Miracle Hill Nursing & Rehabilitation Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Tallahassee, Florida.
- Location
- 1329 Abraham Street, Tallahassee, Florida 32304
- CMS Provider Number
- 105810
- Inspections on file
- 24
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Miracle Hill Nursing & Rehabilitation Center, Inc during CMS and state inspections, most recent first.
A resident with behavioral health needs did not receive prescribed Clonidine patches on multiple occasions due to a medication order discrepancy and communication failures between nursing staff and pharmacy. The order was incorrectly entered as a tablet to be given transdermally, leading to the pharmacy delivering the wrong form. Nursing staff did not promptly escalate the issue, and facility policies for verifying and communicating medication errors were not followed.
A resident with diabetes did not receive prescribed insulin or blood glucose monitoring due to failures in documentation, communication, and staff awareness. Despite abnormal lab results and physician orders present in the chart, nursing staff did not implement diabetes care, and the diagnosis was omitted from the MDS, care plan, and medication records. The resident was hospitalized twice for complications related to unmanaged diabetes.
Three residents requiring assistance with ADLs did not consistently receive necessary bathing and hygiene care, as evidenced by observations of poor grooming, infrequent showers, and incomplete documentation. Staff interviews and record reviews confirmed that scheduled care was not provided or properly documented, and family grievances highlighted ongoing concerns about inadequate personal care.
Surveyors found that two resident rooms were not maintained in a sanitary or homelike condition. One room had a sticky floor and a dried brown substance on the wall that was not fully cleaned, as confirmed by an LPN. Another room had a damaged bedside table with missing paint and a missing drawer knob, as well as walls with deep scratches and exposed plaster, which maintenance staff attributed to the bed's position. These findings reflect a lack of proper upkeep and cleanliness in the resident environment.
A resident admitted with multiple complex medical conditions, including end stage renal disease, diabetes with neuropathy, heart disease, and cirrhosis, did not have these diagnoses properly coded on the admission MDS assessment. The MDS Coordinator acknowledged the error during an interview.
A resident with documented depression and dementia was not referred for a required level 2 PASARR screening, despite the initial assessment indicating suspicion of serious mental illness. Record review showed no evidence of the necessary screening, and staff interviews confirmed the PASARR had not been updated and that facility policy did not address timing or completeness requirements.
A resident with diagnoses of depression, dementia, bipolar disorder, and anxiety disorder did not have an updated PASARR Level 2 screening as recommended. The original PASARR form indicated the need for further review, but no documentation of follow-up was found, and staff interviews confirmed the process was not completed as required.
Surveyors identified that two residents had incomplete care plans, with missing goals and interventions for multiple identified needs, including complex medical conditions and activity participation. Staff interviews confirmed that the care plans had not been fully developed or implemented as required.
A resident at risk for skin breakdown due to decreased mobility, incontinence, and fragile skin developed a pressure ulcer after staff did not consistently assist during incontinence episodes. Although the care plan required weekly skin checks and physician notification of any breakdown, documentation showed a missed skin assessment and lack of follow-up interventions after excoriation was noted. The DON confirmed the assessment was not completed and expected interventions were not implemented.
A resident with contractures in the left upper and lower extremities was not provided with therapy or restorative services for range of motion or splinting since admission, despite care plan goals to prevent complications. Staff interviews and record reviews revealed a lack of therapy screening documentation and no initiation of a restorative program for the resident.
Two residents receiving hemodialysis did not have physician orders documented for dialysis care, services, or monitoring of access sites. Staff interviews confirmed that required orders and assessments were missing from the medical records, and facility policy requiring such documentation was not followed.
Two residents did not receive their ordered medications when an LPN and an RN were unable to locate Zoloft and the correct dose of Coreg, respectively, in the medication cart or Omnicell. Both nurses indicated they would notify the pharmacy and physician, and the DON confirmed that medications are expected to be reordered in advance and should not run out.
Surveyors found that medications were not properly labeled or stored, with several medication cups left in a cart for residents who were not present, and opened medications such as eye drops and nebulizer solutions missing required opened dates. Additionally, a narcotic medication count did not match documentation, as a nurse failed to sign out a dose of Tramadol after administration. These actions were inconsistent with facility policy and accepted professional standards.
