Pinellas Park Fl Opco, Llc

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor a cognitively intact resident’s clearly documented Full Code status and to initiate CPR when the resident was found unresponsive. The resident had multiple medical diagnoses including type 2 diabetes, atrial fibrillation, abnormal gait, blindness in the right eye, shortness of breath, muscle wasting, mood disorder, and hypertension. On admission and throughout the stay, documentation in the EMR, physician orders, nursing assessments, care plan, and an APRN advance care planning note consistently identified the resident as Full Code, with the resident verbalizing understanding of Full Code versus DNR and electing Full Code. A 5‑day MDS showed intact cognition (BIMS 14), and progress notes shortly before the event documented the resident as clinically stable, at baseline, and continuing as Full Code. On the morning of the incident, a CNA assigned to the resident reported finding him unresponsive close to 6:00 a.m. and notified the LPN assigned to him. Another CNA reported being told around 5:30 a.m. that the resident was not responding and, upon entering the room, found the resident not breathing and without a pulse, partially hanging off the bed. Both CNAs described that when the LPN arrived, she checked the resident, left to obtain a pulse oximeter, returned with an oxygen saturation reading of 60, and was told by the CNA that there was no pulse and that a code should be called. The CNAs stated that the LPN delayed, left the room again to check code status, then reported the resident was Full Code, but still did not initiate CPR or call a code blue. Instead, the CNAs were sent to get another nurse from another floor, leaving the resident alone in the room during part of this time. The CNAs consistently reported that no staff initiated CPR before EMS arrived. The LPN assigned to the resident stated she found him unresponsive around 6:00 a.m., performed a sternal rub, noted he was not responding and that his feet were cold, and then left the room to call 911 from her personal cell phone and get the crash cart. She acknowledged that she did not start CPR, stating she believed the resident was already dead, that he was a large man, and that she needed a backboard and additional help to move him to the floor, but did not ask the CNAs to assist. She confirmed that no code blue was called and that no CPR was performed by facility staff. Two additional nurses who responded to the room reported they were summoned to “pronounce” a resident, assumed the resident was a DNR based on how the situation was presented, did not independently verify code status before acting, and did not initiate CPR. The RN who arrived stated she called the DON to ask what to do about pronouncing, was told the resident was Full Code and to start CPR, and that at that moment EMS arrived. EMS arrived at approximately 6:09 a.m., confirmed the resident’s Full Code status, questioned why CPR had not been started, and then initiated CPR, which continued for approximately 45 minutes before the resident was pronounced dead. Facility leadership and the Medical Director later confirmed that CPR had not been initiated by staff and that the resident’s Full Code status had not been honored, resulting in a determination of Immediate Jeopardy.

