Ormond Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ormond Beach, Florida.
- Location
- 103 Clyde Morris Blvd, Ormond Beach, Florida 32174
- CMS Provider Number
- 105458
- Inspections on file
- 18
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Ormond Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain proper sanitation and food safety standards in the central kitchen. Observations included dirty floors, grease-coated skillets, uncovered garbage, and undated food items. Additionally, cold salads were stored at temperatures above the recommended levels. The Food Service Director and Corporate Food Service Manager acknowledged these deficiencies.
The facility failed to dispose of refuse in a sanitary manner, with observations revealing a large roll-off dumpster containing various debris and garbage, an open patio area with used utensils and food wraps, and four gray dumpsters with dirty standing water and trash. The Maintenance Director admitted to not noticing the unsanitary conditions, and the Administrator was informed of the findings.
The facility failed to treat residents with dignity during care and medication administration. An LPN and an RN were observed administering medications in the hallway to two residents with cognitive impairments, which is against the facility's policy. Additionally, an RN improperly signed and dated a dressing directly on a resident's abdomen instead of using a piece of tape as required.
A resident, who is cognitively intact, reported not being given a choice regarding the number and timing of showers. The resident was assigned specific shower days and was not given the option for more frequent showers, despite expressing a desire for them. The facility's policy on resident schedule choices was not followed.
The facility failed to maintain a safe, sanitary, and homelike environment for several residents and common areas. Observations revealed issues such as peeling paint, non-functional light bulbs, debris, and biological growth in shower rooms. Interviews with staff confirmed these issues and acknowledged the need for repairs and cleaning.
The facility failed to implement smoking care plans for two residents and an Enhanced Barrier Precaution (EBP) care plan for another resident. Despite being a non-smoking facility, residents were found smoking off-property without proper care plans. Additionally, a resident with multiple diagnoses did not have EBP interventions included in their care plan, indicating a failure to meet medical and nursing needs.
A facility failed to identify a pressure ulcer on admission for a resident with sepsis and liver abscess. Initial assessments did not document any pressure ulcers, but a stage II pressure ulcer on the coccyx was identified shortly after admission. The DON acknowledged the lack of documentation, leading to delayed care and intervention.
The facility failed to identify and evaluate two residents who smoke, despite having a policy for a smoke-free environment. Both residents admitted to smoking and keeping smoking materials, but the facility did not enforce its smoking policy or conduct necessary evaluations.
The facility failed to provide an anchor for catheter tubing for a resident with a BIMS score of 15 and diagnoses including a thoracic vertebra fracture, hypertension, and neuromuscular bladder dysfunction. During catheter care, a CNA did not use an anchor, contrary to facility policy and physician's orders.
The facility failed to identify significant weight loss and provide timely nutritional interventions for two residents. One resident experienced a severe weight loss of 13.5% within four days, and another resident experienced a 6.9% weight loss within three days. Both residents' nutritional needs were not adequately monitored or addressed, and the Registered Dietitian was unaware of their conditions due to a failure in the clinical dashboard system.
The facility failed to provide appropriate dialysis care for two residents, resulting in missed and improperly timed medication doses. Communication between the facility and the dialysis center was inadequate, leading to a lack of necessary documentation and coordination.
A resident with protein-calorie malnutrition, dysphagia, and type 2 diabetes did not receive the correct diet order as prescribed. Observations showed discrepancies between the diet orders and the meals provided, with the resident receiving improperly prepared food. Interviews revealed communication and implementation issues among staff, leading to the incorrect diet being served.
A resident began receiving OT without a physician order, contrary to the facility's policy. The resident, admitted with multiple diagnoses and cognitively intact, received OT on four occasions before a late clarification order was entered.
The facility failed to document a PICC line dressing change for a resident and did not record a verbal altercation between two residents. The DON confirmed the lack of documentation for the dressing change, and staff members were aware of the resident interaction but did not document it in the EHR.
The facility failed to ensure staff were aware of and used appropriate PPE for a resident on Enhanced Barrier Precautions (EBP) and did not maintain Contact Isolation Precautions for another resident. This led to non-compliance with infection control policies and CDC guidelines.