Two residents did not receive their prescribed medications because the facility failed to ensure medication availability and administration. An LPN and an RN were unable to provide Zoloft and the correct dose of Coreg, respectively, as the medications were not present on the cart or in the emergency supply. The DON and Administrator confirmed that the QAPI plan only addressed thyroid medications and did not cover other medication availability issues, resulting in these deficiencies.
The facility did not provide documentation showing that two residents received education and were offered influenza immunizations, with records indicating vaccine administration on a future date and no current information available at the time of the survey.
The facility did not provide proper documentation showing that two residents received education and were offered the COVID-19 vaccine. In one case, a vaccine refusal was not signed by the resident or responsible party, and in another, records of education and consent or declination were missing. The DON confirmed the vaccine process but could not provide the required documentation during the survey.
Multiple bedrooms were found to have non-functional call light systems, with some missing call light cords entirely. Observations and staff interviews confirmed that the call system was outdated and not regularly checked by facility staff between outside contractor visits. Facility policy requires the call system to be functional and routinely maintained, but documentation of regular checks was lacking.
The facility did not consistently document the administration of Levothyroxine for two residents, as required by policy. Multiple dates were found where the medication was not signed off on the MAR, and one resident's lab results and provider notes indicated ongoing issues with medication adherence. The DON confirmed that documentation should occur at the time of administration, but this was not done.
Failure to Administer Prescribed Clonidine Patch Due to Order and Communication Errors
Penalty
Summary
The facility failed to implement the plan of care for one resident regarding medication administration. The resident, who had a diagnosis including bipolar disorder, reported not receiving his prescribed Clonidine patch for several weeks. Review of the medical record confirmed that the Clonidine patch was not administered on two occasions, with documentation indicating the medication was not available and had been reordered. The hospital discharge orders specified a Clonidine patch, but the order entered into the facility's electronic medical record incorrectly listed a tablet to be given transdermally. This discrepancy led to the pharmacy delivering the incorrect form of the medication, and the resident did not receive the intended treatment as ordered. Interviews with staff revealed that nursing was aware of the issue, as a pill was delivered instead of a patch, but the problem was not escalated promptly. The DON acknowledged that the receiving nurse should have verified the order and contacted the pharmacy upon noticing the error. Facility policies required nursing staff to communicate medication order discrepancies to the pharmacy and DON, and to ensure medications are administered as prescribed. However, these procedures were not followed, resulting in the resident missing prescribed doses of the Clonidine patch.
Failure to Provide Diabetes Management and Monitoring
Penalty
Summary
A resident with a history of diabetes mellitus was admitted to the facility and subsequently exhibited significantly elevated blood glucose levels and A1C values on multiple occasions. Despite these abnormal laboratory results, there was no documented intervention, nursing action, or medical orders to address the elevated blood glucose and A1C. The resident was later hospitalized for altered mental status and diagnosed with diabetic ketoacidosis, encephalopathy, and a urinary tract infection. Upon readmission, the resident's diabetes diagnosis was not reflected in the Minimum Data Set (MDS), care plan, or medication administration record, and no blood glucose monitoring or diabetes medications were provided. Interviews with staff revealed a lack of awareness of the resident's diabetic status, and chart checks intended to identify such issues were not consistently performed. Orders for insulin and blood glucose monitoring were present in the physical chart but were not carried out by nursing staff. The nursing admission screening did document new onset diabetes, but this information was not integrated into the resident's ongoing care. The deficiency resulted from failures in communication, documentation, and adherence to physician orders, leading to the resident not receiving necessary diabetes management.
