Rehabilitation Center Of Orlando
Inspection history, citations, penalties and survey trends for this long-term care facility in Orlando, Florida.
- Location
- 9311 S Orange Blossom Trl, Orlando, Florida 32837
- CMS Provider Number
- 105471
- Inspections on file
- 36
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Rehabilitation Center Of Orlando during CMS and state inspections, most recent first.
Surveyors found multiple environmental deficiencies, including two East Wing shower rooms with stained, deteriorated grout and tiles, and a toilet containing dark brown standing liquid with heavy staining that remained unaddressed on recheck. On one wing, several resident rooms had warped and broken entrance doors with sharp edges, missing or damaged closet doors, cracked baseboards, unfinished drywall patchwork, wall holes, scuffed bathroom doors, and stained ceilings with black speckles. A resident reported that a wheelchair had recently ripped the room door and that the closet door had been broken for a long time, while a family member reported holes and ceiling stains and noted that only another wing had been renovated. In a back hallway, floor tiles around a drain were missing, mismatched, cracked, and eroded, exposing subfloor and creating uneven flooring. The Maintenance Director, working largely alone and relying on CNAs to submit work orders, confirmed the damage but maintenance logs showed no work orders or repairs for these issues, despite policies requiring preventive maintenance and housekeeping oversight.
Surveyors found that the facility failed to implement its QAPI program sufficiently to sustain compliance with homelike environment requirements, resulting in a repeat F584 deficiency. Previously, the facility had been cited for not providing a homelike environment and responded by focusing staff education and monitoring mainly on dining room conditions, such as centerpieces, without extending oversight to other areas like shower rooms and resident rooms. The NHA reported significant leadership turnover, including multiple DON changes, a new Maintenance Director, and gaps in staffing coordination, along with ongoing housekeeping challenges, which coincided with inadequate auditing, monitoring, and tracking of performance needed to maintain a homelike environment throughout the facility.
A CNA was observed wearing gloves while standing by a medication cart in a hallway, conversing with a nurse and holding a soiled bag, then walking down the hallway toward a soiled utility room and removing only one glove while keeping the other on when entering the room. In a subsequent interview, the CNA admitted awareness that gloves should not be worn in hallways and described being distracted. The unit manager and DON both confirmed that wearing gloves in hallways is an infection control concern and that gloves are to be removed inside a resident’s room before exiting, contrary to the facility’s infection prevention and control policy.
The facility did not ensure a homelike dining environment, as residents in both main and west wing dining rooms were observed eating meals from trays, with dishes not removed and tables lacking decorations or tablecloths. Staff interviews confirmed these practices were routine, and facility leadership acknowledged the absence of a policy or consistent approach to creating a homelike setting.
A nurse failed to administer prescribed antihypertensive and diuretic medications to a resident with multiple chronic conditions, despite physician orders and appropriate blood pressure readings. The nurse withheld medications without justification and did not follow protocol after a medication was dropped and unavailable, resulting in a medication error rate of 10.71%.
Surveyors found that food items in nourishment refrigerators on both nursing units were not consistently labeled or dated, and expired foods were not discarded as required. Multiple undated and expired items, including thickened juice, cheese, bologna, nutritional supplements, and resident leftovers, were observed. Staff confirmed that nursing was responsible for labeling and dating, while dietary was responsible for discarding outdated items, in accordance with facility policy.
Staff were repeatedly observed disposing of trash in facility dumpsters without closing the lids and leaving rubbish scattered around the dumpster area, despite being aware of the requirement to keep lids closed and the area clean to prevent pests. The facility's policy assigned responsibility for maintaining the dumpster area to the CDM and Director of Maintenance, but these procedures were not consistently followed, potentially affecting all residents.
The facility was cited for repeat deficiencies in both its QAPI oversight and medication error rate, as the QAPI committee did not sustain prior improvement measures or provide sufficient auditing and oversight. Despite monthly meetings and departmental audits, the committee failed to prevent recurrence of issues, with recent administrative and ownership changes possibly contributing to a lapse in focus.