Failure to Maintain Sanitation and Food Safety Standards in Central Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a tour of the central kitchen, several deficiencies were noted, including dirty floors, opened cardboard boxes on the floor, grease-coated skillets, an uncovered dumpster with exposed garbage, and dirty paper napkins on plate warmers. Additionally, several lights were not working or were broken, air vents were dirty, and a scoop was found sitting on top of canned peaches. The Food Service Director was observed using an incorrect Hydrion Chlorine meter, and a dietary aide admitted that a cleaning cloth in a red bucket contained only soap and water. Other issues included a dirty fryer basket, undated and unlabeled food items in the walk-in refrigerator, and a dirty rag on the kitchen counter. The dry storage area floor was also dirty, and used paper towels were found under the stove area. During a second visit, cold cottage cheese and ham salads were found to be stored at temperatures above the recommended 40 degrees Fahrenheit, with internal temperatures of 46 and 48.8 degrees Fahrenheit, respectively. The Corporate Food Service Manager acknowledged that these items had been recently taken out of the walk-in refrigerator for the tray line. In an interview with the facility's Administrator, she was informed of these findings. The observations and interviews indicate a failure to maintain proper sanitation and food safety standards in the central kitchen, which could potentially compromise the health and safety of the residents. The facility's policies on sanitation and food safety were not adhered to, leading to multiple instances of non-compliance with professional standards for food service safety.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of refuse in a sanitary manner, as observed in the main dumpster area. During observations, a large roll-off dumpster was found containing debris, cardboard boxes, soda boxes, furniture, a mattress, and unidentified garbage. This dumpster had no lid and was only secured on three sides. Additionally, a large open patio area near the kitchen backdoor was observed with used utensils, food wraps, and debris. Four gray round dumpsters were noted with dirty standing water, unidentified trash, and garbage bags, attracting insects and emitting a foul odor. These observations were documented with photographic evidence. In an interview, the Maintenance Director, who oversees the daily cleaning of the dumpster area, admitted to not noticing the large open patio area with the utensils, food wraps, and debris. The Administrator was informed of these findings during an interview. The facility's policy on garbage and rubbish disposal, dated April 2022, mandates that all garbage and rubbish containing food waste be kept in containers with tight-fitting lids, cleaned daily, and stored to be inaccessible to vermin. The facility failed to adhere to these guidelines, resulting in unsanitary conditions in the dumpster area.
Failure to Treat Residents with Dignity During Care and Medication Administration
Penalty
Summary
The facility failed to treat residents in a dignified manner while providing care and services. For Resident #15, who had severe cognitive impairment, an LPN was observed administering medications in the hallway, which is against the facility's policy. The LPN admitted that medications should not be administered in the hallway. Similarly, Resident #38, who had moderate cognitive impairment, was also administered medications in the hallway by an RN, which is also against the facility's policy. For Resident #247, who had moderate cognitive impairment and was being treated for sepsis and an abscess of the liver, an RN was observed changing the resident's abdominal dressing. The RN signed and dated the dressing directly on the resident with a marker, which is not the correct procedure according to the facility's policy. The RN acknowledged that the correct procedure is to sign and date a piece of tape and then apply it to the resident after the wound care is completed. These actions demonstrate a failure to treat residents with dignity and respect during personal care and medication administration.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers according to the resident's preference. Resident #146, who is cognitively intact with a BIMS score of 15, reported that she was not given a choice regarding the number of showers she could receive. She was assigned shower days on Wednesdays and Saturdays during the 3-11 shift and was not given the option to choose morning or evening showers or to have more than two showers per week. The resident expressed a desire for more showers but was not given that option. A review of the resident's medical record showed that she was admitted with diagnoses including congestive heart failure, Type 2 diabetes, and hypertension. The electronic health record indicated that the resident received only one shower on 05/18/24. The Director of Nursing confirmed that all documentation was electronic and that CNAs charted showers in the task section of the EHR. The facility's policy on Activities of Daily Living (ADLS)/Maintain Abilities, dated 8/2022, states that residents have the right to choose their schedules, including bathing, consistent with their interests, assessments, and care plans. However, this policy was not followed in the case of Resident #146.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for several residents and common areas. Observations revealed that Resident #12's room had peeling paint and a non-functional light bulb, while Resident #146's room had similar issues with peeling paint and two non-functional light bulbs. Resident #248's room had mismatched paint and a non-functional light bulb, and Resident #247's room also had a non-functional light bulb. Additionally, Resident #197's room was found to have debris and disposable food packaging around and behind the bed, despite the resident having reported the issue multiple times to the staff without resolution. The facility's shower rooms were also found to be in poor condition. One shower room had loose tiles and black biological growth on the floor, while the other had an overwhelming odor of urine, a hairbrush in the sink, a used brief in a plastic bag on the floor, and personal belongings and towels in a plastic bag on the shower floor. Both shower rooms had black biological growth on the tiles and walls, and one had a non-functional fluorescent light fixture and a lock that did not work. Interviews with the Director of Housekeeping and the Director of Maintenance confirmed these issues and acknowledged the need for repairs and cleaning.