Failure to Provide Adequate ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically related to bathing and personal hygiene, for three residents who required such care. One resident was observed to be disheveled, with unbrushed and oily hair, and reported having only two showers since admission, both provided by Occupational Therapy staff. Documentation review showed that scheduled showers were not consistently provided or documented by nursing staff, and the unit manager confirmed that lack of documentation indicated the care was not performed. Another resident was observed with matted and tangled hair, and records showed only four documented baths in a month, with no documentation of bathing or attempts to bathe for the past 30 days. Staff interviews confirmed that refusals should be documented, but there was no evidence of such documentation in the records reviewed. A third resident was noted to have a strong smell of urine and, according to a family member, had not received a shower for several months, only sponge baths, and was left in urine-soaked clothes. Grievance logs indicated repeated family complaints about inadequate bathing care, with documentation showing only a few showers provided and some refusals recorded. The facility's policy required staff to provide appropriate support and assistance with hygiene for residents unable to perform ADLs independently, but observations, interviews, and record reviews demonstrated that this standard was not met for the residents involved.
Failure to Maintain Sanitary and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that the floor in one resident room was sticky and a dried brown substance was present on both the floor and wall in the left corner near the doorway. Although the substance was removed from the floor after initial observation, it remained on the wall during subsequent visits, and the floor continued to be sticky. An LPN responsible for the hallway confirmed the need for cleaning both the floor and the wall, indicating that the room was not maintained in a sanitary or comfortable condition. In another resident room, the bedside table was found to be in poor condition, with missing paint and exposed particle board, and the top drawer lacked a knob. The wall beside the head of the bed was scraped and scratched, exposing multiple paint layers and plaster, while the wall behind the other bed had deep metal-colored scratches. The maintenance staff member acknowledged these issues, noting that the bed's position against the wall caused repeated damage and that the bedside table required replacement. These observations demonstrate a failure to provide a safe, clean, and homelike environment in two occupied rooms.
Failure to Accurately Code Admission Diagnoses on MDS Assessment
Penalty
Summary
The facility failed to accurately identify and code a resident's diagnoses on the Minimum Data Set (MDS) assessment upon admission. Record review showed that a resident was admitted with multiple significant medical conditions, including end stage renal disease, dependence on renal dialysis, Type 2 diabetes with neuropathy, atherosclerotic heart disease, chronic ischemic heart disease, hypertension, cardiac pacemaker, cirrhosis of the liver, heart failure, atrial fibrillation, osteoarthritis, and pneumonia. However, these diagnoses were not properly coded on the resident's admission comprehensive MDS assessment. During an interview, the MDS Coordinator confirmed that the admission diagnoses were not coded correctly.
Failure to Complete Required Level 2 PASARR Screening
Penalty
Summary
The facility failed to forward a resident for a level 2 Preadmission Screening and Resident Review (PASARR) as required. Record review for a resident revealed that the PASARR form, dated 7/16/20, indicated both depression and dementia, and the completion section specified that a level 2 screening was needed due to suspicion of serious mental illness. However, there was no documentation in the record that a level 2 screening had been completed. During interviews, a Registered Nurse responsible for PASARR compliance stated that the resident's PASARR had not been updated since 2021 and acknowledged it should have been done. Additionally, the Administrator initially reported there was no specific PASARR policy, and when a policy was later provided, it did not address the timing or completeness of PASARRs.
Failure to Update PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASARR) for a resident with mental health diagnoses. Record review showed that the resident had a PASARR form completed in July 2020, which listed depression and dementia and recommended a Level 2 screening due to suspicion of serious mental illness. However, there was no documentation of a Level 2 screening being completed. Additional diagnoses of bipolar disorder and anxiety disorder were added in subsequent years, but no further PASARR actions were documented. Interviews with staff confirmed that the PASARR process was not followed up as required, and the facility did not have a specific policy addressing the timing of PASARR updates.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents, as required. For one resident admitted with multiple complex medical conditions, including end stage renal disease, dependence on dialysis, diabetes with neuropathy, atherosclerotic heart disease, hypertension, cirrhosis, heart failure, atrial fibrillation, osteoarthritis, and pneumonia, the care plan did not include documented goals or interventions for identified focus problems such as risk for falls, complications from anticoagulant use, activity involvement, ADL self-care, and potential complications related to dialysis, diabetes, and cardiovascular disease. Staff confirmed that the care plan remained incomplete since admission, despite the facility's policy allowing 14-21 days to complete care plans after admission assessment. A second resident's care plan was also found incomplete during record review. The care plan for this resident lacked specific instructions and measurable goals regarding activity participation and the resident's level of independence or dependence on staff for meeting emotional, intellectual, physical, and social needs. Staff acknowledged the incompleteness of the care plan and agreed that it required correction. These findings were based on interviews and record reviews conducted by surveyors.
