Miami Shores Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Miami, Florida.
- Location
- 9380 Nw 7th Avenue, Miami, Florida 33150
- CMS Provider Number
- 105449
- Inspections on file
- 17
- Latest survey
- June 24, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Miami Shores Nursing And Rehab Center during CMS and state inspections, most recent first.
A CNA failed to perform hand hygiene, change gloves, or use separate washcloths during hygiene care for a resident on enhanced barrier precautions with a PEG tube. The resident, who was cognitively impaired and fully dependent for ADLs, was left uncovered during care, and the same washcloth was used for the face and body, contrary to facility policy and infection control standards.
Staff failed to consistently document the removal and administration of controlled substances at the time of dispensing, resulting in unreconciled narcotic logs and discrepancies with the EMAR. In several cases, nurses either delayed signing the logs, omitted required information, or reinforced damaged bingo cards with tape instead of returning them to the pharmacy, contrary to facility policy.
The QAPI committee failed to implement effective corrective actions for previously identified deficiencies, resulting in repeated issues with infection prevention—such as improper PPE use, poor hand hygiene, and environmental cleanliness—and medication management, including unattended medication carts and unsecured medical supplies at a resident's bedside.
The facility failed to maintain its automatic sprinkler system according to NFPA 101 standards. During a survey, it was found that the Rehabilitation Standpipe Room lacked a posted list in the sprinkler cabinet and a spare dry sprinkler for the freezer. The Maintenance Director acknowledged these deficiencies, which were also discussed with the Administrator.
The facility failed to maintain compliance with NFPA 101 standards by not providing the required clean agent fire extinguishers in the Telecommunication Equipment Room (TER) within the Rehabilitation Room. This deficiency was observed during a life safety tour with the Maintenance Director, who acknowledged the issue, and was further discussed with the Administrator during the exit conference.
During a Life Safety Survey, a facility was found non-compliant with NFPA 101 smoking regulations. The designated smoking area lacked noncombustible ashtrays and metal containers with self-closing covers for ashtray disposal. The Maintenance Director and Administrator acknowledged these deficiencies during the survey and exit conference.
The facility failed to maintain its essential electric system generator according to NFPA 101 standards. There was no documentation for the fuel quality test since May 2023, and no generator high mortality spare parts were available on the premises. These deficiencies were acknowledged by the Maintenance Director and discussed with the Administrator.
During a Life Safety Survey, it was found that the Oxygen Storage Room lacked the required precautionary signage stating "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." This deficiency was acknowledged by the Maintenance Director and discussed with the Administrator, indicating non-compliance with NFPA 99 and NFPA 101 standards.
The facility failed to follow infection control protocols, with staff entering precaution rooms without PPE and improper hygiene practices. A resident with an open wound was non-compliant with treatment, and environmental issues like trash in the pantry and unsecured utility room doors were noted. These deficiencies highlight lapses in maintaining a safe and sanitary environment.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident had no care plan intervention for floor mats, another had an initially incomplete care plan for floor mat use, and a third lacked a care plan for a required C-collar. These omissions resulted in inadequate documentation and implementation of necessary interventions.
The facility failed to properly store medications, as expired Covid-19 test kits were found in a medication storage room, an unlocked medication cart was observed, and a nurse left a cup of crushed medication and a lancet unattended in a resident's room. The RN supervisor confirmed the expired kits, and the DON stated the tests could still be used due to an extended expiration date. The RN admitted to leaving the cart unlocked and the medication unattended due to being in a hurry and the presence of a surveyor.
A resident's medical records inaccurately documented a COVID-19 positive status and treatment with a Z pack, despite being COVID-19 negative and not receiving such medication. This discrepancy was confirmed by the DON and an LPN, highlighting a failure to maintain accurate records as per facility policies.
A tripping hazard was identified in a resident's room due to an electrical cord for an air mattress being improperly secured, creating a risk of falls. The resident, who had a history of acute failure and COVID-19, was dependent on staff for transfers. Despite facility policies emphasizing safety, the hazard was not addressed until pointed out by a surveyor.
A resident in a facility was observed with kinked and improperly draining tubing, which was also found touching the floor. Despite staff rounds and communication, the tubing issues persisted, indicating a lapse in monitoring. The resident had a significant change in status, and there was confusion among staff regarding the type of system in use, leading to inadequate care.
The facility failed to protect residents' privacy by leaving computer screens unlocked and unattended, displaying resident information. An RN and an LPN were involved in separate incidents where computer screens were left open, violating the facility's privacy policy. The policy requires all patient information to be confidential and stored securely, with access restricted to authorized personnel.
The facility failed to maintain the privacy and confidentiality of residents' information, as two computer screens on the East side nursing station were left unlocked and unattended, displaying resident data. An RN and an LPN were involved in the incidents, acknowledging the breach of protocol. The facility's policy mandates confidentiality and restricted access to patient information, which was not adhered to, resulting in a deficiency.
The facility failed to accurately complete PASARR Level I screenings for three residents, leading to discrepancies in their care needs. The screenings did not reflect the residents' current diagnoses and medication requirements, as confirmed by the DON and other staff. This deficiency was identified during a survey through observations, record reviews, and staff interviews.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident lacked a care plan for floor mats, another had an outdated care plan for floor mat interventions, and a third resident did not have a care plan for a required C-collar. These oversights resulted in inadequate documentation and planning for the residents' safety and care needs.
A resident's room in an LTC facility was found to have a tripping hazard due to an improperly managed electrical cord for an air mattress. The cord was wrapped around a side table and suspended in the air, posing a risk. The resident, who had a history of acute failure and COVID-19, was dependent on staff for transfers. The facility's policy aimed to minimize accident hazards, but this incident highlighted a failure to adhere to safety protocols.
A facility failed to provide appropriate catheter care for a resident, as the tubing was observed kinked and touching the floor, hindering proper drainage. Despite staff rounds and communication, the tubing was found improperly positioned, indicating a lapse in care. The DON acknowledged the issue, noting outdated physician orders and emphasizing the need for proper monitoring to prevent infections.
The facility failed to properly store medications, with expired Covid-19 test kits found in a storage room, an unlocked medication cart left unattended, and a nurse leaving medication and a lancet unattended in a resident's room. These incidents highlight lapses in adhering to protocols for safe and secure medication storage and handling.
The facility failed to properly dispose of cardboard boxes, which were found scattered on the ground outside the kitchen door instead of being placed in the garbage bin as per policy. A Dietary Aide and the Dietary Director confirmed that the boxes should have been disposed of properly.
A resident's medical record inaccurately documented a COVID-19 positive status and treatment with a Z pack, despite the resident being COVID-19 negative and not receiving such medication. This discrepancy was confirmed by the DON and an LPN, highlighting a failure to adhere to the facility's policy on accurate documentation.
The facility failed to implement effective infection control protocols, as evidenced by non-compliance in a soiled utility room and inadequate hygiene for a resident. Despite monthly QAPI meetings, the facility has a history of repeated deficiencies in infection prevention, affecting its ability to provide safe care.
The facility failed to maintain accurate MDS records for two residents, leading to deficiencies in their care plans. One resident was incorrectly coded as a hospice resident without hospice orders, and another was inaccurately coded as returning to a hospital instead of being discharged to an ALF. These errors highlight lapses in documentation and communication within the facility.
The facility failed to maintain accurate MDS assessments for two residents, leading to discrepancies in their care needs and discharge plans. One resident was incorrectly coded as a hospice resident, while another was inaccurately documented as returning to a hospital instead of being discharged to an ALF. These errors were due to oversight by the MDS Coordinator, despite existing communication processes with nursing and social services.
A facility failed to implement a Restorative Care Plan for a resident with a physician's order to wear a C-collar at all times. Observations showed the resident often without the C-collar, and staff interviews revealed inconsistencies in following the order. The C-collar was found in the laundry, wet, and not available for use, and there was no documentation of deviations from the physician's order in the resident's medical records.