Failure to Implement Smoking and EBP Care Plans
Penalty
Summary
The facility failed to implement a smoking care plan for two residents and an Enhanced Barrier Precaution (EBP) care plan for another resident. Resident #7, who has diagnoses including Synovitis, Tenosynovitis, and Generalized Anxiety Disorder, was found to be smoking on the property next door and storing cigarettes and a lighter in an unlocked closet. Despite being a non-smoking facility, the resident's care plan did not adequately address the risks associated with smoking, and the facility staff were unaware of where the smoking materials were kept. Similarly, Resident #28, with diagnoses including Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder, was also found to be smoking off-property without a proper smoking care plan in place. The facility's staff, including the Administrator and Director of Nursing (DON), acknowledged that they did not conduct smoking evaluations because the facility is non-smoking, despite residents' smoking habits being known to them. Additionally, the facility failed to implement an EBP care plan for Resident #247, who has diagnoses including Sepsis and Abscess of the Liver. The resident's care plan included interventions for IV therapy and liver abscess infection but did not include EBP interventions for skin integrity impairment to the coccyx. The facility's policy requires comprehensive care plans to be developed and maintained for each resident, incorporating identified problem areas and risk factors. However, the care plan for Resident #247 lacked necessary EBP interventions, indicating a failure to meet the resident's medical and nursing needs. The facility's policy on comprehensive care plans mandates that they be developed within seven days of the resident's assessment or within twenty-one days after admission, whichever occurs first. Care plans are to be revised as changes in the resident's condition dictate and reviewed at least quarterly. The failure to implement appropriate care plans for smoking and EBP for the residents in question highlights a significant deficiency in the facility's adherence to its own policies and procedures, potentially compromising resident safety and care quality.
Failure to Identify Pressure Ulcer on Admission
Penalty
Summary
The facility failed to identify a pressure ulcer on admission for a resident, leading to a deficiency in pressure ulcer care. The resident was admitted with diagnoses including Other Gram-Negative Sepsis and Abscess of Liver. Initial assessments and documentation did not note any pressure ulcers, and the Minimum Data Set indicated no existing pressure ulcers. However, a physician's order for wound care on the coccyx area was placed shortly after admission, and a stage II pressure ulcer was identified by a Nurse Practitioner on the coccyx area. This discrepancy indicates that the pressure ulcer was either missed during the initial assessment or developed shortly after admission without timely identification and documentation by the facility staff. Further review of the resident's care plan and weekly skin integrity reviews showed that the pressure ulcer on the coccyx was not documented until several days after admission. The Director of Nursing acknowledged the lack of documentation for the coccyx wound on admission and confirmed that the pressure ulcer was identified post-admission. This failure to identify and document the pressure ulcer on admission led to a delay in appropriate care and intervention, which is a significant deficiency in the facility's pressure ulcer care protocol.
Failure to Identify and Evaluate Smoking Residents
Penalty
Summary
The facility failed to identify and evaluate residents who smoke, specifically for two residents. Resident #7 was admitted with diagnoses including Synovitis, Tenosynovitis, and Generalized Anxiety Disorder. Despite the facility's policy of maintaining a smoke-free environment, Resident #7 admitted to smoking and keeping cigarettes and a lighter in an unlocked closet in his room. The care plan for Resident #7 included interventions for safe smoking, but the facility did not enforce these measures effectively. Resident #28, admitted with diagnoses including Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Tobacco Use, also admitted to smoking. Although the facility's policy required a smoking evaluation and proper storage of smoking materials, Resident #28 refused to disclose where he kept his cigarettes and lighter. The facility's staff, including the Administrator and Director of Nursing, acknowledged that they did not keep track of the residents' smoking materials and did not conduct smoking evaluations because they considered the facility to be non-smoking. Interviews with the Administrator and Director of Nursing revealed that the facility did not enforce its smoking policy effectively. Both residents were allowed to sign themselves out to smoke on the property of a neighboring Assisted Living Facility. The facility's failure to monitor and evaluate the residents' smoking habits and materials led to a deficiency in providing a safe environment free from accident hazards, as required by their policies.