Failure to Consistently Prevent and Address Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to consistently provide services to prevent pressure ulcers for a resident at risk due to decreased mobility, incontinence, and fragile skin. The resident reported developing a pressure ulcer, attributing it to insufficient staff assistance during incontinence episodes. The care plan included weekly skin checks and physician orders for weekly skin assessments with notification of any breakdown. However, documentation showed the most recent skin assessment was completed on 5/24/25, noting redness and excoriation in the groin, buttocks, and perineal area, with no evidence of new orders or progress notes addressing these issues. The DON confirmed that the required skin assessment for 5/31/25 was not completed, despite the treatment administration record being signed off, and that the expected intervention of ordering a barrier cream and further assessment was not carried out.
Failure to Provide Range of Motion and Restorative Services for Resident with Contractures
Penalty
Summary
A resident with contractures in the left upper and lower extremities was observed over several days with her left arm and hand contracted to her chest and abdomen. The resident reported not having received any therapy or restorative services since admission. Record review confirmed that the resident was admitted with contractures and her care plan included a goal to remain free of complications related to contracture and immobility. However, there was no evidence in the medical record that a therapy screening or restorative program had been initiated for her. Interviews with facility staff revealed inconsistencies and lack of documentation regarding therapy screenings. The Director of Therapy stated that screenings were conducted on several dates, but no documentation could be provided. The only documented screening was after the resident experienced falls, and no restorative program had been initiated. The restorative nurse confirmed that the resident had not received any restorative services for splinting or range of motion since admission. This failure to assess and provide appropriate services for range of motion and contracture management led to the deficiency.
Lack of Physician Orders and Monitoring for Dialysis Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for two residents receiving hemodialysis. Record reviews showed that neither resident had physician orders for dialysis care, services, or treatments documented in their medical records. For one resident, although there was an order to receive dialysis on specific days, the order did not specify the dialysis location, transportation times, or instructions regarding holding medications during dialysis. The other resident also lacked physician orders for dialysis services, including monitoring of the fistula site for bruit and thrill, signs of infection, bleeding, pressure bandage, swelling, and details about the dialysis schedule and location. There were no orders to hold medications while at the dialysis center for either resident. Interviews with an LPN and the Director of Nursing confirmed that staff are expected to monitor and assess dialysis access sites before and after treatments and that physician orders should be present in the medical record for such care. Both staff members acknowledged the absence of these required orders for the two residents. A review of facility policy indicated that staff are responsible for verifying physician orders, measuring vital signs, and observing shunt sites before and after dialysis, but these actions were not supported by documented orders in the residents' records.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to provide medications as ordered for two residents during medication administration observations. In one instance, an LPN was unable to administer Zoloft, a medication prescribed for depression, to a resident because it was not available in the medication cart or in the facility's emergency medication supply (Omnicell). The nurse informed the resident that the medication had not arrived from the pharmacy and indicated she would notify the physician and pharmacy. In another instance, an RN was unable to administer the ordered dose of Coreg 12.5 mg, a medication used to treat heart failure, to a different resident because the correct dosage was not available in the medication cart or in sufficient quantity in the Omnicell. The nurse indicated she would notify the pharmacy and physician. The DON stated that it is expected for nurses to reorder medications from the pharmacy seven days before running out and to check the Omnicell if medications are not available, but acknowledged that medications should not run out.
Medication Storage, Labeling, and Documentation Deficiencies
Penalty
Summary
Surveyors observed that medications were not stored and labeled according to professional standards and facility policy on two medication carts. On one cart, three medication cups containing medications were found in a drawer, each labeled with numbers, after a nurse prepared them for residents who were not present at the time of administration. The nurse acknowledged that facility policy requires discarding medications if not administered and prohibits pre-pulling medications. Additionally, four bottles of eye drops and a bag of nebulizer medication were found without opened dates, despite the requirement to date medications upon opening due to shortened expiration periods. On another medication cart, two bottles of eye drops were also missing opened dates, and a narcotic card for Tramadol showed a discrepancy between the physical count and the narcotic sign-out sheet, with one tablet unaccounted for and no corresponding documentation in the medication administration record. The nurse responsible admitted to administering the medication but forgetting to sign it out. Facility policies reviewed confirmed the need for dating opened medications and maintaining accurate controlled substance records, including immediate documentation of administration.
