Residents
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment by not providing sufficient hot water to residents in their rooms and showers. This deficiency affected eight residents, as observed by surveyors who found water temperatures significantly below the required range of 105 to 115 degrees Fahrenheit. The facility's policy titled "Water Temperatures Safety Checks" was not adhered to, as water temperatures were recorded at 80 to 90 degrees Fahrenheit in several rooms. Additionally, the facility's "Loss of Hot Water" policy, which outlines procedures for addressing hot water outages, was not effectively implemented. Residents and staff reported ongoing issues with hot water availability, with some residents unable to shower or perform personal hygiene tasks due to the lack of hot water. Text messages and emails reviewed by the surveyor indicated that the facility was aware of the problem, with reports of a malfunctioning circulation pump and faulty check valves contributing to the issue. Despite these communications, the problem persisted, and residents continued to experience discomfort and inconvenience. Interviews with residents and staff revealed that the hot water issue had been ongoing for weeks, with some residents stating it had been a problem for months. Maintenance staff and external plumbing services were involved in attempts to resolve the issue, but the deficiency remained unaddressed at the time of the survey. The lack of hot water not only affected residents' comfort but also their ability to maintain personal hygiene, as evidenced by multiple resident complaints and observations by the surveyor.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 residents # 29, 27, 13, 302, 68, and 23 were assessed by licensed nurse, no concerns identified related to alleged deficient practice. Resident #303 discharged on 3.18.25 and is no longer residing in the facility. Resident #301 discharged on 4.1.25 and is no longer residing in the facility. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. The Maintenance Director contacted an external plumbing vendor to repair hot water and additional mixing valve ordered as additional precaution; repairs completed on 4.4.25. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 the Director of Social Services/Designee completed a quality review of current residents to ensure safe/clean/comfortable/homelike environment with emphasis ensuring sufficient hot water available to residents in their rooms and showers; no concerns identified. On 4.8.25 the Director of Maintenance completed a quality review of resident rooms and shower rooms to check water temperatures to ensure at appropriate temperature, no concerns identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25 Ad Hoc Resident council meeting held to review survey results and plans being implemented for correction of alleged deficiencies. On 4.22.25 Director of Nursing completed education with current staff on the components of F584 safe/clean/comfortable/homelike environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns by the Assistant Director of Nursing/designee. Newly hired nursing staff will be educated on the components of F584 safe/clean/comfortable/homelike environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Maintenance Director/Designee to conduct random audits of 5 resident times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure sustained compliance with F584 safe/clean/comfortable/homelike environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Insufficient Staffing Leads to Delayed Care and Resident Complaints
Penalty
Summary
The facility was found to have insufficient nursing staff to provide timely and appropriate care to its residents, as evidenced by multiple complaints from residents, family members, and staff. Residents reported issues such as delayed response to call lights, inadequate assistance with activities of daily living (ADLs), and a lack of dignity in care. Specific instances included a resident who was not shaved despite requests, another who was left in a soiled brief for an extended period, and a resident who experienced long wait times for assistance, impacting their ability to engage in desired activities. Staff interviews revealed that the facility's staffing levels were inadequate to meet the needs of residents, particularly those with high acuity levels. Nurses and certified nursing assistants (CNAs) were often responsible for a large number of residents, leading to delays in care and medication administration. The facility's staffing coordinator confirmed that staffing was based on census rather than acuity, which contributed to the challenges faced by staff in providing timely care. The report also highlighted issues with the facility's call system, which was not functioning effectively, further exacerbating the delays in care. Additionally, the facility's staffing practices were criticized for not adequately addressing the needs of residents with high acuity or behavioral issues. The lack of a unit manager on certain floors further compounded the staffing challenges, leaving nurses to manage both care and administrative tasks, which affected the overall quality of care provided to residents.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #75, 83, 23, 251, 254, 10, 29, 50, 68, 45, 27, 256, 62, 11, 46, 73, 55 and 85 were assessed by licensed nurse, no concerns identified. Resident #256 discharged on 4.8.25 and is no longer residing in the facility. Resident #250 discharged on 4.2.25 and is no longer residing in the facility. On 4.7.25 resident #73 discharged and is no longer residing in the facility. On 4.4.25 resident #75, 83, 23, 251, 10, 29, 50, 27, and 85 were provided nutritive, palatable meals, at appropriate temperature per their preference; no concerns identified. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. For resident #62 was completed on 4.9.25; resident #62 discharged on 4.10.25 and is no longer residing in facility. On 4.14.25 facility with external provider for dietary services to include management oversight, line staff and cooks. On 4.8.25 the facility ordered 6 Insulated food delivery carts which were shipped on 4.16.25, and have delivery date of 4.22.25. On 4.4.25 resident #72 was assessed by licensed nurse, provided hygiene assistance with nail care, grooming, shaving and shower; no other concerns identified. (**Need to know when he saw the barber to cut the hair) On 4.7.25 Administrator reviewed last 2 weeks of staffing to ensure appropriate staffing in place per current state/federal regulations; no concerns identified. On 4.14.25 facility with external consulting company for dietary services to include management oversight, line staff and cooks. On 4.8.25 the facility ordered 6 insulated food delivery carts which were shipped on 4.16.25, and have delivery date of 4.22.25. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.7.25 Director of Nursing completed review of 24-hour report, to ensure sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity. On 4.11.25 the Director of Social Services completed a quality review of current residents to ensure that residents rights are honored with emphasis treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/ hygiene at preferred temperatures, and timely response to call lights; any concerns identified were corrected. On 4.9.25 a quality review was completed by Registered Dietician on current residents to ensure provided with nutritive/palatable meal at appropriate temperature per their preference. Any issues identified were corrected. On 4.10.25 Director of Nursing completed an audit review of current residents. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25 Ad Hoc Resident Council meeting held to review survey results and plans being implemented for correction of alleged deficiencies identified. On 4.22.25 the Facility Assessment for The Luxe at Jupiter Rehabilitation Center was reviewed and updated by the Administrator and Facility Leadership team, including Medical Director. On 4.22.25 the Director of Nursing completed education with current staff on the components of F725 sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity by the Director of Nursing/designee. Newly hired staff will be educated on the components of F725 sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F725 sufficient staffing with emphasis on ensuring sufficient staffing to provide timely and appropriate care and services, timely call light response, care, ADL assistance and treating residents with dignity. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Food Temperature and Palatability Issues in LTC Facility
Penalty
Summary