Failure to Provide Catheter Anchor
Penalty
Summary
The facility failed to provide an anchor for catheter tubing for a resident who was observed for catheter care. The resident, who was cognitively intact with a BIMS score of 15, had diagnoses including an unspecified fracture of the second thoracic vertebra, hypertension, and neuromuscular dysfunction of the bladder. The facility's policy required the catheter to be secured with a leg strap to reduce friction and movement at the insertion site. During an observation of catheter care performed by a CNA, it was noted that there was no anchor for the catheter tubing either before or after the care. The CNA confirmed that she did not have an anchor for the catheter, which was contrary to the physician's orders and facility policy that mandated changing the catheter anchor and urine bag every night shift on Sundays.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to identify significant weight loss and provide timely nutritional interventions for two residents. Resident #10 experienced a severe weight loss of 13.5% from 118 pounds to 102 pounds within four days and a further loss to 98.1 pounds over the next two weeks. Despite these significant changes, no additional nutritional assessments or interventions were documented after the initial evaluation. Observations showed that Resident #10 consistently consumed less than 65% of her meals, and the Registered Dietitian was unaware of the severe weight loss, indicating a failure in monitoring and addressing the resident's nutritional needs. Resident #199 also experienced a severe weight loss of 6.9% within three days, dropping from 161 pounds to 149.8 pounds. Despite being diagnosed with severe protein-calorie malnutrition and muscle wasting, there were no additional nutritional assessments or interventions documented after the initial evaluation. Observations revealed that Resident #199 consumed very little of his meals and frequently reported pain and nausea, which affected his appetite. The Registered Dietitian was unaware of Resident #199's poor intake and weight loss, as it did not appear on the clinical dashboard used for monitoring. Both cases highlight a failure in the facility's system for monitoring and addressing significant weight loss and poor nutritional intake. The Registered Dietitian's reliance on a clinical dashboard that did not capture these residents' issues contributed to the lack of timely interventions. Additionally, the facility's policy on weighing and weight at-risk protocol was not effectively implemented, leading to missed opportunities for early intervention and support for the affected residents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to ensure that residents receiving hemodialysis received care and services consistent with professional standards of practice. Resident #196, who was admitted with end-stage renal disease and dependence on renal dialysis, did not receive his medication Sevelamer with meals as required. His wife reported that the medication was attempted to be given outside the facility on the way to dialysis, and there were no communication sheets between the facility and the dialysis center in the dialysis binder. Staff confirmed the absence of these communication sheets and admitted that they often had to call the dialysis center to request them. Resident #201, also diagnosed with end-stage renal disease and dependence on renal dialysis, did not receive his Sevelamer medication with meals as required. He returned from dialysis to find his dinner waiting but was unsure if the medication was given with his meal. The Medication Administration Record showed missed doses of Sevelamer and Humalog insulin due to his absence at dialysis. The Director of Nursing confirmed that medications should be scheduled around dialysis times and that the nursing team should review and address medication orders immediately upon admission.
Failure to Provide Correct Diet Order
Penalty
Summary
The facility failed to provide the correct diet order per the physician's orders for Resident #200, who was admitted with diagnoses of protein-calorie malnutrition, dysphagia, and type 2 diabetes. Observations revealed discrepancies between the diet orders and the meals provided. On one occasion, the resident received mechanically ground chicken and pieces of red potatoes that were not mechanically ground, contrary to the meal ticket. On another occasion, the resident received chopped broccoli florets instead of the mechanically ground diet specified. The resident expressed a poor appetite and consumed only a small portion of the meals provided. Interviews with the Director of Nursing (DON), Food Service Director (FSD), and Speech Language Pathologist (SLP) revealed inconsistencies in the communication and implementation of diet orders. The DON was unaware of why the meal tickets did not match the electronic system's diet orders. The FSD explained the process of inputting diet orders into the meal tracker but was unaware of the specific requirements for mechanically altered diets. The SLP noted that the resident preferred a pureed diet and was able to consume more food independently when provided with this texture. The facility's Administrator was informed of the findings and the importance of adhering to the correct diet orders for the resident.