Failure to Follow Infection Control Protocols During Resident Hygiene Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to adhere to infection control standards during hygiene care for a resident on enhanced barrier precautions. The CNA did not perform hand hygiene before the procedure, nor did she change gloves or washcloths at appropriate intervals. The CNA was observed wearing a gown, mask, and gloves upon entry, but did not remove gloves or perform hand hygiene at any point during the care. The same washcloth was used to cleanse the resident's face and the rest of the body, and the resident was left uncovered while the basin was filled with water and soap was added directly to the water. The resident involved had a percutaneous endoscopic gastrostomy (PEG) tube and was under enhanced barrier precautions as ordered by a physician. The resident was cognitively impaired, fully dependent for activities of daily living, and had multiple diagnoses including dysphagia, diabetes mellitus, osteoarthritis, hyperlipidemia, dementia, and GERD. The care plan specified the need for enhanced barrier precautions during hygiene care, including education for caregivers and adherence to infection control guidelines. Facility policy required staff to maintain resident dignity by keeping them covered during care, to use a clean part of the washcloth for each body area, and to perform hand hygiene in conjunction with glove use. Staff interviews confirmed knowledge of these protocols, including the need to change gloves and use separate washcloths for different body areas. However, the observed care did not follow these established procedures, resulting in a failure to meet infection control standards.
Failure to Properly Store and Document Controlled Substances
Penalty
Summary
The facility failed to properly store and document controlled substances on three out of four medication carts, as evidenced by unreconciled medication monitoring/control record sheets. During medication administration observations, staff were found to be signing the narcotic log after administering the medication rather than at the time of removal from the bingo card, resulting in inaccurate and untimely documentation. In one instance, a nurse admitted to forgetting to sign the log at the time of administration, and in another, a nurse did not sign the sheet due to not having a pen. Additionally, discrepancies were noted between the narcotic logs and the electronic medication administration records (EMAR), with missing dates, times, and signatures. Further observations revealed a bingo card containing controlled substances with a broken seal that had been reinforced with tape, contrary to facility protocol, which requires damaged cards to be returned to the pharmacy. The Director of Nursing confirmed that the expected procedure is for nurses to document the date, time, amount, and their initials at the time the medication is removed from the bingo card, and that any abnormalities in the bingo card should be reported to the pharmacy. The facility's policy also requires accurate and timely documentation of controlled substance administration, which was not consistently followed.
Repeated Deficiencies in Infection Control and Medication Management
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA)/QAPI committee failed to demonstrate an effective plan of action to correct previously identified quality deficiencies, as evidenced by repeated citations for F880-Infection Prevention and Control and F761-Label/Store Drugs and Biologicals. During a recertification survey, surveyors observed ongoing issues such as trash and food left on the floor in a resident pantry, an indwelling catheter tube touching the floor, staff not wearing proper personal protective equipment (PPE), and improper hand hygiene during wound care. Additionally, an unattended and unlocked medication cart was found, and medication, a glucometer, and lancets were left at a resident's bedside. The facility's QAPI plan outlines a multidisciplinary committee and a systematic approach to monitoring and improving care, but the repeated deficiencies indicate that these processes were not effectively implemented or sustained. At the time of the survey, there were 91 residents in the facility. The QAPI committee, which includes the DON, department heads, administrator, wound care nurse, dietary staff, and medical director, meets monthly to review quality initiatives and audit outcomes, but the cited deficiencies persisted in the areas of infection control and medication management.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 standards. During a Life Safety Survey tour, it was observed that the Rehabilitation Standpipe Room lacked a posted list in the sprinkler cabinet. Additionally, there was no spare dry sprinkler available for the freezer, nor was there a means to restore service in case of a malfunction. These deficiencies were identified during an inspection conducted at 2:43 pm on April 1, 2025, with the Maintenance Director present. The absence of essential components and documentation in the sprinkler system indicates a lapse in the facility's adherence to the required safety protocols. The Maintenance Director acknowledged these findings during the staff interview, and the issues were also discussed with the Administrator during the exit conference. The report cites specific sections of NFPA 101 and NFPA 25 that were not met, highlighting the facility's failure to comply with established fire safety standards.
Plan Of Correction
This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. **K353 Sprinkler System Maintenance and Testing** **Identify patients that were at risk and what did:** When the surveyor identified the issue we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **How will you identify other patients that are at risk?** When the surveyor identified the issue, we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in the room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **Measure put in place:** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. **How will you monitor?** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. Any Variances will be brought to the QAPI Committee. 5/1/25 This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. **K353 Sprinkler System Maintenance and Testing** **Identify patients that were at risk and what did:** When the surveyor identified the issue we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **How will you identify other patients that are at risk?** When the surveyor identified the issue, we contacted vendor, and they provided the list and the director of plant operations framed it and placed it in the room adjacent to the cabinet. The Dry pipe has been delivered and placed in same location. **Measure put in place:** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. **How will you monitor?** The Director of Plant Operations will check monthly to ensure that the box is supplied and nothing is missing. Any Variances will be brought to the QAPI Committee.
Failure to Maintain Required Fire Extinguishers in TER
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards regarding the maintenance of portable fire extinguishers. During a life safety tour conducted at 2:40 p.m. on April 1, 2025, it was observed that the Telecommunication Equipment Room (TER) in the Rehabilitation Room lacked the required clean agent fire extinguishers. This deficiency was identified during an inspection with the Maintenance Director present. The Maintenance Director acknowledged the absence of the necessary fire extinguishers during a staff interview conducted at the same time. This issue was further discussed and acknowledged by the facility's Administrator during the exit conference. The deficiency was noted under NFPA 101 (2021 Edition) and NFPA 10 (2018 Edition) standards, indicating a failure to adhere to the required fire safety protocols.
Plan Of Correction
Sprinkler System Maintenance and Testing Identify patients that were at risk and what did: When the surveyor identified the issue we contacted vendor and ordered a new Clean Agent Fire Extinguisher to be added to the Telecommunication room. This was installed on 4/17/2025. How will you identify other patients that are at risk? No other residents were identified at risk. When the surveyor identified the issue, we contacted vendor and ordered a new Clean Agent Fire Extinguisher to be added to the Telecommunication room. This was installed on 4/17/2025. Measure put in place: The Director of Plant Operations has added the new extinguishers to his monthly checks for compliance. The Director also checked the rest of the extinguishers to ensure they were ready for use. How will you monitor? The Director of Plant Operations has added the new extinguishers to his monthly checks for compliance. Any variances will be brought to the QAPI Committee.
Smoking Area Safety Deficiency
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations during a Life Safety Survey. The survey, conducted with the Maintenance Director, revealed deficiencies in the designated smoking area. Specifically, the area lacked ashtrays made of noncombustible material and safe design, as well as metal containers with self-closing cover devices for emptying ashtrays. These observations were made at 2:10 pm on April 1, 2025. During the staff interview conducted at the same time, the Maintenance Director acknowledged the absence of the required safety equipment in the smoking area. This acknowledgment indicates that the facility was aware of the deficiency at the time of the survey. The findings were also discussed and acknowledged by the Administrator during the exit conference, further confirming the facility's awareness of the issue. The report does not mention any specific patients involved or affected by this deficiency. The focus is solely on the facility's failure to maintain the smoking area in accordance with the NFPA 101 standards, which are designed to ensure safety in areas where smoking is permitted. The lack of proper equipment in the smoking area represents a failure to adhere to established safety protocols.
Plan Of Correction
Smoking Regulations Identify patients that were at risk and what did: When the surveyor identified the issue, we researched and purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you identify other patients that are at risk? No other patients are a risk as the Ashtrays have been replaced with self-closing metal lids and added the RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. Measure put in place: Purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you monitor? The Director of Plant Operations and Housekeeping will be responsible for ensuring that the ash trays are emptied on a regular basis. This is part of our daily service. Any Variances will be brought to the QAPL Committee. 5/1/25 K741 Smoking Regulations Identify patients that were at risk and what did: When the surveyor identified the issue, we researched and purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you identify other patients that are at risk? No other patients are a risk as the Ashtrays have been replaced with self-closing metal lids and added the RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. Measure put in place: Purchased Ashtrays of noncombustible materials with metal self-closing lids. Additionally, we purchased a RED metal container by which the Ashtrays can be emptied. Both are located in the designated smoking area. How will you monitor? The Director of Plant Operations and Housekeeping will be responsible for ensuring that the ash trays are emptied on a regular basis. This is part of our daily service. 5/1/25
Deficiency in Essential Electric System Maintenance
Penalty
Summary
The facility failed to maintain its essential electric system generator in accordance with NFPA 101 standards. During a records review process conducted with the Maintenance Director, it was discovered that there was no documentation available for the performance of the fuel quality test since a report dated May 24, 2023. This lack of documentation was acknowledged by the Maintenance Director and discussed with the Administrator during the exit conference. Additionally, during a Life Safety Survey tour of the facility, it was observed that there were no generator high mortality spare parts available on the premises. This observation was made in the presence of the Maintenance Director, who acknowledged the finding. The absence of these critical spare parts was also discussed with the Administrator during the exit conference. The report highlights that the facility did not meet the requirements for maintaining the essential electric system generator as per NFPA 101. The findings were based on both the lack of documentation for fuel quality testing and the absence of necessary spare parts for the generator, which are crucial for ensuring the generator's operational readiness and compliance with safety standards.