The facility failed to provide food that was palatable and at acceptable temperatures for nine residents, which had the potential to affect 111 out of 112 residents on PO diets. Observations, interviews, and record reviews revealed that several residents consistently received meals that were not hot or palatable. For instance, Resident #23 noted that while the food was good on one occasion, it was usually not hot, and the green beans were often undercooked. Resident #75 complained about meals being served cold and voiced his concerns to staff, while Resident #83 reported that her food was not served hot, even after reheating. Resident #251 expressed dissatisfaction with the taste of the food, describing it as bland and tasteless, and compared it to eating grass. A test tray conducted by surveyors confirmed that the food was warm but lacked seasoning, making it unsatisfactory. Other residents, such as Resident #10, reported that food trays sat out in the hall for too long, resulting in cold meals. Resident #29 also noted that the food was not hot and suspected that the presence of the survey team led to a temporary improvement in food service. The Registered Dietician (RD) acknowledged awareness of the complaints and suggested that the issue might be due to trays sitting in the hallway for extended periods, possibly related to staffing issues. Despite conducting numerous temperature checks in the kitchen, no concerns were identified there, indicating that the problem likely occurred during the delivery process to residents' rooms.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident # 75, 83, 23, 251, 10, 29, 50, 27, and 85 were assessed by licensed nurse, no concerns identified. On 4.4.25 resident # 75, 83, 23, 251, 10, 29, 50, 27, and 85 were provided nutritive, palatable meals, at appropriate temperature per their preference; no concerns identified. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. On 4.14.25 facility with external consulting company for dietary services to include management oversight, line staff and cooks. On 4.8.25 the facility ordered 6 insulated food delivery carts which were shipped on 4.16.25, and have delivery date of 4.22.25. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.9.25 a quality review was completed by Registered Dietician on current residents to ensure provided with nutritive/palatable meal at appropriate temperature per their preference. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25 Ad Hoc Resident Council meeting held to review survey results and plans being implemented for correction of alleged deficiencies identified. On 4.22.25 Dietary manager completed education with current dietary staff on the components of F804 nutritive value/appear/palatable/temperature with emphasis on ensuring residents are provided nutritive/palatable meals at appropriate temperatures per their preference by the Director of Nursing/designee. Newly hired dietary staff will be educated on the components of F804 nutritive value/appear/palatable/temperature with emphasis on ensuring residents are provided nutritive/palatable meals at appropriate temperatures per their preference Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Registered Dietician/Designee to conduct audits of 5 residents meals twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F804 nutritive value/appear/palatable/temperature with emphasis on ensuring residents are provided nutritive/palatable meals at appropriate temperatures per their preference. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Facility Fails to Provide Adequate Hot Water to Residents
Penalty
Summary
The facility failed to ensure sufficient hot water was available to residents in their rooms and showers, affecting 8 out of 34 sampled residents. The deficiency was identified through observations, record reviews, and interviews. The facility's policy titled "Water Temperatures Safety Checks" requires water temperatures to be maintained between 105 and 115 degrees Fahrenheit, but several rooms had water temperatures significantly below this range, with readings as low as 80 degrees. The facility's policy for "Loss of Hot Water" outlines procedures for addressing hot water issues, but these were not effectively implemented. Multiple residents reported issues with the lack of hot water, impacting their ability to shower and maintain personal hygiene. For instance, one resident stated that the water was too cold to shower or shave, while another resident mentioned that the water had been an issue for at least two months. Staff interviews corroborated these complaints, with some staff members acknowledging the problem and others being evasive about the duration and extent of the issue. The maintenance director and plumbing company were aware of the problem, with the plumbing company identifying faulty check valves and a mixing valve that needed replacement. The deficiency was further evidenced by a resident council grievance and various communications between staff members, including texts and emails discussing the ongoing hot water issues. Despite attempts to address the problem, such as replacing check valves and ordering a new circulation pump, the facility failed to resolve the issue promptly, resulting in continued discomfort and inconvenience for the residents. The lack of hot water persisted for an extended period, with some residents reporting the issue had been ongoing for weeks or even months.
Plan Of Correction
of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 residents # 29, 27, 13, 302, 68, and 23 were assessed by licensed nurse, no concerns identified related to alleged deficient practice. Resident #303 discharged on 3.18.25 and is no longer residing in the facility. Resident #301 discharged on 4.1.25 and is no longer residing in the facility. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. The Maintenance Director contacted an external plumbing vendor to repair hot water and additional mixing valve ordered as additional precaution; repairs completed on 4.4.25. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 4.17.25 Ad Hoc Resident council meeting held to review survey results and plans being implemented for correction of alleged deficient deficiencies. On 4.11.25 the Director of Social Services/Designee completed a quality review of current residents to ensure physical environment with emphasis ensuring sufficient hot water available to residents in their rooms and showers: no concerns identified. On 4.8.25 the Director of Maintenance completed a quality review of resident rooms and shower rooms to check water temperatures to ensure at appropriate temperature, no concerns identified. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 Director of Nursing completed education with current staff on the components of N111 physical environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns by the Assistant Director of Nursing/designee. Newly hired nursing staff will be educated on the components of N111 physical environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Maintenance Director/Designee to conduct random audits of 5 resident times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure sustained compliance with N111 physical environment with emphasis on ensuring sufficient hot water available to residents in their rooms and showers and how to utilize the facilities electronic work order system for reporting environmental concerns. The findings of these quality monitoring to be reported to the Quality Assurance/Performance improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Ensure Dignity and Timely Care for Residents
Penalty
Summary
The facility failed to ensure residents were treated with dignity during activities of daily living (ADLs) care and failed to provide care upon request for several residents. Resident #254 reported feeling uncomfortable when staff spoke in foreign languages during care, which she did not understand. Resident #251 described the staff as rough, pushy, and disrespectful, noting that they did not greet him or work well together. Resident #256's wife expressed concerns about the refusal of aides to shave him, despite her providing a razor, and noted that the aides did not perform the task well. Resident #55 found it rude when staff did not speak English while providing care, and Resident #83 reported that staff had a nasty attitude and argued while caring for her. Resident #250 experienced delays in receiving assistance for a diaper change, with aides showing an attitude and not responding promptly to her requests. She also mentioned filing a complaint without receiving a resolution. Resident #23 reported inadequate care, including an incident where a CNA poured cold water on her, causing her to stop breathing momentarily. The surveyor confirmed the lack of hot water in her bathroom. The Director of Nursing was informed of these concerns during interviews, where the issues raised by residents and their families were discussed. The report highlights multiple instances where the facility did not meet the required standards for treating residents with dignity and providing timely care, as evidenced by the residents' testimonies and the surveyor's observations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 residents #254, 251, 256, 55, 83, and 23 were assessed by licensed nurse, no concerns identified related to alleged deficient practice. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #256 discharged on 4.8.25 and is no longer residing in the facility. Resident #250 discharged on 4.2.25 and is no longer residing in the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 the Director of Social Services completed a quality review of current residents to ensure that residents' rights are honored with emphasis treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. Any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25, an Ad Hoc Resident council meeting was held to review survey results and plans being implemented for correction of alleged deficient deficiencies. On 4.22.25, the Director of Nursing completed education with current staff on the components of N203 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee. Newly hired staff will be educated on the components of N203 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents 2 times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with N203 residents' rights are honored with emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide adequate grooming care for a resident, as evidenced by the presence of a dreadlock in the resident's hair. The resident expressed that grooming services should be part of the care provided, indicating a lack of attention to personal hygiene needs. Additionally, the facility did not implement a bowel management program for another resident, who was at risk for constipation due to decreased mobility and medication side effects. Despite having physician orders for routine and as-needed medications, there was no documentation of bowel movements or administration of as-needed medications over several days. Another deficiency involved the failure to notify a physician about a resident's condition as per the order. The Director of Nursing acknowledged the absence of documentation regarding physician notification. Furthermore, the facility did not ensure proper supervision and education following an incident where a resident was left alone in her room, leading to a fall. The care plan lacked interventions to prevent such incidents, and education was only provided to the staff member directly involved, rather than all staff. The facility also failed to follow physician orders for feeding a resident who was dependent on tube feedings for nutrition and hydration. The resident had severe weight loss and was receiving a significant portion of her daily caloric and fluid intake through tube feedings. The care plan for nutrition was not adequately addressing the resident's needs, contributing to the deficiency in care provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #72 was assessed by licensed nurse, provided hygiene assistance with nail care, grooming, shaving and shower; no other concerns identified. To ensure parameters in place per physician orders and follow up scheduled as indicated. Any issues identified were corrected. On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents who sustained a within the last 30 days to ensure follow up documentation in place, care plan updated, and staff education completed. Any concerns identified were corrected. On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents receiving nutrition to ensure appropriate formula in place and rate reflective of physician orders. Any issues identified were corrected. On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents with sites in place to ensure in place, changed timely and physician orders for monitoring being followed. Any issues identified were corrected. On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents with in place to ensure physician orders being followed and is administered properly. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur? On 4.22.25 Director of Nursing completed education with current staff on the components of N201 right to adequate and appropriate health care with emphasis on providing hygiene/grooming/nail care/showers per resident preference by the Assistant Director of Nursing/designee. Newly hired nursing staff will be educated on the components of N201 right to adequate and appropriate health care with emphasis on providing hygiene/grooming/nail care/showers per resident preference by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. On 4.22.25 Director of Nursing completed education with current staff on the components of N201 right to adequate and appropriate health care with an emphasis on monitoring, parameters, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Director of Nursing/Designee. Newly hired licensed nursing staff will be educated on the components of N201 right to adequate and appropriate health care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Assistant Director of Nursing/designee.
Multiple Care Deficiencies in Resident Management
Penalty
Summary
The facility failed to provide adequate care and services for several residents, as evidenced by multiple deficiencies. Resident #44 did not receive necessary interventions for bowel irregularity, despite being at risk due to decreased mobility and medication side effects. The resident's care plan required administration of medications as needed, but records showed no documentation of bowel movements or administration of as-needed medications over several days. Interviews with the resident and staff confirmed the lack of appropriate care. Resident #10 and Resident #23 both received medications outside of the prescribed parameters. Resident #10 was given a medication despite a blood pressure reading that should have contraindicated its administration. Similarly, Resident #23 received medication for hypertension even when blood pressure readings were below the threshold set by the physician's orders. These actions were acknowledged by staff during interviews, indicating a failure to adhere to physician directives. Resident #62 experienced a failure in coordination for a scheduled medical appointment, resulting in missed transportation to a urologist. Despite having an appointment scheduled for over a month, the resident was not taken to the appointment due to a lack of communication and proper documentation. Additionally, Resident #303's records showed that the facility failed to notify a physician when blood glucose levels exceeded the threshold, as required by the physician's orders. The DON confirmed the absence of documentation regarding physician notification, highlighting a lapse in following medical orders.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #44, 10, 23, and 62 were assessed by licensed nurse, no concerns identified. Resident #44 had movement on 4.7.25, no regimen required. On 4.16.25 physician reviewed medication regimen for resident #10, determined to be stable and hold parameters removed from hypertensive medication. On 4.9.25 physician reviewed medication regimen for resident #23, determined to be stable and hold parameters removed from hypertensive medication. For resident #62 was completed on 4.9.25; resident #62 discharged on 4.10.25 and is no longer residing in facility. Resident #303 was discharged on 3.18.25 and is no longer residing in facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.22.25 a quality review was completed by Director of Nursing on current residents for parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 Director of Nursing completed education with current staff on the components of F684 Quality of care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Director of Nursing/Designee. Newly hired licensed nursing staff will be educated on the components of F684 Quality of care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Assistant Director of Nursing/Designee, at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F684 Quality of care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Inadequate Supervision and Staff Training Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and staff training for a resident, identified as Resident #19, who was at risk due to the use of medications, decreased endurance, and a history of falls. The resident was found lying on the floor in her room, indicating a lack of supervision. The incident occurred after a staff member from the Activities department, who was not aware of the resident's specific needs, left her alone in her room without notifying the nursing staff. The resident's care plan did not include interventions to ensure she was always with staff while in her wheelchair, nor did it provide guidance for all facility staff to communicate with nursing staff when the resident was returned to her room. The facility's investigation revealed that only the Activity Assistant involved in the incident received education, rather than all staff. The Activities Director admitted uncertainty about how staff should know which residents need to be brought to the nursing station instead of their rooms, suggesting a lack of clear policy or training. The care plan lacked specific interventions related to the resident's need for supervision, contributing to the incident where the resident was left unsupervised, leading to her fall.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #19 was assessed by licensed nurse, no concerns identified. On 4.4.25 staff activities aid G was educated by the Assistant Director of Nursing on prevention and safety, and on specifics of resident #19 plan of care. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents who sustained a within the last 30 days to ensure follow up documentation in place, care plan updated, and staff education completed. Any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 Director of Nursing completed education with current nursing/activities staff on the components of F689 free from hazards/accidents/supervision with emphasis on ensuring staff education completed and follow up documentation in place for by the Director of Nursing/Designee. Newly hired nursing/activities staff will be educated on the components of F689 free from hazards/accidents/supervision with emphasis on ensuring staff education completed and follow up documentation in place for by the Assistant Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents who sustained a twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F689 free from hazards/accidents/supervision with emphasis on ensuring staff education completed and follow up documentation in place for. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Follow Physician's Feeding Order