Failure to Obtain Physician Order for Occupational Therapy
Penalty
Summary
The facility failed to obtain a physician order for Occupational Therapy (OT) prior to commencing OT for a resident. The facility's policy requires that therapy services must be ordered in writing by a licensed physician or nurse practitioner. However, Resident #146, who was admitted with diagnoses including Congestive Heart Failure, Type 2 Diabetes, and Hypertension, began receiving OT on 05/16/24 without a physician order. The resident, who was cognitively intact with a BIMS score of 15, expressed that she thought she should be getting more therapy during an interview on 05/20/24. Upon review, it was found that there was no physician order for OT in the resident's records. The Director of Therapy confirmed that the resident had received OT on four occasions without an order and subsequently entered a late clarification order on 05/22/24, effective from 05/16/24. This deficiency was identified during the survey process, highlighting the facility's failure to adhere to its own policy regarding therapy orders.
Failure to Document PICC Line Dressing Change and Resident Interaction
Penalty
Summary
The facility failed to ensure the accuracy of records for a resident with a PICC line dressing and did not document a resident-to-resident interaction. Resident #247, who has moderate cognitive impairment, had a PICC line dressing with a faded date of 05/13/24, but the Treatment Administration Record (TAR) did not document a dressing change on that date. The Director of Nursing (DON) confirmed the lack of documentation for the dressing change on 05/13/24, despite the physician's order to change the dressing weekly on the evening shift every Friday. Additionally, the facility did not document a verbal altercation between Resident #26 and Resident #28. Resident #26, who is cognitively intact, reported being yelled at by Resident #28 on 05/19/24. Staff F, the Admissions Coordinator, and Staff G, the psychiatrist, were aware of the incident but did not document it in the electronic health record (EHR). The DON and the Administrator were also informed of the argument but did not document the interaction, believing it was not an abuse situation. These deficiencies highlight the facility's failure to maintain accurate and complete medical records as per their policy. The lack of documentation for the PICC line dressing change and the resident-to-resident interaction indicates a lapse in following accepted professional standards for record-keeping and safeguarding resident-identifiable information.
Failure to Implement and Communicate Infection Control Precautions
Penalty
Summary
The facility failed to ensure staff were made aware of residents on Enhanced Barrier Precautions (EBP) and did not use appropriate Personal Protective Equipment (PPE) for a resident on EBP. Specifically, Resident #247, who had diagnoses including Other Gram-Negative Sepsis and Abscess of Liver, was not properly identified as requiring EBP. The resident had a PICC line, an abdominal drain, and a wound on the coccyx, all of which necessitated EBP. However, there was no EBP signage on the resident's door, no PPE cart outside the room, and staff did not wear the required gown and gloves while providing care. The Director of Nursing (DON) confirmed that the facility did not place signs on the doors for EBP and relied on care plans and electronic medical records to communicate EBP status to staff. This led to staff being unaware of the need for EBP and not following proper infection control procedures when caring for Resident #247. Additionally, the facility failed to maintain Contact Isolation Precautions for Resident #199, who was on contact isolation for ESBL in the urine. Despite having an order for contact precautions, there was no contact isolation sign posted on the resident's door, and no PPE cart was available outside the room during multiple observations. It was only after several hours and multiple observations that a PPE cart and isolation sign were placed outside the resident's door. The DON confirmed that Resident #199 had been on contact isolation since the initial order and emphasized that the facility follows CDC guidelines for contact isolation, which include placing signage and PPE carts outside the resident's room. These deficiencies indicate a failure in the facility's infection prevention and control program, specifically in communicating and implementing EBP and contact isolation precautions. The lack of proper signage, PPE availability, and staff awareness led to non-compliance with the facility's policies and CDC guidelines, potentially increasing the risk of infection transmission among residents and staff.
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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