Plan Of Correction
Identify patients that were at risk and what did: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you identify other patients that are at risk? No other patients are a risk as the testing was completed on 4/07/2025 and results were pending. On 4/11/25 the Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. Measure put in place: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you monitor? The Director of Plant Operations will be responsible to ensure that the Fuel test is pre-scheduled for annual requirement and that the high mortality parts are always available. Any variances will be brought to the QAPI Committee. K918 Essential Electrical Systems Identify patients that were at risk and what did: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you identify other patients that are at risk? No other patients are a risk as the testing was completed on 4/07/2025 and results were pending. On 4/11/25 the Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. Measure put in place: When the surveyor identified the issue we contacted the Fuel testing company and scheduled the testing. The Plant Operations director also contacted the Generator service company requested and ordered generator high mortality parts i.e. Belts and Filters to be stored at the facility. How will you monitor? The Director of Plant Operations will be responsible to ensure that the Fuel test is pre-scheduled for annual requirement and that the high mortality parts are always available. Any variances will be brought to the QAPI Committee. 5/1/25
Missing Precautionary Signage in Oxygen Storage Room
Penalty
Summary
The facility was found to be non-compliant with NFPA 99 and NFPA 101 standards regarding the storage of gas equipment, specifically oxygen cylinders. During a Life Safety Survey tour, it was observed that the Oxygen Storage Room by the Southwest Exit lacked the required precautionary signage. The sign was missing the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING," which is a mandatory requirement for safety and compliance. The deficiency was identified during an inspection conducted at 2:30 pm on April 1, 2025, with the Maintenance Director present. The absence of the necessary signage was acknowledged by the Maintenance Director during the survey. This oversight indicates a failure to adhere to the safety protocols outlined in NFPA 99 and NFPA 101, which are designed to ensure the safe storage and handling of gas cylinders to prevent potential hazards. The issue was further discussed and acknowledged by the facility's Administrator during the exit conference. The lack of proper signage in the oxygen storage area represents a significant oversight in maintaining the required safety standards for gas equipment storage, as stipulated by the relevant NFPA codes.
Plan Of Correction
K923 Cylinder and Container Storage Identify patients that were at risk and what did: No Specific resident was compromised but, the facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you identify other patients that are at risk? No other patients are a risk as the sign was changed to reflect Caution: Oxidizing Gas (ES) Stored within No Smoking. Measure put in place: The facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you monitor? The Director of Plant Operations will be responsible to ensure that the signage is in place and reads Caution: Oxidizing Gas (ES) Stored within No Smoking. Any Variances will be brought to the QAPI Committee. 15/1/25 K923 Cylinder and Container Storage Identify patients that were at risk and what did: No Specific resident was compromised but, the facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you identify other patients that are at risk? No other patients are a risk as the sign was changed to reflect Caution: Oxidizing Gas (ES) Stored within No Smoking. Measure put in place: The facility had a sign that identified the room but not with the specific wording. When the surveyor identified the issue, we proceeded to change the exiting sign to the one that stated Caution: Oxidizing Gas (ES) Stored within No Smoking. How will you monitor? The Director of Plant Operations will be responsible to ensure that the signage is in place and reads Caution: Oxidizing Gas (ES) Stored within No Smoking. Any Variances will be brought to the QAPI Committee. 5/1/25
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control protocols, as evidenced by several observations and interviews. Staff were seen entering rooms of residents under contact and droplet precautions without wearing the appropriate personal protective equipment (PPE), such as gowns, gloves, and masks. This was particularly noted during the distribution of meal trays, which poses a risk of spreading communicable diseases. Additionally, there were instances of improper hygiene practices, such as double-gloving during care, which is against the facility's policy. Resident #57, who was admitted with an unspecified open wound, was found to have a care plan that included the use of an air mattress, offloading heels with pillows, and turning and repositioning every two hours. However, the care nurse reported that the resident was non-compliant with treatment and medications, which could potentially slow down the healing process. The resident was also on enhanced barrier precautions due to the open wound, yet the care provided did not fully align with the established protocols. Environmental issues were also noted, such as trash and food on the floor of the resident's pantry room, which is supposed to be cleaned by housekeeping staff. The soiled utility room door was found to be unable to lock, posing a security risk. Additionally, there were observations of oxygen tubing touching the floor, which could lead to contamination. These findings indicate a lack of adherence to the facility's infection control policies and procedures, contributing to the overall deficiency in maintaining a safe and sanitary environment.
Plan Of Correction
F 880 Ref F880 QAPI action Plan: Once identified by the surveyor, all staff that distribute meal service were reeducated on the process of Donning and Doffing when entering a room with droplet precautions. Once identified by the surveyor, resident #57 was assessed and is in stable condition. Regarding the staff member that double gloved, she was counseled for not following proper control procedures. Once identified by the surveyor, all staff were reeducated on the process of hygiene and also were provided individual education with acknowledgment. All staff were in-serviced on keeping the Common and the Pantry areas cleaned with no trash to be found on the floor, and this was done on [insert date]. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and are now being monitored randomly to ensure that the battery-operated lock system is working regularly. All shower rooms are the responsibility of any staff member that enters the shower room to take a resident into the shower room; there will be no cartons or food-related items nor masks in the shower room. Resident tubing touching the floor education was done on [insert date]. When a patient is on droplet precaution, we will do all possible to keep doors closed at all times. If the resident cannot comply due to mental state or is at risk, the team will care plan and possibly look for alternatives to include discharge. We will always try to mediate the issue for compliance with standards. We also have to honor the fact that this is their home and will work on reasonable accommodations. How will you identify other patients that are at risk: Initially, the management team created a QAPI from the initial exit with areas of concerns. We started immediate in-services since and changed systems and strengthened our quality assurance process and created all new tracking tools. Once the final 2567 came through, we updated the audits and worked on our plans as a team. The system was reevaluated by the QAPI Committee, and education was required for all staff since all residents were at risk as a facility-wide initiative. The following identified areas were used for education to staff and will be maintained on our QAPI for the remainder of the year for tracking and trending data: The following identified areas were used for education to staff: - F583-(N202) Personal Rights and Confidentiality - F-645 PASSAR Screening - F-656- (N054 and N072) Develop and implement Care Plans - F-761-(N095)- Label Drugs and Biologicals - F-842- Resident Records Identifiable Information - F-814 Dispose Garbage and Refuse Property - F-867- QAPI/QAA Improvement Activities - F-880- Control Plan - Proper techniques of Donning and Doffing - Droplet vs Enhanced Barrier Precaution - Meal tray distribution - Transmission Based Precautions - Hygiene - High Touch areas - Linen Handling Including clean and soiled - Cath Tubing not touching the floor Nursing focus will include: - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional System Response: Once identified by the surveyor, all staff that distribute meal service were reeducated on the process of Donning and Doffing when entering a room with droplet precautions. Once identified by the surveyor, resident #57 was assessed and is in stable condition. Regarding the staff member that double gloved, she was counseled for not following proper control procedures. Once identified by the surveyor, all staff were reeducated on the process of hygiene and also were provided individual education with acknowledgment. All staff were in-serviced on keeping the Common and the Pantry areas cleaned with no trash to be found on the floor, and this was done on [insert date]. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and are now being monitored randomly to ensure that the battery-operated lock system is working regularly. All shower rooms are the responsibility of any staff member that enters the shower room to take a resident into the shower room; there will be no cartons or food-related items nor masks in the shower room. When a patient is on droplet precaution, we will do all possible to keep doors closed at all times. If the resident cannot comply due to mental state or is at risk, the team will care plan and possibly look for alternatives to include discharge. We will always try to mediate the issue for compliance with standards. We also have to honor the fact that this is their home and will work on reasonable accommodations. Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. The following identified areas were used for education to staff: - F583-(N202) Personal Rights and Confidentiality - F-645 PASSAR Screening - F-656- (N054 and N072) Develop and Implement Care Plans - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional - K353 Tags Sprinkler System - K355- Tags- Sprinkler Regulations Maintenance and Testing - K 741 Smoking regulations - K-918 Essential Electrical Systems - K923 Cylinder and Container Storage How will you monitor: The Administrator and Director of Nursing will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #291 was observed with a floor mat on one side of the bed, but there was no care plan intervention for the use of floor mats. The MDS Coordinator confirmed that the floor mats had not been care planned until the day of the survey. Additionally, there were no physician orders for the floor mats, although the facility's policy did not require such orders. The lack of a comprehensive care plan for Resident #291's floor mat intervention was a clear deficiency. Resident #74 was observed with a floor mat on the right side of the bed, but the care plan did not initially reflect this intervention. The MDS Coordinator later revised the care plan to include the floor mat intervention, which had been implemented over the weekend. Despite the revision, the initial absence of a care plan for the floor mat intervention constituted a deficiency. The facility's policy allowed for the use of floor mats without a physician's order, but the care plan should have been updated to reflect the intervention. Resident #43 required a C-collar as per physician's orders, but there was no care plan for its use. Interviews with staff revealed that the resident was supposed to wear the C-collar constantly, but it was not always in place, and the resident was not compliant with wearing it during sleep or in the dining room. The C-collar was found in the laundry, wet and not ready for use. The absence of a care plan for the C-collar and the lack of consistent application of the physician's orders were significant deficiencies in the resident's care.