Removal Plan

• Initiated an internal investigation with resident record review, staff interviews, and notification to DCF, AHCA, and local law enforcement.
• Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
• Suspended and terminated two additional nurses who responded to the scene and reported their licenses to the licensing board.
• Completed a facility audit of resident code status preferences and verified that orders and care plans were correct.
• Conducted a 100% audit of the crash carts in the facility to ensure all required items were present.
• Held an Ad Hoc QAPI meeting with the Executive Director, Director of Clinical Services, and at least three other department heads.
• Reviewed facility deaths to ensure residents’ advance directives were followed related to code status.
• Implemented a requirement that licensed nursing staff sign a Honoring Advance Directive Attestation upon hire.
• Educated facility staff on Abuse, Neglect and Exploitation with emphasis on Advance Directives.
• Educated licensed staff on Honoring Advance Directives, timeliness of initiated CPR, following physician orders, and the Code Blue process.
• Provided all-staff Abuse, Neglect and Exploitation education with 100% completion.
• Provided all-staff Resident Rights education with 100% completion.
• Provided licensed nursing staff education with 100% completion on Honoring Advance Directives, Physicians Orders, timeliness of initiated CPR, and the Code Blue process.
• Conducted Code Blue quality assurance drills.
• Implemented a requirement that licensed nurses will not work prior to attending a mock Code Blue quality assurance drill.
• Interviewed staff members to confirm training and knowledge of code status policies, roles during a Code Blue, and where to find advance directives, and confirmed receipt of abuse and neglect training.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor a resident’s clearly documented Full Code status by not initiating CPR when the resident was found unresponsive. The resident had multiple diagnoses including Type 2 diabetes, atrial fibrillation, abnormal gait, blindness in the right eye, shortness of breath, muscle wasting, mood disorder, and hypertension. On admission, the resident had no DNR order, was documented as alert, oriented, able to follow instructions, and capable of making healthcare decisions. Advance Care Planning notes from an APRN and a physician documented that the resident understood the difference between Full Code and DNR and elected/confirmed Full Code status. The admission evaluation, care plan, and subsequent physician notes all consistently reflected a Full Code status, and the resident’s cognition was documented as intact with a BIMS score of 14. On the night of the incident, CNAs and nursing staff described discovering the resident unresponsive in the early morning hours. One CNA reported being told by another CNA that her resident was not responding around 5:30 a.m. and, upon entering the room, found the resident not breathing and without a pulse. The CNA stated that the LPN assigned to the resident was notified but did not immediately come to the room, and when she did arrive, she used a pulse oximeter that showed an oxygen saturation of 60. The CNA reported that she repeatedly questioned the need to call a code and start CPR, but the LPN left the room to check the resident’s status and did not initiate CPR. The CNAs then went to obtain another nurse from another floor, leaving the resident alone in the room for a period of time. When they and additional nurses returned, the CNA reported that no one was performing CPR, no code blue was called, and 911 had not yet been contacted until directed by another RN. The LPN assigned to the resident stated that when notified by the CNA around 6:00 a.m., she found the resident unresponsive, with cold feet and no response to a sternal rub. She reported calling 911 from her personal cell phone at 6:04 a.m. and obtaining the crash cart, but acknowledged that she did not start CPR, stating she believed the resident was already dead, that he was a large person, and that she needed a backboard and help to move him to the floor. She also stated that she did not ask the CNAs to help move the resident and that no compressions were performed by her or the other nurses who arrived. Other nurses who responded to the scene reported that they were summoned under the impression that a resident needed to be pronounced dead, assumed the resident was a DNR, did not verify the code status themselves, did not call a code blue, and did not initiate CPR. The Medical Director later confirmed that the expectation for a Full Code resident found unresponsive was immediate initiation of CPR prior to EMS arrival and agreed that staff failed to honor the resident’s wishes for resuscitation. The surveyors determined that CPR was not initiated for approximately 35 minutes, resulting in physical pain and ultimate death for the resident and leading to an Immediate Jeopardy finding. Facility policies in place at the time required staff to follow American Heart Association guidelines for CPR, to provide basic life support including CPR prior to EMS arrival in accordance with the resident’s advance directives, and to ensure CPR-certified staff were available at all times. The policies also required clear communication of code status and adherence to residents’ rights to formulate advance directives. Despite these policies and the resident’s clearly documented Full Code status, staff did not call a code blue overhead, did not promptly verify and act on the code status, and did not initiate CPR while waiting for EMS. EMS personnel, upon arrival, questioned why CPR had not been started for a Full Code resident and then initiated resuscitative efforts themselves. The surveyors concluded that the failure to initiate CPR and honor the resident’s advance directive for end-of-life care created a situation that resulted in a worsened condition and the likelihood of serious injury and/or death, and they cited this as an Immediate Jeopardy deficiency.