Penalty
Summary
The facility failed to follow the physician's order for the administration of feeding for a resident who was dependent on tube feeding for nutrition and hydration. The resident, who had severe malnutrition and a history of weight loss, was supposed to receive a continuous feeding of Jevity 1.5 at 85 milliliters per hour for 12 hours daily, along with a bolus feeding of 237 milliliters at 5:00 PM. However, observations revealed that the resident was receiving the continuous feeding at a rate of 80 milliliters per hour, resulting in a significant shortfall in the total volume of Jevity administered. This discrepancy was due to the nurse on duty not checking the updated order and not being informed of the change during the shift report. The resident's care plan indicated a risk for malnutrition due to inadequate oral intake, and the resident often refused the bolus feedings. The Registered Dietitian had recommended increasing the rate of Jevity to compensate for the resident's poor oral intake and difficulty swallowing. Despite these recommendations, the facility did not ensure the correct administration of the feeding order, as evidenced by the nurse's failure to verify the updated order and the lack of communication during shift changes. Observations also noted the resident's dry mouth, which was acknowledged by staff but not adequately addressed in terms of hydration management.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #31 was assessed by licensed nurse, no concerns identified. On 4.4.25 staff C nurse was provided 1:1 education by Assistant Director of Nursing on following physician orders for the administration of feeding. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents receiving nutrition to ensure appropriate formula in place and rate reflective of physician orders. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 education completed with current licensed nursing staff on the components of F693 management with an emphasis on ensuring accurate formula administered at rate per physician orders by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F693 management with an emphasis on ensuring accurate formula administered at rate per physician orders by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with nutrition twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure accurate formula administered at rate per physician orders. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Timely Change Mid-line Dressing
Penalty
Summary
The facility failed to ensure timely changes of a mid-line dressing for a resident, leading to a deficiency in the administration of fluids as per professional standards and physician orders. The policy review indicated that changes should occur if the dressing becomes damp, loosened, or visibly soiled, and at least every seven days. However, the resident's mid-line dressing was observed to be loose around the perimeter and dated, indicating it was not changed in a timely manner. The resident expressed dissatisfaction, stating that they had to request changes and that staff were reluctant to perform the task. Interviews with staff revealed a lack of clarity and adherence to the policy regarding mid-line dressing changes. A Licensed Practical Nurse (LPN) acknowledged the delay in changing the dressing and noted that the task should appear on the computer system as a reminder. However, the LPN was unable to locate the specific order for the mid-line change in the system. This oversight contributed to the deficiency, as the resident had a multi-drug resistant organism (MDRO) infection, necessitating strict adherence to infection control protocols.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.1.25 resident #29 was assessed by licensed nurse, no concerns identified. On 4.1.25 the site was changed for resident #29 by LPN staff L.. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents in with sites in place to ensure place, changed timely and physician orders for monitoring being followed. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 Director of Nursing completed education with current licensed nursing staff on the components of F694 nutrition/ fluids with emphasis on ensuring in place, changed timely and monitoring per physician orders by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F694 nutrition/ fluids with emphasis on ensuring in place and monitoring per physician orders by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with sites twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure in place, changed timely and monitored per physician orders. The findings of these quality monitoring...s to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Adhere to Physician Orders for Care and Suctioning
Penalty
Summary
The facility failed to properly administer care and suctioning for two residents, as evidenced by the lack of proper physician orders and adherence to prescribed orders. For one resident, the facility did not have a clear physician order specifying the liters per minute (LPM) or the type of device to be used for continuous care. Observations revealed that the resident's device was set at 4.5 LPM, while the resident mentioned using 4 LPM at home and 5 LPM at the facility due to increased activity. The Unit Manager was unaware of the missing details in the order and only realized the discrepancy upon review. For another resident, the facility failed to follow the prescribed physician order for care, which was set at 2 liters via as needed for exertion. Observations showed the resident receiving 4 liters continuously, contrary to the order. A Licensed Practical Nurse confirmed the order was for 2 liters but did not ensure compliance, as the resident was observed receiving 4 liters during multiple checks. These deficiencies highlight a lack of adherence to physician orders and proper administration of care and suctioning for the residents involved.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.2.25 resident #54 and #302 were assessed by licensed nurse, no concerns identified. On 4.2.25 physician orders reviewed for resident #354 and #302 to ensure administered per physician orders and monitoring in place, any concern identified were corrected. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents with in place to ensure physician orders being followed and is administered properly. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 Director of Nursing completed education with current licensed nursing staff on the components of F695 / suctioning with emphasis on residents with in place to ensure physician orders being followed and is administered properly by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F695 / suctioning with emphasis on residents with in place to ensure physician orders being followed and is administered properly by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure in place to ensure physician orders being followed and is administered properly. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of side rails for a resident. Observations revealed that the resident's bed had two metal side rails on the right side and one on the left, despite the admission assessment indicating that side rails were not needed. There were no physician orders or further assessments documented to justify the use of side rails for this resident. Interviews with facility staff, including the ADON, Rehab Director, and an LPN, revealed confusion and inconsistency regarding who is responsible for conducting bed rail assessments. The ADON stated that 'Rehab' is responsible, while the Rehab Director indicated that 'Nursing' handles the assessments. The LPN mentioned that both Nursing and Rehab conduct the assessments, but acknowledged the lack of an order for bed rails and the admission assessment's indication that side rails were unnecessary.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.7.25 resident #302 was assessed by licensed nurse for use of bed rails and consent was obtained for use; no concerns identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A facility quality review was completed on 4.22.25 by Director of Nursing on current residents for use of bed rails to ensure appropriate physician order in place for mobility to reflect current status. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 Director of Nursing completed education with current nursing staff and staff on the components of F700 bed rails with emphasis on ensuring assessment in place and reflective of resident current status for use of bed rails for mobility by the Director of Nursing/designee. Newly hired nursing staff and staff will be educated on the components of F700 bed rails with emphasis on ensuring assessment in place and reflective of resident current status for use of bed rails for mobility by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F700 with emphasis on ensuring assessment in place and reflective of resident current status for use of bed rails for mobility. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee.