Plan Of Correction
N072-Comprehensive Care Plans Identify patients that were at risk and what did: Ref Resident #43 Regarding Resident #43 the brace with appropriate interventions was added to Care Plan. How will you identify other residents that are at risk: 100 % audit was completed to identify residents with brace. Any residents with brace were reviewed to ensure appropriate Care Plan was completed. Measures put in place: Upon admissions residents are assessed for devices. Any Devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During morning meeting the MDS Coordinator will update and validate to the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also training was completed on for care plan team members regarding Floor mats, C-Collar Devices and Following Physician Orders. Nursing staff to communicate and document anytime a resident refuses treatment such as the C-Collar to update care plan. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on assistive devices (brace and floor mats). How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse and or Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Regarding Resident #74 the Care Plan was completed with appropriate interventions to address. How will you identify other residents that are at risk: 100% audit was completed to identify residents at risk for and Care Plan with appropriate interventions. Measures put in place: Upon admissions residents are assessed for risk. Any residents at risk for a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on precautions and floor mats. How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Ref Resident #291 Regarding Resident #291 the Care Plan was completed with appropriate interventions to address floor mats. How will you identify other residents that are at risk: 100% audit was completed to identify residents with floor mats and Care Plan in place with appropriate interventions. Measures put in place: Upon admissions residents are assessed for floor mats. Any residents found to need a floor mat a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on floor mats. (risk for) How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications, as evidenced by several observations made by surveyors. In the West Wing medication storage room, a box containing multiple expired Covid-19 test kits was found. The Registered Nurse (RN) supervisor confirmed the expiration dates and removed the expired kits. The Director of Nursing (DON) later stated that the expired tests could still be used due to an extended expiration date listed on the FDA website, although the specific tests found expired were not covered by this extension. Additionally, an unlocked medication cart was observed on the West side nursing station. A Registered Nurse (RN) admitted to leaving the cart unlocked because they were in a hurry to assist residents. This action was contrary to the facility's policy, which requires medication carts to be locked when not in use to prevent unauthorized access. Furthermore, a surveyor observed a Registered Nurse (RN) leaving a resident's room with a cup of crushed medication and a lancet unattended. The RN left the room to retrieve an item needed for a procedure, leaving the medication and lancet accessible. The RN later stated that they left the items because the surveyor was present, although the proper protocol is to take medications and materials with them when leaving a room. The DON and Nursing Home Administrator were informed of this incident, and it was noted that the nurse was unaware that medications should not be left unattended.
Plan Of Correction
N095-FAC Drug Storage Identify patients that were at risk and what did: Once identified by surveyor the staff address of expired COVID Test, they were discarded. Central supply and Nursing managers educated immediately when identified by the surveyor and the Pharmacy consultant held a meeting with all nurses' about this topic on about expired medications and provided education. The nurse that left the medication cart unlocked was disciplined on Inservice with all nurses was done on to ensure compliance with Storage Biologicals Medications, Med Pass Administration and procedure by Pharmacist consultant. The DOH did a pharmacy audit on An. How will you identify other patents that are at risk: Medication Rooms and Medication Carts were checked for expired medications once identified by surveyor. DON and Nurse management checked med carts. The pharmacy was contacted to help with Med pass inservice and came to educate nurses on The Inservice included ensuring keeping carts locked when not in use and expired meds. Measures put in Place: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with Medication Administration sample. The supervisor form will be handed to DON for compliance tracking. In-service completed by Pharmacy consultant on for all nurses on expired medications and provided education. Training was also done by the Consultant pharmacist on regarding any expired testing kits and or medications. The inservice also included ensuring keeping carts locked when not in use. The DON Created new audit tolls called on -Medication Cart Audit -Treatment Cart Audit -Med room Audit. Investigator from the Florida Department of Health Division of Medical Quality Assurance conducted an inspection No findings. How will you monitor: The Pharmacist will conduct a monthly audit of all medications and Carts. Nursing staff will conduct weekly audit of all medication and carts. The DON Managers and Consultant Pharmacist will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, as required by professional standards and practices. The deficiency was identified when a Nurses' Progress Note inaccurately documented that the resident was COVID-19 positive and receiving treatment with a Z pack, despite the resident being COVID-19 negative and not receiving such medication. This discrepancy was confirmed through interviews with the Director of Nursing and a Licensed Practical Nurse, both of whom stated that the resident did not have COVID-19 and was not receiving the mentioned treatment. The resident in question had a severe mental status as indicated by a Brief Interview of Mental Status Summary Score of 00, requiring dependent assistance for activities of daily living. The resident's demographic sheet and Minimum Data Set Quarterly Assessment were reviewed, revealing diagnoses including protein-calorie malnutrition and atherosclerotic conditions. Despite these documented conditions, the medical records inaccurately reflected the resident's COVID-19 status and treatment, which could potentially affect the care provided. The facility's policies on charting and documentation, as well as charting errors and omissions, were reviewed. These policies require that all services and changes in a resident's condition be accurately documented by licensed personnel. However, the inaccurate entry in the resident's medical record was not corrected, highlighting a failure to adhere to these policies. This inaccuracy in medical records has the potential to impact the care of any resident within the facility.
Plan Of Correction
N101-FAC Resident Medical Records Identify patients that were at risk and what did: Once identified by surveyor regarding Resident #33, the Director of Nursing contacted the LPN that erroneously documented that the patient was COVID positive when he was not and was asked to clarify the note. This was done on How will you identify other patients that are at risk: The LPN received a 1:1 training on Accurate Documentation. An audit was done on all remaining residents with diagnosis to ensure that the documentation was correct. Measures put in Place: An inservice was done for all Nurses on Resident Records - Identifiable Information and Resident Accuracy was started for all nurses on an ongoing basis. Example of Error identified was presented and discussed. Thereafter, the DON has an ongoing QAPI Plan for incorrect documentation Audit Tool. This was started on a weekly review. How will you monitor: The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Tripping Hazard Due to Improperly Secured Electrical Cord
Penalty
Summary
The facility failed to maintain a safe environment for its residents, as evidenced by an observation of an electrical cord creating a tripping hazard in a resident's room. The cord, which was connected to an air mattress, was wrapped around a side table and suspended in the air, posing a risk of tripping. This observation was made in the presence of a registered nurse, who was informed of the hazard by the surveyor. The resident involved had a history of acute failure and COVID-19, and was dependent on staff for transfers. The resident's care plan indicated a risk related to monoplegia of the right dominant side, and interventions were in place to follow facility protocol. Despite these measures, the tripping hazard was not addressed until it was pointed out by the surveyor. The facility's policy on safety and supervision emphasizes the importance of maintaining an environment free from accident hazards. Employees are expected to be trained to identify and report potential hazards. However, the presence of the tripping hazard suggests a lapse in adherence to these policies, as the electrical safety risk was not mitigated until after the surveyor's intervention.