Removal Plan

• Initiated an internal investigation including resident record review, staff interviews, and notification to DCF, AHCA, and local law enforcement.
• Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
• Suspended and terminated two additional nurses who responded to the scene and reported their licenses to the licensing board.
• Conducted a facility audit of resident code status preferences to verify orders and care plans were correct.
• Completed a full audit of the crash carts to ensure all required items were present.
• Held an Ad Hoc QAPI meeting with the Executive Director, Director of Clinical Services, Medical Director, and department heads.
• Placed overhead page system instructions by telephones at the nurse’s station, reception area, and dining room with instructions on how to page overhead.
• Reviewed facility deaths to ensure residents’ advance directives were followed related to code status.
• Completed an audit of licensed nurse licensure and verified CPR cards were valid.
• Implemented a requirement that all new employees participate in a Code Blue drill upon hire.
• Implemented a requirement that licensed nursing staff sign a Honoring Advance Directive Attestation upon hire.
• Educated facility staff on Resident Rights, including the right to choose code status.
• Educated licensed staff on honoring advance directives, timeliness of initiating CPR, following physician orders, and the Code Blue process.
• Provided all-staff education on abuse, neglect, and exploitation with full completion.
• Provided all-staff Resident Rights education with full completion.
• Provided licensed nursing staff education on honoring advance directives, physician orders, timeliness of initiating CPR, and the Code Blue process.
• Conducted Code Blue drill quality assurance drills.
• Implemented a requirement that licensed nurses will not work prior to attending a mock Code Blue drill.
• Conducted staff interviews to confirm training and knowledge of code status policies, Code Blue roles, where to find advance directives, and abuse and neglect training.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that nursing staff demonstrated competency in performing CPR and honoring a resident’s full code status. The resident involved had a documented physician progress note confirming that he understood the difference between full code and DNR and elected full code status. On the night of the incident, the resident was found unresponsive and without vital signs, yet facility staff did not initiate CPR. The facility’s LPN job description required current CPR certification and outlined responsibilities including directing CNAs, complying with policies and procedures, and participating in end-of-life care, but these expectations were not met in this event. According to interviews, a CNA who was not assigned to the resident was informed by the assigned CNA that the resident was not responding and not moving. As they proceeded to the room, they encountered the LPN at the nurses’ station, notified her of the situation, and the LPN stated she was on her way but continued what she was doing. When the LPN entered the room, she applied an oximeter and obtained an oxygen saturation of 60, which she described as “kind of low.” The CNA reported telling the LPN that the resident “is not here” and asking if they needed to call a code. The LPN left the room to check the resident’s code status, returned and confirmed he was full code, but still did not initiate CPR. The CNA stated that no one called a code blue, no overhead page was made, and no staff began CPR before EMS arrived. The LPN later stated she found the resident unresponsive, with cold feet and no response to sternal rub, and that she called 911, obtained the crash cart, and asked a CNA to get another nurse. She reported that she did not start CPR because she believed the resident was already dead, said she needed a backboard and help to move the resident due to his size, and did not ask the CNAs to assist. She acknowledged that she did not call a code, did not perform compressions, and that all staff present “did not do anything” while waiting for EMS. Other nurses who responded to the room, including an RN and another LPN, stated they did not start CPR, assumed the resident was a DNR based on how the situation was presented, did not verify the code status themselves, and did not call a code blue. The RN reported that she did not initiate CPR because she assumed the resident was a DNR and was focused on the idea that she was being asked to pronounce death, and only after contacting the DON did she learn the resident was full code and was told to start CPR, at which point EMS arrived. EMS personnel questioned why CPR had not been started if the resident was full code. The medical director stated that the expectation was that immediate CPR should be started for a full code resident and that nurses are not to pronounce death or rely on signs such as cold extremities, but instead should confirm code status and initiate CPR.