A CNA was observed standing while assisting a resident with severe cognitive impairment and multiple medical conditions during meals, rather than sitting as expected to promote dignity. Facility leadership confirmed that staff were expected to sit while assisting with meals to ensure residents felt valued and not rushed, although no formal policy was in place.
The facility failed to address and resolve concerns raised by the Resident Council, including long call light response times, late meal deliveries, and insufficient ice availability. Despite repeated complaints from January to July 2024, the administration provided no detailed updates or resolutions, leaving residents feeling ignored. The facility's policy mandates prompt action on grievances, but the Administrator admitted to not paying sufficient attention to these issues.
The facility failed to implement policies effectively, leading to deficiencies in handling Resident Council grievances and abuse reporting. Despite a Plan of Correction approved by the QAPI committee, similar issues were noted in a previous survey. The Administrator, new to the role, expressed surprise at the findings.
A resident with dementia and requiring a Creole interpreter was allegedly verbally abused by a CNA, as reported by her daughter. The facility failed to report this allegation to State agencies as required. The Social Services Director did not consider it abuse due to the resident's impaired cognition, and the Administrator was initially unaware of the grievance. The facility's policy required immediate reporting of abuse allegations, but the incident was not reported, and the investigation was undocumented.
Environmental Disrepair and Unsanitary Shower Areas Compromise Homelike Conditions
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident care areas and rooms. Surveyors observed that two shower rooms on the East Wing were in deteriorated and unsanitary condition. In one shower room, walls and grout were discolored and stained, grout at the base of the walls was cracked, deteriorated, and separated, and the 2x2 inch floor tiles were worn, uneven, damaged, and included missing and mismatched tiles. In the second shower room, the toilet bowl contained dark brown standing liquid with heavy staining consistent with prolonged buildup, poor drainage, or inadequate cleaning and maintenance, and this condition remained unchanged when rechecked the following day. The Housekeeping Director and Environmental Services District Manager, after reviewing photographs, acknowledged degraded or missing grout and apparent growth on the walls, and the Housekeeping Director stated that housekeepers entered the shower rooms daily but had not reported the clogged toilet. Additional environmental deficiencies were identified in resident rooms on the [NAME] Wing and in the West Wing back hallway. In one resident room, the lower portion of the entrance door was warped and broken with sharp edges, and the bottom panel was lifted approximately eight inches; the closet door was chipped, uneven, and did not close properly. Another room had missing closet doors, a cracked baseboard near the bathroom door measuring approximately three to five inches, scratches on the bathroom door, and unfinished drywall patchwork near the bathroom entrance and window. A third room had deteriorated wall surfaces along the lower portion near the floor, unfinished drywall patchwork with visible spackling, and a cracked baseboard near the bathroom door measuring approximately two to four inches. In another room, the baseboard near the bathroom door was cracked two to four inches wide, the bathroom door had multiple scuff marks, and four to six penny-sized holes were present on the wall above the B-side dresser, with black speckles on the ceiling above bed B and in the bathroom. Surveyors also found that the back hallway floor on the [NAME] Wing around a drain was in poor repair, with multiple missing tiles, mismatched and patchworked tiles, visible cracked and broken tile edges, exposed subfloor material, erosion, and uneven flooring. Interviews revealed that a resident reported the entrance door damage occurred when a roommate’s wheelchair got caught in it a few days earlier and that the closet door had been broken for a long time. A family member reported holes in the wall and stains on the bedroom and bathroom ceilings and stated that while the East Wing had been renovated, nothing had been done on the [NAME] Wing. The Maintenance Director, who had been working alone for several weeks and relied on CNAs to enter work orders, confirmed the damaged doors, patchwork flooring, and deteriorated room conditions and stated he had been unaware of the missing tiles in the shower floor. Review of maintenance logs from November 2025 through the survey date showed no documented work orders or repairs for the deteriorated shower rooms, unsanitary toilet, damaged resident room doors and walls, or hallway flooring, despite facility policies requiring ongoing inspections, preventive maintenance, and housekeeping to promote a sanitary, safe, and comfortable environment.