Failure to Obtain Ordered Laboratory Result for Medication Level
Penalty
Summary
The facility failed to obtain an ordered laboratory result for a medication level for one resident, identified as Resident #61. The facility's policy requires that physician orders be followed as prescribed, and any deviations should be recorded in the resident's medical record with the physician and responsible party notified if indicated. Resident #61 was admitted with multiple diagnoses and was prescribed a medication that required monitoring of its levels due to its significant impact on chemistry. The pharmacist consultant, who reviews medications monthly, recommended that the physician order a level for the medication, but the level was not found in the resident's record. The deficiency was identified when the pharmacist, during a review, noted the absence of the medication level in the chart, and the physician subsequently ordered it to be collected. However, the laboratory result for the medication level was not located in the resident's record. This issue was discussed with the Assistant Director of Nursing and the Administrator, highlighting the facility's failure to ensure the timely and accurate acquisition of necessary laboratory results, which is crucial for the safe administration of the medication.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.3.25 resident #61 was assessed by licensed nurse, no concerns identified. On 4.18.25 physician orders reviewed for resident #61-labs/ level completed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: On 4.16.25 a quality review was completed by the Director of Nursing on current residents with lab recommendations ordered per pharmacy recommendations in the last 3 months to ensure reviewed/follow up documentation in place. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 Director of Nursing completed education with current licensed nursing staff on the components of F770 lab services with emphasis on ensuring labs completed per physician orders with follow up reviewed and documentation in place by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F770 lab services with emphasis on ensuring labs completed per physician orders with follow up reviewed and documentation in place by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F770 lab services with emphasis on ensuring labs completed per physician orders with follow up reviewed and documentation in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for five residents, leading to deficiencies in meeting their nutritional needs. Resident #27 expressed dissatisfaction with not receiving her preferred chef salad on scheduled days and noted issues with the oatmeal's texture and receiving coffee instead of her preferred hot tea. Despite her requests, the facility did not consistently provide her with whole milk at every meal. Photographic evidence confirmed the absence of the chef salad on a scheduled day, and the Certified Dietary Manager acknowledged the oversight. Resident #29, who required a double protein portion due to his size, was served a regular portion of meat, contrary to his meal ticket. He expressed the need to supplement his intake with additional food due to the insufficient portion size. Similarly, Resident #44 did not receive her preferred peanut butter and jelly sandwich or dry cereal, as documented on her breakfast ticket. The resident expressed enjoyment of a specific brand of sandwich that was no longer provided, and photographic evidence supported the absence of these items. Resident #50, who was supposed to receive large portions and fortified foods, did not receive fortified oatmeal and was served a regular-sized portion of meat. His wife confirmed his dislike for oatmeal, and the resident expressed willingness to eat more meat if provided. Resident #85, who was on fortified foods and chocolate milk, reported inconsistencies in receiving these items. Observations confirmed the absence of milk and fortified foods, and the resident expressed resignation to the situation. The Certified Dietary Manager and Registered Dietitian acknowledged the discrepancies when shown photographic evidence.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #27, 29, 44, 50, and 85 were assessed by licensed nurse, no concerns identified. On 4.4.25 resident #27, 29, 44, 50, and 85 were provided meals per their preference and meal ticket; no concerns identified. Resident #27 discharged on 4.14.25 and is no longer residing in the facility. On 4.14.25 facility with external consulting company for dietary services to include management oversight, line staff and cooks. Same practice and what corrective actions will be taken: On 4.9.25 a quality review was completed by Registered Dietician/designee on current residents to ensure food preferences in place, accurately reflected on meal tray tickets and resident provided with correct meal per menu. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.17.25 Ad Hoc Resident Council meeting held to review survey results and plans being implemented for correction of alleged deficiencies identified. On 4.22.25 Dietary Manager completed education with dietary staff and nursing staff on the components of F803 menus meet resident needs/prep in adv/followed with emphasis on ensuring food preferences are in place per resident preferences and reflected on meal tray ticket by the Director of Nursing/designee. Newly hired dietary and nursing staff will be educated on the components of F803 menus meet resident needs/prep in adv/followed with emphasis on ensuring food preferences are in place per resident preferences and reflected on meal tray ticket by Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Registered Dietician/Designee to conduct audits of 5 residents meals twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F803 menus meet resident needs/prep in adv/followed with emphasis on ensuring food preferences are in place per resident preferences and reflected on meal tray ticket. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in unsanitary conditions and potential foodborne illness risks. During an inspection of the main kitchen, several issues were identified, including a microwave with debris, dirty recessed circular insets, and residue on utensil holders. The ovens had black and brown residue with a pool of brown fluid on the floor. The reach-in fridge contained unlabeled thickened fluids, and the ice machine had a thick white and blue substance on the hinges. Additionally, metal shelves storing plastic cups and bowls were dirty, and the floor beneath them was littered with debris. In the nourishment room, an opened bottle of Jevity 1.5 was found with splattered liquid and no date of opening. Unlabeled items, such as a Styrofoam cup and a McDonald's coffee cup, were found in the refrigerator. A cottage cheese container and a brown paper bag of food were also undated. The facility's policy stated that food and beverages without a name or date should be discarded. Furthermore, during a lunch meal temperature check, the kitchen's garbage pail was overflowing, and the ice machine was found to have a crack with rust and sealant substances. These observations indicate a failure to maintain sanitary conditions in food storage and preparation areas.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3.31.25 the Dietary Manager cleaned the Amanda Microwave and removed the light and dark brown debris from all sides of the interior of the microwave. On 3.31.25 the Dietary manager cleaned the 2 recessed circular inserts to the right of the coffee station, removed the brown liquid from the bottom, and removed the brown residue and black powdery residue from the top of the utensil holder. On 3.31.25 the Dietary Manager cleaned the 2 Garland double-door ovens, removed the black and brown residue from the exterior of the front of the ovens, removed the pool of brown fluid from the lower bottom right corner of the oven and cleaned the brown liquid dripping from the pool of liquid that dripped on the floor. On 3.31.25 the Dietary manager removed the 3 unlabeled plastic cups with liquid in them from the reach-in Delfield fridge. On 3.31.25 the Manitowoc ice machine was cleaned by Maintenance Director and the white and blue substance from the hinges directly above the ice were removed. On 3.31.25 the Dietary manager cleaned the bottom shelf of the rack of metal shelves that stored small plastic cups, bowls, and glasses stored and removed the tan, yellow and brown residue. On 3.31.25 the Dietary Manager cleaned the floor under the metal shelves and removed the plastic cup, round foil cover, paper and food. On 3.31.25 the opened feed formula, the small Styrofoam cup, Daisy Cottage cheese, brown paper bag of food and orange disposable coffee cup were removed from the first floor nourishment room and discarded by the Unit Manager. On 4.2.25 the dietary manager removed the overflowed garbage pail from the kitchen and disposed of it properly. (2) What residents have the potential to be affected by the same practice and what corrective actions will be taken; On 4.16.25 a Kitchen Sanitation audit was completed by the Dietary manager, no concerns identified. On 4.22.25 a quality review was completed by Dietary Manager to ensure food is stored, prepared, distributed and served in accordance with professional standards for food safety, sanitary conditions and prevention of foodborne illnesses. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 the Dietary manager completed education with dietary staff on the components of F812 Food Procurement/Store/Prepare/Serve/Sanitary with emphasis on ensuring food is stored, prepared, distributed and served in accordance with professional standards for food safety, sanitary conditions and prevention of foodborne illnesses by the Director of Nursing/designee. Newly hired dietary and nursing staff will be educated on the components of F812 Food Procurement/Store/Prepare/Serve/Sanitary with emphasis on ensuring food is stored, prepared, distributed and served in accordance with professional standards for food safety, sanitary conditions and prevention of foodborne illnesses by Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Registered Dietician/Designee to conduct audits of kitchen and nourishment room twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F812 Food Procurement/Store/Prepare/Serve/Sanitary with emphasis on ensuring food is stored, prepared, distributed and served in accordance with professional standards for food safety, sanitary conditions and prevention of foodborne illnesses. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Properly Execute Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were properly explained to residents or their representatives in a manner they could understand, as required by federal regulations. Specifically, the facility did not obtain signatures from residents or their representatives acknowledging their understanding and agreement to the arbitration terms. This deficiency was identified during a survey where three residents were reviewed for arbitration agreements. Resident #87, who was admitted to the facility with intact cognition, did not have a signature on the arbitration agreement, although an electronic signature by a staff representative was present. During an interview, the resident stated that he was unable to recall any discussion about the arbitration agreement due to being heavily medicated upon admission. Similarly, Resident #306 and his wife both confirmed that no one explained the arbitration agreement to them, and the resident did not sign the document or receive a copy of it. Resident #307's records also lacked the necessary signatures from either the resident or their representative. Interviews with facility staff revealed confusion and miscommunication regarding the process of obtaining and documenting consent for arbitration agreements. The Admissions Director and the Concierge provided conflicting information about the list of residents who had signed the agreements, and the Concierge admitted to using a tablet to document refusals without obtaining actual signatures from residents or their representatives.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #87 discharged on 4.5.25 and is no longer residing in the facility. On 4.9.25 the arbitration agreement was reviewed and completed for resident #306 with resident signature confirming understanding. On 4.9.25 the arbitration agreement was reviewed and completed for resident #307 with resident signature confirming understanding. Resident #307 discharged on 4.14.25 and is no longer residing in the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.9.25 the Vice President of Business Development completed a quality review of current residents to ensure arbitration agreement reviewed with resident/responsible party and documentation of comprehension of agreement in place; any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.4.25 the Vice President of Business Development completed education with current admissions staff on the components of F847 arbitration agreement with emphasis on arbitration agreement reviewed/signed with resident/responsible party and documentation of comprehension of agreement. Newly hired admissions staff will be educated on the components of F847 arbitration agreement with emphasis on arbitration agreement reviewed/signed with resident/responsible party and documentation of comprehension of agreement in place by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Administrator/Designee to conduct random audits of 5 newly admitted residents 2 times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F847 arbitration agreement with emphasis on arbitration agreement reviewed/signed with resident/responsible party and documentation of comprehension of agreement in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide timely care and assistance for activities of daily living to residents who are unable to perform these tasks themselves. Resident #5, who is dependent on staff for all activities of daily living due to multiple medical conditions including dysphasia, hemiplegia, and metabolic encephalopathy, was observed lying in bed with a wet adult incontinent brief. Staff E admitted that the last care provided to the resident was approximately four hours prior to the observation, indicating a significant delay in care. Resident #1 was found unresponsive in bed by paramedics, with old urine soiling his clothing and bed sheets. Despite being treated for the flu and a urinary tract infection, the facility staff were unable to determine how long the resident had been unresponsive. Interviews with staff revealed inconsistencies in care documentation and a lack of timely incontinence care, as the Activities of Daily Living Task sheet showed no documentation for two consecutive days. A confidential random resident reported issues with night shift staff, stating that after requesting assistance for incontinence, staff delayed care for four hours. This indicates a pattern of inadequate and delayed care for residents requiring assistance with personal hygiene and incontinence management, contributing to the facility's failure to meet the necessary standards of care.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 no longer resides in the facility as of Resident #5 was assessed On by nursing no negative outcomes observed. Confidential/random resident: On a current audit was conducted on current residents to ensure no issues related to ADL care were identified, no like residents noted. 2. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. By an audit was completed by the DON/designee on current residents identified as dependent for ADL care, any concerns identified were addressed at the time of assessment. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. By current nursing staff were educated on ADL care for dependent residents by the Assistant Director of Nursing/Designee. Newly hired staff will be educated on ADL care for dependent residents by the Assistant Director of Nursing/Designee at orientation as part of the systematic changes. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The DON/Designee will audit 5 residents receiving ADL care 2x week x 4 weeks then 1x week for 4 weeks then 2 x month for x 1 month then monthly for 1 month to ensure substantial compliance is achieved. The findings of these audits will be reviewed in the monthly QAPI meeting.
Deficient Wound Care Practices in LTC Facility
Penalty
Summary
The facility staff failed to provide necessary treatment and services to promote healing and prevent infection of existing pressure wounds for two residents. Resident #2, who was admitted with dementia and heart failure, had an unstageable pressure wound on the right hip. Despite a care plan that included specific wound care instructions, the resident was transferred to the hospital with maggots in the wound, indicating a lack of proper wound management. The Wound Nurse, who had recently taken over wound care duties, did not notice any signs of infection or foreign bodies during her care, and the dressing was found to be soiled and undated upon hospital evaluation. Resident #6, who was readmitted with multiple pressure ulcers, did not receive the prescribed treatment for tissue granulation and autolytic debridement. The care plan required specific wound care interventions, including the application of Collagen Powder and Calcium Alginate, which were not followed by the Wound Nurse during an observed wound care session. The nurse failed to apply the prescribed treatments to the resident's wounds, as confirmed by the Unit Manager during an interview. The report highlights deficiencies in the facility's wound care practices, including inadequate training and failure to adhere to physician orders. The Wound Nurse, a Licensed Practical Nurse, lacked documented prior wound care experience, and the facility's job description required a Registered Nurse License for the position. These deficiencies contributed to the inadequate care provided to the residents, resulting in severe consequences for their health and well-being.