Removal Plan

• Initiated an internal investigation including resident record review, staff interviews, and notifications to DCF, AHCA, and local law enforcement.
• Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
• Suspended and terminated two additional nurses who responded to the scene and reported their licenses to the licensing board.
• Completed a facility-wide audit of resident code status preferences and verified that orders and care plans were correct.
• Reviewed residents with Do Not Resuscitate preferences to ensure a valid Florida DNRO was physically available at the facility.
• Conducted an audit of the facility’s crash carts to ensure all required items were present.
• Held an Ad Hoc QAPI meeting with the Executive Director, Director of Clinical Services, and Medical Director.
• Placed overhead paging system instructions by telephones at the nurse’s station, reception area, and dining room with instructions on how to page overhead.
• Reviewed facility deaths to ensure residents’ advance directives were followed related to code status.
• Completed an audit of licensed nurse licensure and verified cardiopulmonary resuscitation (CPR) cards were valid.
• Implemented a requirement that all new employees participate in a Code Blue drill upon hire.
• Implemented a requirement that licensed nursing staff sign an Honoring Advance Directive Attestation upon hire.
• Educated facility staff on Resident Rights, including the right to choose code status.
• Educated licensed staff on honoring advance directives, timeliness of initiating CPR, following physician orders, and the code blue process.
• Provided all-staff education on abuse, neglect, and exploitation.
• Provided all-staff Resident Rights education.
• Provided licensed nursing staff education on honoring advance directives, physician orders, timeliness of initiating CPR, and the code blue process.
• Conducted code blue quality assurance drills.
• Implemented a requirement that licensed nurses will not work prior to attending a mock code blue quality assurance drill.
• Conducted staff interviews to verify knowledge of facility policies regarding code status, roles during a code blue, and where to find advance directives, and confirmed staff received abuse and neglect training.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a failure to maintain complete and accurate medical records for a resident with multiple diagnoses, including Parkinson's disease, sarcopenia, cognitive communication deficit, dementia, history of TIA, and cerebral infarction without residual deficits. The resident was admitted and discharged within a few days, and review of the toileting task documentation for that period showed no recorded incontinence care during 8 out of 10 opportunities. Review of the nutrition/eating task documentation for the same period showed no record that the resident received meals during 7 out of 9 opportunities. There were no documented refusals of care or meals. Staff interviewed on later dates did not remember the resident due to the short stay and could not describe the care provided. The DON stated she was not familiar with the resident and confirmed that documentation should verify whether care was provided or refused, and that there was no reason for care opportunities to be left blank. The resident’s MDS showed severe cognitive impairment (BIMS score of 04), dependence for toileting hygiene, and always incontinent for bowel and bladder. The care plan identified potential/actual skin integrity impairment related to decreased cognition, mobility, incontinence, pain, and weakness, with interventions to keep skin clean and dry. Facility policies on incontinence, ADLs, and serving meals required provision of appropriate toileting and nutritional care, but the facility did not provide a policy on documentation, and the existing record did not allow determination of whether incontinence care and meals were actually provided.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain kitchen equipment and surfaces in a clean and sanitary manner, as observed during a tour of the kitchen. The handwashing sink in the food preparation area was found on the floor, with exposed materials and an uncapped drainpipe, and had been out of service for approximately two weeks. The alternative sink in the dishwashing area was blocked by a dish rack cart, lacked paper towels, and had food debris partially blocking the water flow. Additionally, the commercial ice maker had visible dry white, tan, and black material around its perimeter and on its exterior surface, and the kitchen lighting was inadequate with several non-functioning fluorescent lights. The kitchen floor drain in the dessert area had standing liquid, and the industrial can opener was rusted with a black substance around the blade. The walk-in refrigerator and freezer contained a used glove, trash, and an open beverage can, with floors covered in a thick layer of black, grey, and brown substance. The bottom shelves of metal food preparation tables had rust spots and crumbs, and a sanitizing bucket contained cloudy liquid and food debris. The kitchen floor perimeters and areas under equipment had debris and dirt buildup, with sticky and discolored grout between tiles. Interviews with staff revealed that there was no schedule for deep cleaning the kitchen, and concerns were raised about the night shift not cleaning properly. The Dietary Supervisor confirmed that a cleaning schedule was posted but not consistently followed, and the Nursing Home Administrator acknowledged awareness of the sink issue. Despite documentation indicating that daily cleaning tasks were completed, observations and staff interviews contradicted this, highlighting a lack of adherence to cleaning protocols.