Failure to Ensure Medication Availability and Administration Due to Ineffective QAPI
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems related to medication availability and administration. During a survey, it was observed that two residents did not receive their prescribed medications because the medications were not available on the medication cart or in the facility's emergency medication supply (Omnicell). In one instance, a resident did not receive Zoloft, an antidepressant, because it had not arrived from the pharmacy and was not available in the Omnicell. In another case, a resident did not receive the correct dose of Coreg, a medication for heart failure, because the required dosage was not available on the cart or in sufficient quantity in the Omnicell. Interviews with nursing staff and facility leadership revealed that the expectation was for nurses to reorder medications from the pharmacy seven days before running out, and to check the Omnicell or contact the pharmacy if medications were not available. However, these procedures were not followed, resulting in missed medication doses. The Director of Nursing and the Administrator acknowledged that their QAPI plan was limited in scope, focusing only on thyroid medications, and did not address broader issues with medication availability, leading to the deficiencies observed.
Lack of Documentation for Influenza Vaccine Education and Offer
Penalty
Summary
The facility failed to provide documentation that two out of five residents received education and were offered influenza immunizations. Record reviews for these residents showed that the influenza immunization was documented as being administered on a future date, which had not yet occurred. During an interview, the DON confirmed that flu, pneumonia, and COVID vaccines are offered yearly in the fall, but was unable to provide current documentation for the influenza vaccines for these two residents at the time of the survey.
Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to provide documentation that two of five residents received education and were offered a COVID-19 immunization. For one resident, the record indicated a refusal of the COVID vaccine, but there was no signature from the resident or a responsible party to confirm this decision. For another resident, the medical record lacked both documentation of education and a consent or declination form regarding the COVID immunization. During an interview, the DON stated that COVID vaccines are offered yearly in the fall, but the missing documentation for these residents was not provided before the survey exit.
Failure to Maintain Functional Resident Call System in Multiple Bedrooms
Penalty
Summary
The facility failed to maintain a fully functional resident call system in 4 out of 8 sampled bedrooms, as evidenced by direct observations and staff interviews. During inspections, the call light systems in several rooms were found to be non-functional, with some rooms missing call light cords entirely. These deficiencies were observed in both occupied and unoccupied rooms, and photographic evidence was obtained for at least one instance. The Administrator confirmed that the call system was old and acknowledged the lack of evidence for regular staff checks between the biannual visits by an outside company. Service request documents and invoices indicated ongoing issues with the call system, including its obsolescence and the inability to order new parts for repair. Facility policy requires that the resident call system remain functional at all times and be routinely maintained and tested by the maintenance department. However, the only audit provided by the Administrator was from a previous month, and it showed that some repairs had been made, but there was no documentation of ongoing or recent checks for the rooms found deficient during the survey. The lack of a fully operational call system in multiple rooms demonstrates a failure to adhere to facility policy and ensure residents have a reliable means to call for assistance.
Failure to Document Administration of Thyroid Medications
Penalty
Summary
The facility failed to follow pharmacy documentation procedures for the administration of thyroid medications for two residents. For one resident, review of physician orders and medication administration records (MARs) over a three-month period showed multiple instances where Levothyroxine was not signed off as administered on specific dates. The resident's medical record indicated persistently high thyroid stimulating hormone (TSH) levels, and the resident reported not taking her medication as prescribed. The physician assistant's notes also reflected concerns that the resident had not been receiving her Levothyroxine as ordered while at the facility, leading to dose adjustments. For another resident, the MARs revealed several dates in February and March where Levothyroxine administration was not documented. An interview with the Director of Nursing confirmed that medication administration should be documented at the time of administration, and acknowledged awareness of the documentation lapses. Facility policy requires immediate documentation of all administered medications, but this procedure was not consistently followed for these residents.
Latest citations in Florida
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