Failure to Report Allegation of Neglect for Resident with Wound Issues
Penalty
Summary
The facility staff failed to report an allegation of neglect for a resident who was found to have live maggots in the dressings of a wound on his right hip. The resident was admitted to the emergency department with altered mental status and was diagnosed with septic shock, bilateral lower lobe pneumonia, a urinary tract infection, and elevated Troponin levels. The hospital expressed concerns about the condition of the resident's wound, which prompted the facility to conduct an internal review. The facility's policy requires that any allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the appropriate authorities. However, the facility did not report the hospital's concerns as an allegation of neglect. The Regional Nurse Consultant and the Nursing Home Administrator stated that they conducted a thorough investigation and determined that the facility had provided appropriate care for the resident's wound. Despite this, the facility did not document the hospital's concerns as a reportable event or incident. Interviews with facility staff revealed that the information regarding the resident's wound condition was communicated through the marketing team and corporate leadership, rather than directly to the Nursing Home Administrator. The facility's leadership acknowledged that they may have delayed in addressing the issue with the hospital, but maintained that their investigation showed the resident received appropriate care. The lack of immediate reporting and documentation of the hospital's concerns as an allegation of neglect constitutes a deficiency in the facility's adherence to its own policies and regulatory requirements.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The nursing staff failed to adhere to the facility's policy for the storage of nebulizer equipment, affecting one resident. During an observation, a nebulizer machine was found on a nightstand with a mask that was dirty and stained with a yellow substance. The mask was improperly stored inside a plastic bag from a grocery store. The resident's spouse reported that the staff did not change the mask and that he placed it in the bag because it was left on the table. A Licensed Practical Nurse confirmed the mask was not dated, was unsure of the last change, and acknowledged the improper storage. The resident involved had a prescription for Ipratropium-Albuterol Solution to be inhaled twice daily for shortness of breath, with a medical history of Chronic Obstructive Pulmonary Disease. The resident was assessed as severely impaired in daily decision-making skills and required extensive assistance with activities of daily living. The care plan indicated the resident was at risk for altered respiratory status and required monitoring for signs of respiratory distress. However, the medication and treatment administration records did not document when the nebulizer tubing, mask, and storage bag were last changed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of two residents, resulting in a finding of Immediate Jeopardy. Resident #1, who was severely cognitively impaired with a BIMS score of 07, was not properly monitored for elopement risk despite a physician's order. On the night of the incident, Resident #1 left the facility through an unlocked front door and was found by police approximately one mile away. The staff's failure to transcribe and act on the elopement monitoring order contributed to this incident. Resident #2, also severely cognitively impaired with a BIMS score of 06, managed to exit the facility through a stairwell door that opened after being pushed for 15 seconds. She was found across the street at a rehabilitation hospital. The staff did not observe any exit-seeking behavior prior to her elopement, and the facility's alarm system failed to alert staff effectively, as no response was made to the alarms. The facility's alarm systems were tested, and it was observed that staff did not respond to the alarms when they were triggered. Additionally, an alarmed door leading to the kitchen was found propped open, and another door leading outside was not alarmed, allowing potential unnoticed exits. These lapses in security and supervision contributed to the residents' ability to leave the facility unsupervised.
Deficiencies in Wound Care and PICC Line Management
Penalty
Summary
The facility failed to provide daily wound care for a resident with a surgical incision, leading to significant complications. The resident, who was cognitively intact, had a surgical wound on the right foot that required specific daily care as per physician orders. However, the Treatment Administration Records indicated that wound care was not provided on two occasions, and there was no documentation explaining the lack of care. This oversight resulted in the maceration of the surgical skin flap, exposing the bone and necessitating additional surgery. The facility's wound care nurse claimed to have received a verbal order for a change in wound care, but no documentation was found to support this claim. Another deficiency involved a resident with a Peripherally Inserted Central Catheter (PICC) line. The PICC line was dislodged, and the facility failed to respond in a timely manner, causing psychological harm to the resident. The resident became hysterical due to the incident, and emergency services were called by the family. Staff interviews revealed confusion and lack of documentation regarding the incident, with discrepancies in the accounts of what occurred and when. The Assistant Director of Nursing documented the event eight days later, noting a small amount of blood, which contradicted other staff reports of significant bleeding. The facility's handling of both incidents demonstrated a lack of adherence to care protocols and inadequate communication among staff. The failure to provide necessary wound care and the delayed response to the PICC line dislodgement highlight significant deficiencies in the facility's care practices. These incidents resulted in physical and psychological harm to the residents involved, underscoring the need for improved care coordination and documentation practices.
Failure to Provide Appropriate Care for Resident with Dislodged PICC Line
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Peripherally Inserted Central Catheter (PICC) line, leading to psychological harm. The incident occurred when the PICC line was dislodged, and the resident was found hysterical with blood on her clothing and bed. The resident had been admitted to the facility and was receiving IV antibiotics when the incident happened. The lack of timely response from the staff contributed to the resident's distress. On the day of the incident, the assigned nurse, Staff C, had clocked out early, leaving Staff B, RN, to manage the situation. Staff B was informed by a CNA that the IV line had been pulled out, and upon entering the room, found the resident in distress. Despite the presence of blood, Staff B did not document the incident, citing that it was shift change and the resident was not on his assignment. The emergency personnel were called by the resident's family, who had been contacted by the resident herself, and they arrived shortly after the incident. Interviews with various staff members revealed inconsistencies in the handling and documentation of the event. Staff D, CNA, and Staff F, CNA, both described the resident as being covered in blood, contradicting the ADON's later documentation of a small amount of blood. The ADON, who was not present during the incident, documented the event based on second-hand information and did not conduct interviews with all relevant staff. The lack of immediate and appropriate response to the resident's condition and the failure to document the incident accurately contributed to the deficiency.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify the representative of a resident with cognitive impairment about a change in condition and treatment. The resident, who had a Brief Interview of Mental Status (BIMS) score of 6, indicating cognitive impairment, was admitted to the facility and had a specified family member as the first emergency contact. On a specified date, the resident experienced malaise and poor appetite, prompting orders for laboratory work, including a urinalysis. The change in condition form did not document any notification to the resident's representative, and the progress notes also lacked such notification. The urinalysis results later confirmed a urinary tract infection (UTI), yet there was still no record of notification to the resident's representative. When questioned, the Director of Nursing (DON) had no response regarding the lack of notification.
Facility Fails to Secure Hazardous Areas and Provide Timely Maintenance
Penalty
Summary
The facility failed to ensure a safe and functional environment, as evidenced by multiple unsecured areas and improperly stored items. During a facility tour, it was observed that several Soiled Utility/Holding rooms and a housekeeping area were not secured, with doors propped open or left unlocked. These areas contained hazardous materials, such as biohazard boxes and cleaning solutions, which were accessible due to the unsecured doors. Additionally, an emergency exit was found ajar, and oxygen tanks were left free-standing in a corridor, contrary to facility protocol. These observations were documented with photographic evidence, and staff interviews revealed a lack of awareness and response to these security lapses. The facility also failed to provide timely maintenance for resident toilets, as evidenced by a confidential document reporting a resident's toilet backing up twice, with maintenance delayed for 24 hours on one occasion. A review of the Work Orders report showed four orders related to broken toilets, but lacked evidence of when these issues were reported and resolved. Despite requests, the Administrator did not provide the necessary documentation to verify the timeliness of repairs. These deficiencies highlight significant lapses in maintaining a safe and functional environment for residents.
Incomplete Investigation of Resident's PICC Line Dislodgement
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of neglect involving a resident who experienced a dislodgement of their Peripherally Inserted Central Catheter (PICC). The incident occurred when the resident was found with the PICC line on the floor, accompanied by blood on the floor, sheets, and near the IV site. The Assistant Director of Nursing (ADON) documented the event eight days later, noting a small amount of blood, but the investigation lacked comprehensive written statements from all staff involved and presented contradictions in staff interviews. The investigation primarily included interviews with the Registered Nurse (RN) who assisted the resident, another RN who left early, and a Certified Nursing Assistant (CNA) who was requested to assist during the incident. However, it did not include interviews with the day shift CNA assigned to the resident or any night shift nurses or aides who were present at the time of the incident. This omission hindered the facility's ability to accurately determine the events and assess if neglect or other concerns were present. Interviews with staff revealed inconsistencies in their accounts of the incident. The RN involved did not document a progress note, citing that the resident was not on his assignment. The CNA who assisted described the resident as hysterical and noted significant blood on the resident's clothes and bed, contradicting the ADON's report of a small amount of blood. Additionally, a family member reported calling 911 after the resident contacted them, stating there was blood everywhere and staff were not responding to the call bell.