Failure to Sustain QAPI Oversight for Homelike Environment Requirements
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its Quality Assurance and Performance Improvement (QAPI) program so that previously identified quality concerns were comprehensively monitored and sustained. Survey history showed a prior deficiency under F584 for failure to provide a homelike environment during the last recertification survey. The facility’s Plan of Correction at that time focused on re-educating staff about maintaining a clean and homelike dining environment, including providing centerpieces, and on educating new and agency staff during orientation. During the current survey, a repeat deficiency under F584 was identified, demonstrating that the earlier improvement efforts were not adequately monitored or sustained. The Administrator reported that the prior homelike environment concern had been interpreted narrowly as an issue with missing centerpieces in the dining room, and the QAPI-driven Plan of Correction focused mainly on common areas related to the dining experience. The Administrator acknowledged that the homelike environment was not evaluated or monitored throughout the facility, and that shower rooms and residents’ rooms were not included in the POC or auditing process. She also described significant turnover and operational challenges, including three DON changes in six months, a new Maintenance Director, and periods without a Staffing Coordinator, as well as ongoing housekeeping issues and limited progress in that area. The facility’s written QAPI policy stated that the program was intended to be comprehensive and data-driven, addressing all care and services and ensuring ongoing monitoring and sustained improvement, but the survey findings showed this was not carried out in practice for the homelike environment requirement.
Improper Glove Use in Hallway Breaches Infection Control Practices
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices regarding the use of personal protective equipment (PPE) on the West Wing. During observation, a CNA was seen standing by a medication cart in the hallway talking with a nurse while holding a soiled bag and wearing gloves on both hands. After several minutes, the CNA walked down the hallway toward the soiled utility room, removed the glove from her left hand but kept the glove on her right hand while still holding the soiled bag and then entered the utility room. In an interview immediately afterward, the CNA acknowledged she had been wearing gloves in the hallway, confirmed she knew she was not supposed to wear gloves in the hallway because it was a break in infection control practice, and stated she had gotten distracted. The Unit Manager confirmed that staff should not wear gloves in the hallways because it was an infection control concern and that gloves must be removed inside the resident’s room before exiting, and the DON also confirmed that the CNA walking down the hallway wearing gloves was an infection control concern. Review of the facility’s Infection Prevention and Control Program policy showed it was intended to prevent the development and transmission of communicable diseases and infections, which was not followed in this instance.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for residents in both the main and west wing dining rooms. Observations revealed that residents were served meals on trays, with dishes not removed and placed on the tables, despite the presence of tablecloths in the main dining room. In the west wing dining room, tables were bare, lacking both tablecloths and centerpieces, and residents consistently ate from trays. Staff interviews confirmed that the practice of not removing dishes from trays and the absence of table decorations was routine, particularly in the west wing dining room. Further interviews with facility staff, including a CNA and the Business Office Manager, indicated a lack of clarity and consistency regarding dining room setup and the provision of a homelike environment. The Administrator acknowledged the ongoing issue of residents eating from trays and the lack of decorations, stating that previous centerpieces had been discarded and there was no specific policy addressing the creation of a homelike dining environment. The Unit Manager also recognized the importance of making the environment homelike, as the facility serves as the residents' home.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer medications as ordered for a resident with multiple diagnoses, including hypertension, COPD, schizophrenia, type 2 diabetes, chronic pulmonary edema, and chronic hepatitis C. During a medication pass, the nurse withheld two antihypertensive medications, Losartan Potassium and Sotalol HCl, despite the resident's blood pressure being above the physician-ordered parameters for holding the medications. The nurse did not provide an explanation for this decision, and the Director of Nursing confirmed that the medications should not have been held under the circumstances. Additionally, the nurse failed to administer the resident's prescribed dose of Furosemide after dropping the last available tablet into the medication cart drawer. The nurse did not attempt to retrieve the medication from another source, nor did she contact the pharmacy or physician for further instructions, as required by facility policy. These actions resulted in three medication errors out of 28 opportunities, leading to a medication error rate of 10.71%, which exceeds the acceptable threshold.