Plan Of Correction
N0110-Physical Environmental-Safe Clean, Homelike Identify patients that were at risk and what did: Patient #2 bed cord was identified by surveyor and told Administrator; the director of plant operations was instructed to tie all the to the frame to be removed from any potential trip hazard. Thereafter, a full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety on. How will you identify other patients that are at risk: A full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety. Staff were also inserviced on to discuss the risk of tripping hazards. Measures put in Place: On and Staff were inserviced on all risk and precautions and safety measures that required. Upon admission, resident rooms are assessed for room safety. The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with any potential trip hazards such as any electronic charging devices. We have also added to our Gang Tackling Quality programs where scheduled rooms are checked monthly to ensure that any findings out normal are addressed immediately and reported to Management. The Forms are part of Housekeeping and Maintenance department QAPI Tracking. Training occurred on staff were also provided with 6-point training on overall safety hazards and the risk associated. The supervisor form will be handed to DON for compliance tracking. How will you monitor: The DON /Maintenance and Housekeeping Supervisors will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inadequate Monitoring of Tubing Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident, as evidenced by observations of the tubing being kinked and touching the floor. The resident was observed in bed with a system in progress at 2 liters per minute, and no apparent distress was noted. However, the tubing was observed to be kinked in a circle and not properly draining. A Registered Nurse (RN) was present and was notified about the kinking, after which the RN straightened the tubing to allow free flow. The RN mentioned that they round every morning to check the tubing, but did not notice the kink due to the night nurse working with the system. Further observations revealed the tubing touching the floor, which was attributed to the bed being lowered too low. A Licensed Practical Nurse (LPN) stated that they round every two hours and communicate with the Certified Nursing Assistant (CNA) about required interventions. The CNA confirmed receiving in-services on care and stated that they ensure the collection bag does not touch the floor and is anchored to the bed. Despite these measures, the tubing was found touching the ground, indicating a lapse in monitoring and intervention. The resident had a significant change in status, with a diagnosis that included neuropathic conditions. The care plan for the resident included checking tubing for kinks and ensuring proper drainage. However, there was confusion among staff regarding the type of system in place, as the LPN was unaware of a change from one system to another. The Director of Nursing (DON) acknowledged the need for staff to monitor the system to ensure proper drainage and prevent tubing from touching the floor. The physician orders were updated to reflect the correct system in use.
Plan Of Correction
Identify patients that were at risk and what did: Once identified by surveyor, the staff addressed the issue for resident #2, the tubing being kinked and tubing touching the floor. Thereafter, a full house audit was completed after surveyors identified the issues of cath care and rooms were checked for compliance. All rooms were checked for safety. All nurses and CNAs were educated on control and the difference between super pubic and regular. How will you identify other patients that are at risk: Thereafter, a full house audit was completed after surveyors identified the issues of care and rooms were checked for compliance. All rooms were checked for safety. All nurses and CNAs were educated on control and the difference between super pubic and regular. Measures put in place: A clinical inservice was held to discuss care. The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with safety as far as positioning and ensuring that it is not touching the floor. Additionally, the supervisor form will be handed to the DON for compliance tracking. The DON created a care random audit observations checklist. How will you monitor: The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Privacy Breach Due to Unattended Computer Screens
Penalty
Summary
The facility failed to ensure the privacy of residents' information, as evidenced by observations of unlocked and unattended computer screens displaying resident information. On two separate occasions, surveyors observed computer screens left unlocked and unattended, with resident information visible. The first incident occurred at the East side medication cart, where a Registered Nurse (RN) left the screen unlocked while attending to other duties. The RN acknowledged the oversight, attributing it to being preoccupied with finding a supervisor for the surveyor. The second incident was observed at the East side nursing station, where another computer screen was left unlocked and unattended, displaying resident information. A Licensed Practical Nurse (LPN) was informed of the situation by the surveyor and promptly locked the screen, indicating that another staff member had left it open. These observations highlight a breach in the facility's policy to protect patient privacy and confidentiality, as outlined in their Patient Privacy Policy. The facility's policy mandates that all patient information be treated as confidential and that unauthorized access, use, or disclosure is prohibited. It requires that electronic records be stored in password-protected systems with encryption to prevent unauthorized access. The policy applies to all employees, contractors, volunteers, and other personnel working in the nursing home, emphasizing the importance of safeguarding personal, medical, and financial information of residents.
Plan Of Correction
This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. N202 Right to Privacy Identify patients that were at risk and what did: Immediately, once identified by the surveyor, all Department managers were notified and asked to meet with their staff and go over HIPAA and protection of patient privacy. A facility-wide in-service was held on through /2025 that reviewed HIPAA privacy and all staff were started on individual HIPAA training. The assessment completed included the issue, Root Cause Analysis, and Performance Improvement Plan. Staff were trained on specific education related to HIPAA with acknowledgement forms. Regarding the Nurse that left the computer unattended at the med cart, they were counseled on the importance of HIPAA and protecting privacy; counseling was completed on. How will you identify other patients that are at risk? A full house audit was completed on , to determine that no other privacy screens were being left unattended by not only nurses but staff that use the tablets for documentation as well. Staff and Managers were reminded of HIPAA Policy, and Department managers were tasked to keep vigilant about any screens with patient information being left unattended. Thereafter, the DON created the Audit checklist to spot check for computer security during use. Measure put in place: A facility-wide in-service was held on and /2025 that reviewed HIPAA privacy and all staff were started on individual HIPAA training. The assessment completed included the issue, Root Cause Analysis, and Performance Improvement Plan. Staff were trained on specific education related to HIPAA with acknowledgement forms. Training will continue upon hire and annual review. A new system tool has been created whereby the Nurse manager that covers 24 hours per day has a form that was developed and included the surveillance of HIPAA Compliance with all electronics including computers and tablets. The DON created an audit checklist which will be located at the Nurses' desk and is a daily spot check for computer security during use. All department heads are also required to monitor for the same on their daily rounds and when finding any non-compliant staff, to report to managers and provide ongoing education and progressive discipline if rules are not adhered to. We posted a sign at the nurses' station and on med carts as a reminder to lock screens before leaving long-term prevention through inclusion and annual training and orientation. How will you monitor? The DON and all department heads are also required to use the form to track compliance. The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur daily for 30 days, then monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Privacy Breach of Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as required by federal regulations. During a survey, it was observed that two out of four computer screens on the East side nursing station were left unlocked and unattended, displaying resident information. This breach of privacy was noted on the East side medication cart #1 and at the East side nursing station, where resident information was easily accessible and visible to unauthorized individuals. At 7:39 AM, a surveyor observed an unlocked, unattended computer screen on the East side medication cart #1. The Registered Nurse (RN) responsible for the cart returned at 7:41 AM and acknowledged the protocol breach, stating that they forgot to lock the screen due to being preoccupied with finding a supervisor for the surveyor. Similarly, at 8:08 AM, another unlocked, unattended computer screen was observed at the East side nursing station. A Licensed Practical Nurse (LPN) was informed of the situation at 8:09 AM and immediately locked the screen, indicating that another staff member had left it open. The facility's policy on patient privacy, which aligns with the Health Insurance Portability and Accountability Act (HIPAA) and state-specific regulations, mandates that all patient information be treated as confidential. Unauthorized access, use, or disclosure of patient information is prohibited, and access to such information should be restricted to authorized personnel only. Despite these policies, the facility failed to adhere to the required standards, resulting in a deficiency in maintaining the privacy and confidentiality of residents' information.