Staffing Deficiencies Lead to Delayed Response in Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing, resulting in a lack of timely response to a critical incident involving a resident with a Peripherally Inserted Central Catheter (PICC) line. The resident, who was receiving IV antibiotics, experienced a dislodgement of the PICC line, leading to significant bleeding and distress. Despite the resident's attempts to summon help using the call bell, no staff responded promptly, and the resident had to contact a family member, who then called 911. The incident occurred after the assigned nurse had clocked out, and the night CNA, upon hearing the resident's distress, struggled to locate another nurse to provide immediate care. The delay in response was attributed to insufficient staffing on the floor, with one scheduled CNA being a no call/no show. Additionally, the facility had received numerous complaints regarding inadequate staffing and slow response times to call bells. Complaints included reports of residents left in distress, staff sleeping during night shifts, and a general lack of urgency in attending to residents' needs. These complaints were documented over several months, indicating a persistent issue with staffing levels and staff responsiveness. The facility's staffing records showed that the number of staff on duty was often insufficient to meet the needs of the residents, contributing to the deficiencies observed.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to ensure food preferences were accommodated for two residents, leading to dissatisfaction with meal options. Resident #7, admitted on an unspecified date, expressed that some of the food was inedible and unrecognizable. The resident mentioned a lack of availability of preferred tuna sandwiches, despite the kitchen having sufficient stock. The Kitchen Manager admitted to not receiving requests for tuna sandwiches and had not spoken to Resident #7 to obtain their food preferences. The menu ticket for Resident #7 lacked any preferences, indicating a failure in communication and documentation of resident preferences. Resident #8, also admitted on an unspecified date, expressed dissatisfaction with the meals, having eaten only a few bites of lunch and stating a dislike for the food. The resident reported not receiving any menu or options for alternate meals, despite being told they should receive a packet with this information. The Kitchen Manager acknowledged that the concierge should provide new residents with the menu cycle and available items but admitted to not providing this information to Resident #8. The resident's family member eventually picked up the menu, highlighting a lapse in the facility's process for communicating meal options to new residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection control program by not implementing Enhanced Barrier Precautions (EBP) for four residents who required them. The policy for EBP, revised on 05/28/24, mandates the use of personal protective equipment (PPE) such as gowns and gloves for residents with wounds or indwelling medical devices, even if they are not known to be colonized with multidrug-resistant organisms (MDRO). However, the records for Resident #1, who was admitted for wound care and IV antibiotics via a PICC line, lacked documentation of EBP use. Similarly, Resident #6, admitted for wound care following an above-knee amputation, did not have any signage indicating EBP on her door, and Resident #7, receiving IV antibiotics, reported that staff did not wear gowns during care. Resident #8, with a fresh surgical wound, also lacked EBP signage on the door. Observations and interviews further confirmed the deficiency. During an observation, Resident #6's surgical dressing was visible, and there was no EBP sign on the door. Resident #7 stated that staff only wore uniforms and gloves, not gowns, during care activities. Staff K, a CNA, was able to articulate what EBP was and when to use gowns but indicated that EBP signage on doors was the method to identify residents requiring these precautions. The absence of EBP signage and appropriate PPE use for these residents highlights the facility's failure to adhere to its infection control policy.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility staff failed to immediately report an allegation of abuse involving a resident. The resident reported that a Certified Nursing Assistant (CNA) was mean to her and pulled on her arms during care, causing pain due to her stiff and painful shoulders and arms from a stroke. The resident initially reported the aide's actions to therapists, who then helped her write a grievance. The grievance was filed on the same day but was not reported to the abuse hotline until two days later, after a state agency representative arrived at the facility to investigate the matter. The Director of Nursing (DON) confirmed that the Assistant Director of Nursing (ADON) investigated the grievance by speaking to both the resident and the aide, and provided the aide with education, addressing it as a customer service concern. However, the facility's policy requires that all allegations of abuse be reported immediately, but not later than 2 hours if the events involve abuse or result in serious bodily injury, or no later than 24 hours if they do not. The delay in reporting the abuse allegation was a violation of this policy.
Improper Urinary Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure proper urinary catheter care for a resident, leading to several deficiencies. During an observation, it was noted that the resident's urinary catheter was not secured, causing tension on the tubing. The resident's catheter bag was half full with dark amber urine and visible from the hallway, compromising privacy. Additionally, the staff used the same water to bathe the resident and provide catheter care, which is against infection control practices. The resident also had a small skin injury on the left arm and a soiled dressing on the coccyx, which were not properly addressed during the care process. The Director of Nursing and Unit Manager were both involved but failed to correct the issues promptly. The catheter tubing was pulling on the resident's insertion site, causing discomfort, and the staff had to be reminded multiple times to watch out for the catheter. The resident was assessed as severely impaired for daily decision-making skills and had an indwelling catheter and pressure wound. The care plan included monitoring for complications related to catheter use, but these guidelines were not followed during the observed care.
Failure to Assess and Report Resident Injury
Penalty
Summary
The clinical staff failed to complete an assessment after a resident sustained an injury, failed to obtain and report all pertinent information to the provider to ascertain the best course of treatment, failed to complete an incident report after the injury was reported by the resident, and failed to complete an investigation to determine if the resulting injury, a fractured wrist, met the criteria for an adverse event. These failures affected one resident who was admitted for rehabilitation services and was assessed as high risk for falls. The resident's care plan included several interventions to minimize fall-related injuries, but these were not effectively implemented or followed up on after the incident. The resident was observed holding a swollen wrist and was unable to describe the incident. The ARNP was notified, and an x-ray was ordered, but the resident was sent to the hospital for evaluation and returned with a diagnosis of a Colles fracture. Despite the resident's report of a fall and subsequent injury, the incident was not documented in the incident logs, and no post-fall assessment was completed by the nursing staff. Interviews with various staff members, including the Regional Nurse Consultant, Nurse Practitioner, Administrator, Director of Nursing, and Care Plan/MDS Registered Nurse, revealed a lack of communication and documentation regarding the incident. The facility staff failed to assess the resident after reporting an injury and did not provide sufficient information to the ARNP to determine the appropriate course of action. Additionally, the facility did not have a policy regarding incident reports, event investigations, or adverse events, relying instead on regulations. The lack of documentation and investigation into the fall and injury resulted in a failure to determine if the injury met the criteria for an adverse event, highlighting significant gaps in the facility's incident management and reporting processes.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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