Failure to Label, Date, and Discard Outdated Food Items in Nourishment Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items stored in the snack/nourishment refrigerators on both nursing units were properly labeled and dated with open and use by dates. During a tour of the west wing nourishment room, the Unit Manager confirmed the presence of multiple undated and unlabeled food items, including thickened juice, cheese, bologna, containers of peaches and applesauce, unidentified leftover resident food, and salami. The Unit Manager stated that nursing staff were responsible for labeling and dating food items when received or opened, while the dietary department was responsible for monitoring and discarding expired or outdated resident leftovers. In the east wing nourishment room, the Certified Dietary Manager verified that the refrigerator contained undated cartons of thickened water and nutritional supplements, as well as several expired or unlabeled food items. These included a sandwich and a bag of food items dated several weeks prior, an unlabeled loaf of bread, a plastic container of leftover chicken dated over a month prior, and other resident-labeled containers of food that were also significantly outdated. The Assistant Director of Nursing confirmed the responsibilities of nursing staff and the dietary department regarding labeling, dating, and discarding food items. The facility's policy required all food items held for residents to be labeled with the resident's name, food item, and use by date, and for nursing staff to discard perishable foods on or before the use by date.
Improper Garbage Disposal and Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of garbage and maintain the cleanliness of the dumpster area, as observed on multiple occasions. Rubbish was found scattered around the three dumpsters, and several staff members, including a housekeeper, dietary aides, and a laundry aide, were observed disposing of trash without closing the dumpster lids. Staff acknowledged awareness of the requirement to keep lids closed to prevent pests and contamination but did not consistently follow this protocol. The Certified Dietary Manager (CDM) indicated that housekeeping was responsible for maintaining the area, and the Environmental Services Regional Manager confirmed the importance of keeping the area clean and lids closed. The facility's policy on garbage disposal required that all garbage be disposed of safely and efficiently, with the CDM and Director of Maintenance responsible for ensuring the area around the dumpsters remained free of debris. Despite this policy, repeated failures to close dumpster lids and maintain the area were observed, with staff admitting to not following procedures even though they understood their importance. No specific residents were directly involved or affected at the time of the observations, but the deficiency had the potential to impact all 112 residents in the facility.
Repeat Deficiencies in QAPI Oversight and Medication Error Rate
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee effectively conducted performance improvement activities to sustain prior corrective measures. Despite having a QAPI policy that required ongoing actions, measurement of success, and tracking of performance, the facility was cited for repeat deficiencies in medication error rate (F759) and QAPI processes (F867) during the current and previous recertification surveys. The report notes that there was insufficient auditing and oversight to prevent recurrence of these deficiencies, indicating that the QAPI committee did not maintain adequate follow-up or monitoring to ensure sustained improvement. The Administrator confirmed that the QAPI committee met monthly and reviewed departmental audits, with Performance Improvement Plans (PIPs) developed for identified concerns. However, the Administrator, who had only recently returned to the facility, was unable to specify where the process failure occurred. She acknowledged that recent changes in ownership and administration may have contributed to a loss of focus, but also recognized that the performance improvement process should have continued regardless of staff changes. The repeat citations and lack of sustained improvement measures were directly observed by surveyors during the current survey.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed standing while assisting a resident with eating in the main dining room. The resident in question had a history of Parkinson's disease, diabetes mellitus type II, seizures, depression, anxiety, and a psychotic disorder, and required maximum to total assistance for eating due to deficits in activities of daily living and a risk for nutritional decline. The resident also had severe cognitive impairment, as indicated by a low score on the Brief Interview for Mental Status. The CNA explained that she stood while assisting the resident in the dining room in case she needed to move and do something else during the meal, although she acknowledged that she was supposed to sit while assisting residents with meals. The Business Office Manager confirmed observing the CNA standing while assisting the resident during both lunch and breakfast. The facility's Administrator stated that staff were expected to sit while assisting residents with meals, as this practice communicated to residents that they and their meals were important and not to be rushed, and that it was a matter of dignity. However, the facility did not have a formal policy requiring staff to sit while assisting with meals, but the expectation was considered part of treating residents with dignity under residents' rights.