Plan Of Correction
This Plan of Correction does not constitute admission or agreement by Miami Shores Nursing & Rehabilitation Center of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. This Plan of Correction is prepared solely because it is required by State and Federal Laws. F583 Personal Rights and Confidentiality Identify patients that were at risk and what did: Immediately, once identified by the surveyor, all Department managers were notified and asked to meet with their staff and go over HIPPA and protection of patient privacy. A facility wide Inservice was held on through /2025 that reviewed HIPPA privacy and all staff were started on individual HIPPA training. The assessment completed included the issue, Root Cause Analysis and Performance improvement Plan, Staff Were trained on specific Education related to HIPPA with acknowledgement forms. Regarding the Nurse that left the computer unattended at med cart was counseled on the importance of HIPPA and protecting privacy, counseling was completed on. How will you identify other patents that are at risk? A full house audit was completed on, to determine that no other Privacy screens were being left unattended by not only nurses but staff that use the tablets for documentation as well. Staff and Managers were reminded of HIPPA Policy and Department managers were tasked to keep vigilant about any screens with patient information being left unattended. Thereafter the DON created the Audit checklist to spot check for computer security during use. Measure put in place: A facility wide Inservice was held on and /2025 that reviewed HIPPA privacy and all staff were started on individual HIPPA training. The assessment completed included the issue, Root Cause Analysis and Performance improvement Plan. Staff Were trained on specific Education related to HIPPA with acknowledgement forms. Training will continue upon Hire and annual review. A new system tool has been created whereby the Nurse manager that covers 24 hrs per day has a form that was developed and included the surveillance of HIPPA Compliance with all electronics including computers and tablets. The DON created an audit checklist which will be located at Nurses desk and is a daily spot checks for computer security during use. All department heads are also required to monitor for the same on their daily rounds and when finding any non-compliant staff, to report to managers and provide ongoing education and progressive discipline if rules are not adhered to. We posted a sign at nurses' station and on med carts as a reminder to Lock screens before leaving long term prevention through inclusion and annual training and Orientation. How will you monitor? The DON and All department Heads are also required will use the form to track compliance. The DON and or designee will be responsible for bringing the finding and summary to the QAPI Committee. This will occur daily for 30 days, then Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inaccurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately prior to admission for three residents. The PASARR Level I screenings for these residents were either incomplete or incorrect, failing to reflect the residents' current diagnoses and medication needs. This deficiency was identified during a survey, which included observations, record reviews, and interviews with facility staff. Resident #50 was admitted with certain diagnoses, but the PASARR Level I did not include these diagnoses, and no PASARR Level II was deemed necessary. The Minimum Data Set (MDS) assessment indicated severe mental status issues, yet the PASARR did not reflect this, leading to a discrepancy in the resident's care needs. Interviews with the Admissions Director and Director of Nursing (DON) confirmed that the PASARR was incorrect and should have included the relevant diagnoses. Similarly, Resident #83's PASARR Level I was completed without acknowledging the resident's acute failure and affective disorder diagnoses. The MDS assessment showed severe mental status issues, but the PASARR did not require a Level II review. The DON acknowledged the oversight, stating that the PASARR should have included the diagnoses. Resident #60 also had an incomplete PASARR, which did not reflect the resident's known condition and aggressive behaviors. The DON admitted that the PASARR should have been updated to reflect the resident's current mental illness diagnoses and medication needs.
Plan Of Correction
PASARR screening for MD and ID Identify patients that were at risk and what did: Patients #50, 83 & 60 were reassessed in the PASSAR. Resident #50 was discharged on home with Daughter. Patients #83 and #60 remain in the facility. PASARS were reevaluated to reflect proper diagnosis, and PASARR resident review screening was requested. This was completed on for resident #83. Ref #60 the resident review was completed on. A full house audit was completed identified the issues, all residents PASSARS were reviewed for accuracy. How will you identify other patents that are at risk: On a QAPI Meeting occurred to review the PASSAR and provided education to the committee. A full house audit was completed identified the issues, all residents PASSARS were reviewed for accuracy. The consistency of the audit was to make the PASSARES Level 1 and 2 are accurate and in place. Any updates were made and being made during the course of the audit. Measures put in Place: The facility admissions team will work with local hospitals to ensure prior to admission, that the screening uses the PASSAR criteria. Admissions Director and Director of Nursing as well Social Service were provided the PASSAR education on. The Director of Nursing and admissions will review all new admissions during the week, to ensure accuracy during morning meeting and on weekend a nursing supervisor will review for accuracy and compliance, and if patient was readmitted to compare with prior PASSAR to ensure if any new changes have occurred. Additionally, the Social Service Department and Nursing will also address when Physician changes orders for medications, then the PASSAR will be reviewed and updated if necessary. The MDS Department will also be part of reevaluating during the quarterly assessments. Additionally, as of a QAPI tool was developed as part of Pre-Admission Screening & Resident Review (PASARR) Audit was implemented and will be done upon admission and Gang Tackling, which is the facilities continuous quality improvement program Monthly Review. How will you monitor: The Administrator/ Nursing Management team and or Designee will review all admissions for compliance and keep a running list for QAPI. Pre-Admission Screening & Resident Review (PASSAR) Audit will be done upon admission and Gang Tackling Monthly Review. The Admissions Director and Director of Nursing and or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. One resident was observed with a floor mat on the right side of their bed, but there was no comprehensive care plan with interventions for the use of floor mats. The MDS Coordinator confirmed that the floor mats had not been care planned until the day of the survey. Additionally, there were no current physician orders for floor mats for this resident, indicating a lack of proper documentation and planning. Another resident was observed with a floor mat on the right side of their bed, but the care plan did not reflect the correct intervention until it was revised on the day of the survey. The resident was under precautions, and the floor mat was used for safety, but the care plan was not updated to reflect this intervention until after the surveyor's inquiry. The Restorative nurse communicated the need for floor mats to the MDS Coordinator, but the care plan was not updated in a timely manner. A third resident required a C-collar as per physician's orders, but there was no care plan for its use. The resident was supposed to wear the C-collar constantly, but staff reported that the resident did not like to wear it while sleeping or in the dining room. The C-collar was found in the laundry, wet and not in use, indicating a failure to follow physician's orders and ensure the resident's safety. The facility's policy required that physician orders be followed as prescribed, but this was not adhered to in this case.
Plan Of Correction
Develop implement Comprehensive Care Plan Identify patients that were at risk and what did: Ref Resident #43 Regarding Resident #43 the brace with appropriate interventions was added to Care Plan. How will you identify other residents that are at risk: 100 % audit was completed to identify residents with brace. Any residents with brace were reviewed to ensure appropriate Care Plan was completed. Measures put in place: Upon admissions residents are assessed for devices. Any Devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During morning meeting the MDS Coordinator will update and validate to the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also training was completed on for care plan team members regarding Floor mats, C- Collar Devices and Following Physician Orders. Nursing staff to communicate and document anytime a resident refuses treatment such as the C-Collar to update care plan. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on assistive devices (brace and floor mats). How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse and or Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Ref Resident #74 Regarding Resident #74 the Care Plan was completed with appropriate interventions to address. How will you identify other residents that are at risk: 100 % audit was completed to identify residents at risk for and Care Plan with appropriate interventions. Measures put in place: Upon admissions residents are assessed for risk. Any residents at risk for a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on precautions and floor mats. How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing. Ref Resident #291 Regarding Resident #291 the Care Plan was completed with appropriate interventions to address floor mats. How will you identify other residents that are at risk: 100% audit was completed to identify residents with floor mats and Care Plan in place with appropriate interventions. Measures put in place: Upon admissions residents are assessed for floor mats. Any residents found to need a floor mat a Care Plan will be completed with appropriate interventions to address. This will be reported and presented to the QAPI committee to ensure compliance. All nursing staff were in-serviced on floor mats, (risk for). How will you monitor: Through the continuous quality improvement program (Gang tackling) we will monitor compliance. The Director of Nursing, MDS Coordinators, Restorative Nurse and our Designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Tripping Hazard Due to Improper Electrical Cord Management
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not adequately managing an electrical cord, which created a tripping hazard. During an observation, it was noted that an electrical cord for an air mattress was wrapped around a side table and suspended in the air, posing a risk of tripping in the resident's room. A registered nurse was present during the observation and was informed of the hazard by the surveyor. The nurse then readjusted the plug behind the bed. The resident involved had a history of acute failure and COVID-19, and was dependent on staff for transfers due to monoplegia of the right dominant side. The resident's care plan indicated a risk related to their condition, and interventions were in place to follow facility protocol. The facility's policy emphasized making the environment as free from accident hazards as possible, with a focus on resident safety and supervision. However, the presence of the tripping hazard indicated a lapse in adhering to these safety protocols.