Plan Of Correction

The handwashing sink located in the food preparation area was repaired on by maintenance. The dishwashing area sink was cleaned, and no objects are blocking access to the sink. The paper towel dispenser was filled with paper towels, and a trash can was placed next to the sink. The commercial ice maker, ice storage bin, and floor were cleaned on. Kitchen lighting was replaced by maintenance on. The floor drain in the dessert prep area was cleaned, and the grate cover was replaced. An industrial can opener was purchased on and is cleaned daily and as needed. The walk-in refrigerator and freezer, including the floors, were cleaned on. The food preparation table, including bottom shelves, was cleaned. The red sanitizing bucket was emptied, and the kitchen floor, including perimeters, was cleaned. The Nursing Home Administrator and Dietary Manager completed a kitchen inspection and kitchen sanitation audit on. Any areas of concern were addressed as they were identified. On, the Nursing Home Administrator completed education with the Dietary Manager related to the components of this regulation, with emphasis on kitchen sanitation, ensuring a working handwashing sink was available in the kitchen and adequate lighting in the kitchen. Education was conducted on by the Nursing Home Administrator on the component of this regulation, with emphasis on maintaining proper sanitation standards throughout the food production and serving areas of the kitchen to include service tables that are clean, free from rust, working handwashing sinks, and adequate lighting. The Dietary Manager/designee will conduct a sanitation audit daily for one week, then weekly for a month, and every two weeks for two months. A report on sanitation audit results will be submitted by the Dietary Manager to the Quality Assessment and Assurance Committee monthly for one quarter until substantial compliance is met. The findings of these quality monitorings will be reported to the Quality Assurance/Performance Improvement Committee monthly. Quality monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/designee.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs used were labeled in accordance with clinical professional standards. During an inspection of a medication cart on two floors, it was observed that two translucent brown medication bottles had labels with spaces to write the medication expiration date and the date opened, but no information was filled in. Additionally, an injector pen was found with a label to document the 'date opened' and instructions to discard after 28 days, but these dates were not documented. Staff A, a Registered Nurse, admitted to not knowing the expiration dates for the medications and acknowledged that the labels should have been dated. Further inspection on the second floor revealed another injector pen without the open date and discard date listed. Staff B, an LPN, confirmed that the medication should be discarded 28 days after first use and immediately removed the injector pen from the cart. The Director of Nursing stated that the facility expects staff to write the medication expiration dates on the labels when medications are first used. The facility's policy on medication administration requires identifying expiration dates and notifying the nurse manager if medications are expired.

Plan Of Correction

Identified and injector pens were discarded on 04/23/2025. On 04/23/2025, new medications were provided by the pharmacy and dated appropriately. Quality review was conducted by the Director of Nursing/designee of current medication carts to ensure proper labeling/storage of drugs and biologicals, with emphasis on medications being dated at time of opening and discarding medication when expired. Any concerns noted were addressed as identified. Current Licensed Nurses were re-educated by the Director of Nursing/designee on the components of this regulation, with emphasis on ensuring proper labeling/storage of drugs and biologicals, with emphasis on medications being dated at time of opening and discarded at time of expiration. The Director of Nursing/designee will conduct quality monitoring of medication carts to ensure proper labeling/storage of drugs and biologicals, with emphasis on medications not being dated when opened and expired drugs twice weekly for 4 weeks, weekly for 2 weeks; then weekly and PRN as indicated. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly. The quality monitoring schedule will be modified based on findings, with quarterly monitoring by the Regional Director of Clinical Services/designee.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs used were labeled in accordance with clinical professional standards. During an inspection of a medication cart on two floors, it was observed that two translucent brown medication bottles had labels with spaces to write the medication expiration date and the date the medication was first used, but no information was written on them. Additionally, an injector pen was found with a label to document the 'date opened' and instructions to discard after 28 days, but the necessary dates were not documented. Staff A, a Registered Nurse, admitted to not knowing the expiration dates and acknowledged that the labels should have been dated. Further observations on a second-floor medication storage cart revealed another injector pen without the open date and discard date listed. Staff B, an LPN, confirmed that the pen should be discarded 28 days after first use and immediately removed it from the cart. The Director of Nursing stated that the facility expects staff to write the medication expiration dates on the labels when medications are first used. The facility's policy on Medication Administration requires medications to be administered by licensed nurses in accordance with professional standards to prevent contamination, but this was not adhered to in these instances.

Plan Of Correction

Identified and injector pens were discarded on. New medications were provided by the pharmacy and dated appropriately. Quality review was conducted on, by Director of Nursing/designee, of current medication carts to ensure proper labeling/storage of drugs and biologicals with emphasis on medications being dated at time of opening and discarding medication when expired. Any concerns noted were addressed as identified. Current Licensed Nurses were re-educated by Director of Nursing/designee on the components of this regulation with emphasis on ensuring proper labeling/storage of drugs and biologicals with emphasis on medications being dated at time of opening and discarded at time of expiration. The Director of Nursing/designee to conduct quality monitoring of medication carts to ensure proper labeling/storage of drugs and biologicals with emphasis on medications not being dated when opened and expired drugs twice weekly x 4 weeks, weekly x 2 weeks; then weekly and PRN as indicated. The findings of these quality monitorings to be reported to the Quality Assurance/Performance improvement Committee monthly. Quality Monitoring schedule modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/designee.