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly address and resolve concerns raised by the Resident Council, leading to a deficiency in honoring residents' rights to organize and participate in resident/family groups. The Resident Council President reported ongoing issues such as long response times to call lights, staff neglecting to return after promising to assist, and staff refusing to help outside their assigned sections. Additional concerns included late meal deliveries, cold food due to a broken plate warmer, insufficient ice availability, language barriers with staff, and inappropriate staff attendance at council meetings without invitation. Despite these issues being repeatedly raised in meetings from January to July 2024, the facility administration provided no detailed updates or resolutions, leaving residents feeling ignored. The facility's policy on Resident Rights, dated April 1, 2022, mandates that resident groups have the right to meet privately and that the facility must act promptly on grievances and recommendations, providing rationale for their responses. However, the facility's actions did not align with this policy. The Administrator acknowledged the unresolved call light complaints and admitted that the action plan was marked as 'In progress' without actual resolution. The Certified Dietary Manager confirmed ongoing issues with meal delivery and the broken plate warmer, while the Administrator admitted to not paying sufficient attention to the Resident Council's concerns. This lack of effective response and communication contributed to the deficiency.
Failure to Implement Policies and Address Resident Concerns
Penalty
Summary
The facility failed to implement policies effectively, particularly in monitoring previously identified areas of concern and tracking performance to ensure sustained improvements. During the current survey, deficiencies were noted in the facility's handling of Resident Council grievances and recommendations, as well as in the reporting of an abuse allegation. These issues were not addressed adequately, as similar deficiencies were identified in a previous recertification survey conducted earlier in the year. The Plan of Correction (POC) approved by the Quality Assurance and Performance Improvement (QAPI) committee included education for the Interdisciplinary team on the QAPI process and the implementation of plans to prevent repeat deficiencies. However, the survey findings indicated that these measures were not effectively realized or sustained. The Administrator, who took the position in January, expressed surprise at the survey findings, despite having met with the Resident Council and addressing issues observed during his initial weeks in the role.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State agencies as required. The resident, who was readmitted to the facility with diagnoses including encephalopathy, paraplegia, and dementia, was dependent on staff for all activities of daily living and required a Creole interpreter for communication. Her daughter, who was her Power of Attorney, filed a grievance stating that a CNA had verbally abused the resident by yelling and cursing at her in Creole, which left the resident upset and unwilling to eat. The grievance was logged but not reported as an abuse allegation. The Social Services Director, who was responsible for handling grievances, did not consider the incident as abuse because the resident had severely impaired cognition and did not speak. The grievance was mentioned in a daily meeting with the Administrator and other management, but it was not discussed thoroughly. The Administrator, who was the abuse coordinator, was initially confused about the grievance and did not recall being informed about it. He later acknowledged that it could be a verbal abuse allegation that warranted investigation. The facility's policy required abuse allegations to be reported immediately or within 24 hours if no serious bodily injury occurred. However, the grievance was not reported to the State agency, and the investigation was not documented. The Assistant Director of Nursing conducted a quick investigation and concluded that no Creole-speaking staff were assigned to the resident on the dates in question, but no documentation was kept. The facility's failure to report the allegation and properly document the investigation led to the deficiency.
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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