Plan Of Correction
F-689 Free of Hazards / Supervision/Devices Identify patients that were at risk and what did: Patient #2 bed cord was identified by surveyor and told Administrator; the director of plant operations was instructed to tie all the to the frame to be removed from any potential trip hazard. Thereafter, a full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety on. How will you identify other patients that are at risk: A full house audit was completed after surveyors identified the issues on potential tripping hazards. All rooms were checked for safety. Staff were also inserviced on to discuss the risk of tripping hazards. Measures put in place: Staff were inserviced on all risk and precautions and safety measures that required. Upon admission, resident rooms are assessed for room safety. The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with any potential trip hazards such as any electronic charging devices. We have also added to our Gang Tackling Quality programs where scheduled rooms are checked monthly to ensure that any findings out normal are addressed immediately and reported to Management. The forms are part of Housekeeping and Maintenance department QAPI Tracking. Training occurred on staff were also provided with 6-point training on overall safety hazards and the risk associated. The supervisor form will be handed to DON for compliance tracking. How will you monitor: The DON/Maintenance and Housekeeping Supervisors will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Deficiency in Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a catheter, as evidenced by observations of the tubing being kinked and touching the floor. During the survey, Resident #2 was observed in bed with oxygen in progress at 2 liters per minute via a nasal cannula, and no apparent distress was noted. However, the catheter tubing was observed to be kinked in a circle and not properly draining. A Registered Nurse (RN) present in the room was notified by the surveyor about the kinking of the tubing, and the RN then straightened out the tubing to allow free flow. The RN stated that they round every morning to check the tubing, but on this occasion, they did not notice it was kinked. Further observations revealed that the catheter tubing was touching the floor. A Licensed Practical Nurse (LPN) stated that the tubing was not touching the floor during their rounds and suggested that the bed being lowered too low might have caused the tubing to touch the floor. The LPN rounds every two hours and communicates with the Certified Nursing Assistant (CNA) about required interventions for care. The CNA confirmed receiving in-services on catheter care and stated that they ensure the collection bag does not touch the floor and is anchored to the bed. Despite these measures, the tubing was found touching the ground, indicating a lapse in maintaining proper catheter care. The Director of Nursing (DON) was made aware of the concerns and stated that staff are to monitor the catheter to ensure it is draining properly and that the tubing is not kinked or touching the floor. The physician orders for Resident #2's care were found to be outdated, as they did not reflect the current catheter in use. The facility's policy on catheter care emphasizes securing and checking drainage tubing and bags to prevent urinary tract infections, but the observations during the survey indicated non-compliance with these procedures.
Plan Of Correction
Identify patients that were at risk and what did: Regarding Resident #2, the drainage tubing was immediately changed, and the bed was raised. The assigned Nurse and C.N.A were immediately in-serviced on control protocol and the difference between Super pubic and regular. Identify patients that were at risk and what did: A 100% audit was completed to identify residents with care and/or to ensure bags are not kinked and not touching the floor. All nurses and CNAs were educated on control protocol and the difference between Super pubic and regular. Measures put in Place: A clinical in-service was held for all nursing staff to discuss care and control protocol. How will you monitor: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with safety as far as positioning and ensuring that it is not touching the floor. Additionally, the supervisor form will be handed to the DON for compliance tracking. The DON created a care random audit observations checklist. The random audit will be done daily. Continuous in-service on the care of residents with super pubic and needed will be done monthly and as needed.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly store medications, as evidenced by several observations made during a survey. In the West Wing medication storage room, a box containing multiple expired Covid-19 test kits was found. Staff S, a Registered Nurse supervisor, confirmed the expiration dates and removed the expired kits. Despite the Director of Nursing (DON) stating that the expired tests could still be used due to an extended expiration date listed on the FDA website, the presence of expired items in the storage room indicates a lapse in the facility's protocol for monitoring and removing expired supplies. Additionally, an unlocked medication cart was observed on the West side nursing station. Staff U, an RN, acknowledged that the cart should have been locked when unattended but admitted to forgetting due to being in a hurry to assist residents. This oversight highlights a failure to adhere to the facility's policy that requires medication carts to be locked when not in use, ensuring that medications are not accessible to unauthorized individuals. Furthermore, in the room of a resident, Staff H, an RN, left a cup of crushed medication mixed in water and a lancet unattended while retrieving an item to assist with a procedure. Staff H later explained that the presence of the surveyor led to the oversight, but acknowledged that the proper protocol is to take medications and materials when leaving a resident's room. This incident underscores a breach in the facility's policy for safe and secure medication storage and handling, as medications should not be left unattended to prevent potential misuse or errors.
Plan Of Correction
Identify patients that were at risk and what did: Once identified by surveyor the staff address of expired COVID Test, they were discarded. Central supply and Nursing managers educated immediately when identified by the surveyor and the Pharmacy consultant held a meeting with all nurses' about this topic on about expired medications and provided education. The nurse that left the medication cart unlocked was disciplined on. An Inservice with all nurses was done on to ensure compliance with Storage Biologicals Medications, Med Pass Administration and procedure by Pharmacist consultant. The DOH did a pharmacy audit on. How will you identify other patents that are at risk: Medication Rooms and Medication Carts were checked for expired medications once identified by surveyor. DON and Nurse management checked med carts. The pharmacy was contacted to help with Med pass Inservice and came to educate nurses on. The Inservice included ensuring keeping carts locked when not in use and expired meds. Measures put in Place: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with Medication Administration sample. The supervisor form will be handed to DON for compliance tracking. In-service completed by Pharmacy consultant on for all nurses on expired medications and provided education. Training was also done by the Consultant pharmacist on regarding any expired testing kits and or medications. The inservice also included ensuring keeping carts locked when not in use. The DON Created new audit tolls called on: - Medication Cart Audit - Treatment Cart Audit - Med room Audit Investigator from the Florida Department of Health Division of Medical Quality Assurance conducted an inspection. No findings. How will you monitor: The Pharmacist will conduct a monthly audit of all medications and Carts. Nursing staff will conduct weekly audit of all medication and carts. The DON Managers and Consultant Pharmacist will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Improper Disposal of Cardboard Boxes
Penalty
Summary
The facility failed to properly dispose of cardboard boxes, as observed outside the kitchen door. The facility's policy requires that food storage boxes and containers be disposed of by the end of each shift into the outside dumpsters. However, during an observation at 7:01 AM, multiple cardboard boxes were found scattered on the ground and not contained in the garbage bin. This was confirmed by photographic evidence. Interviews with staff further highlighted the deficiency. A Dietary Aide stated that someone is responsible for breaking down the cardboard boxes and taking them to the garbage container, indicating that the boxes should not be left on the ground. The Dietary Director also confirmed that the cardboard boxes were removed from the ground outside the kitchen door and acknowledged that they should not have been there.
Plan Of Correction
F-814 Dispose Garbage and Refuse property: Identify patients that were at risk and what did: Once identified by surveyor with multiple cardboard boxes on the ground and not contained in the garbage bin. The Certified Dietary manager and Registered Dietician met with staff on and to ensure that the empty cardboard boxes were no longer allowed to be left unattended and not broken down and discarded. No residents were placed at risk. How will you identify other patents that are at risk: Once identified by surveyor with multiple cardboard boxes on the ground and not contained in the garbage bin. The Certified Dietary manager and Registered Dietician met with staff on and to ensure that the empty cardboard boxes were no longer allowed to be left unattended and not broken down and discarded. No residents were placed at risk. Measures put in Place: The CDM/RD or designee created a QAPI spot check form and created a new process to Discard cardboard boxes by dietary staff. This Inservice was completed on and Additionally, a Cardboard only bin was placed on the outside of building as a general cardboard disposal location. Ali other non-dietary boxes were also detailed to be broken down and discarded in a main garbage container. How will you monitor: The CDM /RD or designee will be responsible for bringing the findings or progress to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, as evidenced by a discrepancy in the Nurses' Progress Note. The note inaccurately documented that the resident was COVID-19 positive and receiving treatment with a Z pack, while in reality, the resident was COVID-19 negative and not receiving such medication. This inaccuracy was confirmed during interviews with the Director of Nursing and a Licensed Practical Nurse, who both stated that the resident did not have COVID-19 and was not on the mentioned medication. The facility's Charting and Documentation Policy requires that all services provided to residents and any changes in their medical or mental condition be accurately documented in their medical records. However, the review of the resident's records revealed a failure to adhere to this policy, as the progress note contained incorrect information about the resident's COVID-19 status and treatment. This error was not corrected in the medical record, which is a violation of the facility's policy on maintaining accurate medical records. The resident involved had a severe cognitive impairment, as indicated by a Brief Interview of Mental Status score of 00, and required dependent assistance for activities of daily living. The inaccurate documentation in the resident's medical record has the potential to affect the care and treatment provided to the resident, as well as other residents in the facility, by leading to inappropriate precautions or treatments based on incorrect information.
Plan Of Correction
F-842 Resident Records- identifiable Information Identify patients that were at risk and what did: Once identified by surveyor regarding Resident #33, the Director of Nursing contacted the LPN that erroneously documented that the patient was COVID positive when he was not and was asked to clarify the note. This was done on How will you identify other patents that are at risk: The LPN received a 1:1 training on Accurate Documentation. An audit was done on all remaining residents with diagnosis to ensure that the documentation was correct. Measures put in Place: An inservice was done for all Nurses on Resident Records- Identifiable information and Resident Accuracy was started for all nurses on and ongoing. Example of Error identified was presented and discussed. Thereafter, DON has an ongoing QAPI Plan for incorrect documentation Audit Tool. This was started on as a weekly review. How will you monitor: The DON and or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur Monthly for 3 months, then quarterly and or if any variances are reported ongoing.
Repeated Deficiencies in Infection Control Protocols
Penalty
Summary
The facility failed to implement effective plans of action to address quality deficiencies related to infection prevention and control protocols. Specifically, the facility did not follow control protocols in the east side soiled utility room and failed to implement hygiene protocols for a resident. This deficiency was identified during a recertification survey, where it was noted that the facility had previously been cited for similar issues. The survey history revealed that during a previous recertification survey, the facility was cited for failing to implement control procedures for three residents out of a sample of 28. This indicates a repeated pattern of deficient practices in infection prevention and control, which the facility has not adequately addressed. The Director of Nursing confirmed that the facility holds monthly Quality Assurance and Performance Improvement (QAPI) meetings, involving various department heads, to review deficiencies and track corrective actions. Despite these meetings and efforts to monitor quality assurance, the facility's actions have not been effective in preventing repeated deficiencies. The failure to follow established protocols in the soiled utility room and for the resident's hygiene suggests a lack of systematic implementation and monitoring of infection control measures. This ongoing issue affects the facility's ability to provide safe and effective care to its residents.
Plan Of Correction
F-867 QAPI/QAA Improvement Activities Identify patients that were at risk and what did: Initially, the management team created a QAPI from the initial exit with areas of concerns. We started immediate in-services since and changed systems and strengthened our quality assurance process and created all new tracking tools. Once the final 2567 came through, we updated the audits and worked on our plans as a team. Ref F880 QAPI action Plan: Once identified by the surveyor, all staff that distribute meal service were reeducated on the process of Donning and Doffing when entering a room with droplet precautions. Once identified by the surveyor, resident #57 was assessed and is in stable condition. Regarding the staff member that double gloved, she was counseled on not following proper control procedures. Once identified by the surveyor, all staff were reeducated on the process of hygiene and also were provided individual education with acknowledgment. All staff were in-serviced on keeping the Common and the Pantry areas cleaned with no trash to be found on the floor, and this was done on. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and is now monitoring randomly to ensure that the battery-operated lock system is working regularly. All shower rooms are the responsibility of any staff member that enters the shower room to take a resident into the shower room; there will be no cartons or food-related permits nor masks in the shower room. Resident tubing touching the floor education was done on. When a patient is on droplet precaution, we will do all possible to keep doors closed at all times. If the resident cannot comply due to mental state or is at risk, the team will care plan and possibly look for alternatives to include discharge. We will always try to mediate the issue for compliance with standards. We also have to honor the fact that this is their home and will work on reasonable accommodations. How will you identify other patients that are at risk: Ref F880 QAPI action Plan: Besides the care nurse, all staff were re-educated on control procedures on (25). Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. Measures put in Place: Besides the care nurse, all staff were re-educated on control procedures on (25). Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. The following identified areas were used for education to staff and will be maintained on our QAPI for the remainder of the year for tracking and trending data: F583-(N202) Personal Rights and Confidentiality F-645 PASSAR Screening F-656- (N054 and N072) Develop and Implement Care Plans F-761-(N095)- Label Drugs and Biologicals F-842- Resident Records Identifiable Information F-814 Dispose Garbage and Refuse Property F-867- QAPI/ QAA Improvement Activities F-880- Control Control Plan - Proper techniques of Donning and Doffing - Droplet vs Enhanced Barrier Precaution - Meal tray distribution - Transmission Based Precautions Hygiene - High Touch areas - Linen Handling including clean and soiled - Cath Tubing not touching the floor Nursing focus will include: - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional How will you monitor: The Administrator and Director of Nursing will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing. Since QAPI was identified as needing improvement, we have changed the reporting and all citations will have a structured monitoring designated by accountable reporting, trending, analysis, and follow-through.
Penalty
Summary
Tags Sprinkler System.
Penalty
Summary
Smoking regulations.
Penalty
Summary
Cylinder and Container Storage.
Plan Of Correction
Cylinder and Container Storage Measure put in place: The system was revaluated by the QAPI Committee and education was required for all staff since all residents were at risk as a facility wide initiative.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to maintain accurate Minimum Data Set (MDS) records for two residents, leading to deficiencies in their care plans. Resident #24 was incorrectly coded as a hospice resident in the MDS, despite having no hospice orders in their medical records. This discrepancy indicates a lack of accurate documentation and communication within the facility regarding the resident's care status. The resident's medical history included surgical aftercare, but there was no care plan related to hospice, highlighting a significant oversight in the resident's care documentation. Similarly, Resident #89 was inaccurately coded in the MDS as having a planned return to a short-term general hospital, although the resident was actually discharged to an Assisted Living Facility (ALF). The medical records and physician's orders confirmed the discharge to an ALF, yet the MDS did not reflect this change. This error suggests a failure in updating the resident's discharge status accurately, which is crucial for ensuring continuity of care and appropriate resource allocation. Interviews with the MDS Coordinator revealed that there was an oversight error in the communication process between departments, including nursing, social services, and billing. The coordinator acknowledged the need for modifications to correct these inaccuracies. The facility's policy requires timely and appropriate resident assessments, but the errors in the MDS coding for these two residents indicate a lapse in adherence to these procedures, resulting in the noted deficiencies.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to maintain accurate Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their documented care needs and discharge plans. Resident #24 was incorrectly coded as a hospice resident in the MDS, despite having no hospice orders in their medical records. This resident was admitted for surgical aftercare, and the MDS inaccurately reflected their status, as there was no care plan related to hospice. Similarly, Resident #89 was inaccurately coded in the MDS as having a planned return to a short-term general hospital, while their medical records indicated a discharge to an Assisted Living Facility (ALF). The care plan for Resident #89 supported discharge to an ALF, with interventions for transportation and post-discharge care planning. The inaccuracies in the MDS assessments were attributed to oversight errors by the MDS Coordinator, who acknowledged the need for modifications to correct these errors. The facility's policy requires timely and appropriate resident assessments, but the discrepancies in the MDS coding for these residents indicate a failure to adhere to these requirements. The MDS Coordinator stated that communication with nursing, social services, and billing departments occurs to clarify discharge plans, but these processes did not prevent the errors in the residents' MDS documentation.
Failure to Implement Restorative Care Plan for C-Collar Use
Penalty
Summary
The facility failed to create and implement a Restorative Care Plan for a resident who had a physician's order to wear a C-collar at all times. Observations revealed that the resident was often found lying in bed without the C-collar, and there was no care plan in place for its use. The resident was observed at different times of the day, appearing tired and disoriented, but without visible signs of distress or discomfort. The resident's medical records indicated a diagnosis that required the use of a C-collar, with specific instructions to keep it in place at all times, except during care, and to inspect the skin for abnormalities every shift. However, interviews with staff revealed inconsistencies in following these orders. A Registered Nurse acknowledged the requirement for the C-collar to be worn constantly, while a Restorative Certified Nursing Assistant noted that the resident often did not like to wear it while sleeping or in the dining room. The C-collar was found to be in the laundry, wet, and not available for immediate use. The Director of Nursing confirmed that staff monitored the resident every two hours and mentioned the resident's participation in a prevention program. Despite this, there was no new order received for the removal of the C-collar after a CT scan was conducted. The facility's policy requires that physician orders be followed as prescribed, and any deviations must be documented in the resident's medical records, which was not done in this case.
Plan Of Correction
Identify patients that were at risk and what did: Patient #43. Care plans were updated accordingly, and different interventions were made. Regarding Resident #43, the brace was added to the care plan. All other residents with similar devices were also identified and care plans verified. How will you identify other patients that are at risk: Regarding Resident #43, the brace was added to the care plan. All other residents with similar devices were also identified and care plans. (Audit Tool) Measures put in Place: Upon admissions, residents are assessed for devices. Any devices such as braces or other devices are reviewed upon admission and reviewed in our morning meeting. During the morning meeting, the MDS Coordinator will update and validate the team when this is completed. Restorative Nursing will be maintaining a weekly checklist of all new devices and will be addressed on care plan. Also, training was completed for care plan team members regarding floor mats, C-Collars, devices, and following physician orders, and nursing to communicate anytime a resident refuses treatment such as the C-Collar. This will be reported and presented to the QAPI committee to ensure compliance. How will you monitor: The Director of Nursing, MDS Coordinators, Restorative Nurse, and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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